SURGERY - INVESTIGATIONS PLAIN X-RAY ABDOMEN 01

PLAIN X-RAY ABDOMEN

INV - 08

Muhammad Shuja Tahir, FRCS(Edin) FCPS (Hon)

It is the radiological examination of abdomen and its contents. It is used as a screening investigation in various abdominal problems such as; ! Gastro-intestinal problems ! Inflammations of abdominal viscera ! Abdominal trauma ! Urinary tract problems ! Gynaecological problems. ! Vascular problems ! Retroperitoneal problems.

Sometimes the patient is unfit to stand, then lateral decubitus film is exposed. It is a relatively poor alternate and does not provide enough information. The areas of lower chest and pelvis are also exposed to have complete visualization of the abdomen.

Plain x-ray abdomen (normal film) without preparation

The clinical data is always critically examined before performing the radiological investigations. It is inspected and interpreted in an organized and structured manner.

OVER VIEW
Plain x-ray abdomen (normal film) after preparation

The plain film is exposed with or without preparation. The abdominal x-ray is exposed in appropriate position. The x-ray pictures are exposed in erect or standing position and supine or lying position. Occasionally the films are exposed in lateral position as well.
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Whole of the exposed film is seen over an illuminater and never against sunlight or electric light to avoid wrong conclusions. Possible provisional diagnosis is made and objective interpretation is done. Large amount of gas is seen in stomach and colon. Stomach is identified because of its anatomical position and contents. An air-fluid level is seen under the left

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hemidiaphragm normally. The presence of gas in the bowel is seen on plain film. Gas is normally present in the stomach, small and large intestine in small quantities. The gas is present as individual bubbles of gas scattered in the bowel.

If a loop of bowel is seen filled with gas, it should not be longer than 5-8 cm and should not be distended under normal circumstances. The gas does not form a loop pattern in healthy persons. Gas shadows outside the intestine always indicate intraabdominal pathology. Multiple gas-fluid levels in the dilated loops of small or large gut indicate obstruction to the gastrointestinal flow. The level of obstruction is usually looked for. The psoas shadows are visible as diverging lines on both sides of spine starting from first lumbar vertebra towards pelvis. The psoas shadows may be obliterated by inflammatory, neoplastic and hemorrhagic (traumatic) lesions of the organ in front and in the vicinity (pancreas, spleen, liver etc.)

Plain x-ray abdomen showing diverging psoas shadows

Ascites or presence of pus in the peritoneal cavity is identified by typical ground glass appearance. It offers valuable diagnostic information. Radio-opaque shadows and calcifications in the film are seen and their anatomical correlation is interpreted. Soft tissue shadows of liver, spleen, kidneys, and psoas muscle are visible normaly. Outline of urinary bladder, if filled with urine may be seen on plain film. The plain x-ray film of the abdomen showing complete urinary system is called KUB film (Kidney, Ureter, Bladder film).

Peritoneal and extra-peritoneal contents of abdomen and pelvis are examined. Pancreas cannot be seen on plain film of abdomen.

ABDOMINAL TRAUMA
The injuries of abdomen show various radiological features depending upon the type, time and site of injury. The common features seen on plain x-ray abdomen after various type of trauma are:
! ! ! !

Plain x-ray abdomen (normal) KUB film

Pneumoperitoneum Ground glass appearance Psoas shadow obliteration Sentinel loops

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! ! ! !

Trauma may be; ! Penetrating ! Blunt The penetrating injuries are usually visible on clinical examination. But the extent of injury may not be evaluated specifically on clinical examination. It presents with pneumoperitoneum on radiological examination in the earlier part. Similarly blunt injuries of abdomen are diagnosed from clinical history and examination but extent of injury can only be assessed by various investigations and sometimes even laparoscopy or laparotomy may be required.

Penetrating intraperitoneal injuries Diagnostic fallopian tube insufflation Gas gangrene of intra peritoneal viscera. Septic peritonitis with gas forming organisms

GROUND GLASS APPEARANCE

This is a typical feature seen on x-ray abdomen. It is visible due to presence of fluid, pus or blood in the peritoneal cavity. The presence of fluid gives this appearance on plain x-ray abdomen. This is seen within few hours after penetrating injuries of abdomen when the peritonitis has already set in. The blunt injury of abdomen may lead to injury to the hollow viscera leading to leakage of gastro-intestinal contents into the peritoneal cavity and similar radiological features.

PNEUMOPERITONEUM
Normally no air is present in peritoneal cavity. Pneumoperitoneum is the presence of free air in the peritoneal cavity. The most common site is usually under the right dome of diaphragm. The penetrating injuries of abdomen present with free air in the peritoneal cavity. (Pneumoperitoneum) The free air may be either due to perforation of the hollow viscus or the air entering from the exterior. The free gas appears about 1-2 hours after the perforation of bowel. Absence of free gas in the peritoneal cavity does not necessarily exclude presence of perforation as it is absent in approximately 25 % cases of perforated duodenal ulcer. It is very rare in acute appendicitis even if it is perforated. It is seen in following conditions; ! Perforated duodenal ulcer ! Perforated gastric ulcer ! Perforated gastric carcinoma ! Perforated colonic carcinoma ! Perforated colonic diverticulum ! Traumatic gastric rupture ! Traumatic small gut rupture ! Traumatic colonic rupture ! Typhoid perforation ! Diagnostic pneumoperitoneum ! Post laparotomy pneumoperitoneum ! Post laparoscopy pneumoperitoneum.
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Plain x-ray abdomen showing ground glass appearance due to presence of fluid or pus in the peritoneal cavity

PSOAS SHADOW OBLITERATION

The hematomas are formed which may obliterate the psoas shadow in case of injury to the solid organs. This feature is seen in hepatic, splenic and renal trauma. It is also seen in pancreatic injuries or infections.

SENTINEL LOOPS
An isolated distended loop of bowel is seen near the site of injured viscus or inflamed organ. This loop is called a "sentinel loop". It is a feature due to body's efforts to localize traumatic or inflammatory lesions. The local distention of intestinal loop is due to local paralysis and

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accumulation of gas in the intestinal loop. In acute pancreatitis, the sentinel loop is usually seen in left hypochondrium while in acute appendicitis, the sentinel loop is seen in right iliac fossa. The sentinel loop is seen in right hypochondrium in acute cholecystitis. Other radiological features of peritonitis are also seen in late cases of blunt injuries of abdomen, when peritonitis has developed (Ground glass appearance and pneumoperitoneum).

These conditions can be diagnosed reasonably well by looking at the plain x-ray of the abdomen. It shows free gas under the diaphragm specially on right side in most of the cases. Ileal perforation due to typhoid presents in this manner. Perforations of other intra peritoneal hollow viscera also present similarly. Perforation of appendix is rarely associated with pneumoperitoneum.

INTESTINAL OBSTRUCTION
The obstruction to the flow of contents of gastrointestinal tract can be;

INFLAMMATORY & MISCELLANEOUS LESIONS OF ABDOMEN

There are many inflammatory lesions of peritoneal viscera. The history of illness is present for some period. The acute symptoms of intestinal perforation and resulting peritonitis are seen as pneumoperitoneum, ground glass appearance and Psoas shadow obliteration. The duodenal ulcer and gastric ulcer perforations used to be one of the most common surgical emergencies during previous decades. Now in our Indo-Pak subcontinent the incidence of typhoid perforation is higher.

MECHANICAL
! ! !

Acute Subacute Chronic Adynamic ileus

PARALYTIC
!

The causes of intestinal obstruction may be external or internal hernias, adhesions, neoplasia, volvulous, stenotic lesions, inflammatory lesions, meconeum and gallstones. After 3-5 hours of acute intestinal obstruction, enough gas and fluid accumulates to show distension of intestinal loops and gas fluid levels inside the intestine. The gas shadows are better seen in supine or lying position film. More than two fluid levels seen in small gut are abnormal and pathological. The gas filled loops of gut show increase in their diameter due to distension. The fluid levels are seen in erect or standing films or lateral decubitus films.

SMALL INTESTINAL OBSTRUCTION

The small gut distended loops are recognized by the following features;
! !
Plain x-ray abdomen (supine film) showing dilated jejunal loops due to small gut obstruction

The caecum is not distended in cases of small intestinal obstruction. The location of distended loops or air fluid level is central. Fine serrations along the margins formed by

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than those normally seen in a single x-ray view. The serrations are partial and incomplete. These look like indentations into the transverse diameter of the colon. These are not opposite each other but are alternating.

VOLVULUS OF COLON
In cases of volvulus of sigmoid colon, an inverted U shaped distended loop of colon is seen in the pelvis and abdomen. Double fluid levels may be seen. In cases of peritonitis, the signs of free fluid present in the peritoneal cavity, sentinel loop or a localized distended loop of bowel is seen adjacent to the lesion.

COLONIC CARCINOMA

Plain x-ray abdomen (erect film) showing multiple air fluid levels in the loops of jejunum due to small gut obstruction.

! ! !

mucosal folds are complete along the transverse axis in case of jejunum. These fine serrations are very close to each other. Featureless gut (with serrations) is seen in ileal obstruction. Step ladder pattern of air fluid shadows is also seen some times.

COLONIC OBSTRUCTION
The colon is distended from caecum to the obstructive lesion where the distension ends abruptly. Haustrations are deeper and these are not continuous along the transverse axis of colon. These are in fact alternating type. If caecum gets distended more than 9-10 cm it is likely to perforate. Colonic obstruction presents with following features on xray abdomen;
! ! !
Plain x-ray abdomen showing marked dilatation of the large gut from caecum to splenic flexure due to large gut obstruction.

Most often these are not diagnosed from presence of soft tissue shadows. When these lesions are causing partial or complete obstruction or perforation, these can be detected indirectly from;
! ! !

Radiological features of intestinal obstruction Features of intestinal perforation Features of generalized peritonitis

The caecum and colon are distended The distended colonic loops are present at the periphery in the abdomen. The gas fluid levels are seen and these are more
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ACUTE MESENTERIC OCCLUSION

It shows the features of peritonitis and may be detected by plain x-ray abdomen.

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INTRA ABDOMINAL ABSCESSES

These can not be seen on plain x-ray film directly. Various features such as presence of sentinel loops, abnormal diaphragmatic shadows and ground glass

Air fluid level under the right dome of diaphragm due to presence of gas in the right subphrenic abscess (Plain x-ray abdomen)

! ! ! ! !

Colo-biliary fistula due to gall stone erosion. Duodeno-biliary fistula due to gall stone erosion or duodenal ulcer penetration. Sphinterotomy or sphinteroplasty of sphinter of oddi Choledocho-duodenal anastomosis Acute cholecystitis with gas forming organisms.

GYNAECOLOGICAL PROBLEMS (FIBROID UTERUS)

Dilatation of large gut due to twisted caecum and ascending colon due to volvulus of caecum (Plain x-ray abdomen)

appearance may help in suspecting the lesion. Presence of air fluid level under the diaphragm is highly suspicious of subphrenic collection. Ultrasound examination helps to confirm the diagnosis.

In women, uterine shadow may also be seen specially if the patient is not fat or the fibroid is calcified. It is easily seen on plain film x-ray of the pelvic area.

OVARIAN TUMOURS
Normally these are not picked up on plain film at an early stage. Teratomas may be detected because of radiopaque structures present in these tumours (cartilage, teeth etc)

GALL STONE ILEUS

In cases of gall stone ileus when the gall stone has ulcerated into the duodenum and descended along the small intestine, it causes small gut obstruction. It presents with following features;
! ! ! !

All the features of small intestinal obstruction are present. It is diagnosed by presence of stone which is usually radio-opaque. Gas shadow is seen in the biliary tree (common bile duct, common hepatic duct and hepatic ducts). The gall bladder may also be filled by the gas.

Gas shadow is seen in biliary tree in following conditions;

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Gas in the biliary passages and gall bladder due to gall stone ileus (Plain x-ray abdomen)

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RENAL TUMOURS
Soft tissue renal shadow is usually seen in properly prepared patients and occasionally renal lesion may be detected on plain x-ray abdomen.

CYSTS
Soft tissue shadows of larger cysts may occasionally be out lined on plain film. But most often these are undetected and require ultrasound examination or urography for proper detection.

CALCULUS DISEASE
Stones in the gall bladder and stones in the urinary system are seen as radio-opaque shadows in the relevant area. These cases are diagnosed if the stones are radioopaque otherwise ultrasonography, cholecystography or urography is required.

FOREIGN BODIES
Foreign bodies may be ingested accidently. These usually pass through the gastro intestinal tract easily if small and not pointed. Even needles may pass without causing perforation. The plain x-ray of abdomen helps in finding the site and type of foreign body if it is radio-opaque. If the foreign body is obstructed at some place, it may be removed surgically.

Multiple radio-opeque shadows in the upper part (multiple biliary and bilateral renal stones) (Plain x-ray abdomen)

REFERENCES
1. Peter Armstrong. Martin L. Wastie. Plain Abdomen: In Diagnostic Imaging. 4th Edition Blackwell Scientific publications London. pp 133-143, 1998

Plain x-ray abdomen (normal film) after preparation

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