Abdominal X-ray

Lenny Violetta Departement of Radiology

Image data and quality

Patient and image data

You should always check that the image data refers to the correct patient and that the X-ray is the current examination. Check the image data to see if it is a standard Anterior-Posterior (AP) supine projection.

Supine Anterior-Posterior (AP) projection

Abdominal X-rays are usually acquired using an AP (Anterior-Posterior) projection (X-rays pass through the patient from front to back), with the patient positioned supine.

Other projections

If perforation of the bowel is suspected then an ERECT chest X-ray must be requested. This is the most sensitive plain radiographic study to detect the presence of free gas in the abdomen. Occasionally a patient will be too ill to be positioned erect. In this case a DECUBITUS (on the side) radiograph can be obtained. For a decubitus image the patient lies on their side ('Right decubitus' - patient lies on their right), and X-rays pass through the body from back to front.

Key points

Check the patient details Check which projection has been used - AP or decubitus If assessing for perforation always look at the ERECT chest x-ray Check you can see the whole abdomen

Bowel gas pattern

Any part of the bowel may be visible if it contains gas/air within the lumen. Gas/air is of low density and forms a natural contrast against surrounding denser soft tissues. It is often difficult to differentiate between normal small and large bowel, but this often becomes easier when the bowel is abnormally distended. The upper limit of normal diameter of the bowel is generally accepted as 3cm for the small bowel, 6cm for the colon and 9cm for the caecum (3/6/9 rule).

Normal stomach

If the stomach contains air it may be visible in the left upper quadrant of the abdomen. The lowest part of the stomach crosses the midline.

Normal small bowel

Central position in the abdomen Valvulae conniventes - mucosal folds that cross the full width of the bowel (arrowheads)

Normal large bowel

Normal large bowel may be identified by -

Peripheral position in the abdomen (the transverse and sigmoid colon occupy very variable positions)
Haustra Contains faeces

Soft tissues

Although plain radiographs of the abdomen provide limited detail of the abdominal organs, occasionally a knowledge of their normal appearance will allow identification of abnormalities. Visible soft tissue organs visible on abdominal X-rays include the liver, spleen, kidneys, psoas muscles, bladder (within pelvis), and lung bases (within thorax).

Liver on abdominal X-ray

The liver lies in the right upper quadrant (RUQ) and is seen as a bland area of grey on an abdominal X-ray.
The superior edge of the liver forms the right hemidiaphragm contour (arrowhead). In this patient the breast shadow (red line) overlies the liver, and markings of the right lung are visible behind the liver. The gallbladder is only rarely visible on an abdominal X-ray. Its position is very variable. This patient has had a cholecystectomy. The clips mark the previous location of the gallbladder.

Lung bases on abdominal X-ray

The lung bases, which pass behind the liver and diaphragm in the posterior sulcus of the thorax, may be visible on some abdominal X-rays. It is worth checking the lung bases as some patients with lung pathology present with abdominal symptoms. If there is consolidation suspected from the abdominal X-ray then a review of the patient's respiratory system is necessary. Costophrenic angle (*)

Psoas edges on abdominal X-ray

The psoas muscles (red) arise from the transverse processes of the lumbar vertebrae (arrowheads) and combine with the iliacus muscles. Together these powerful muscles form the iliopsoas tendon, which attaches to the lesser trochanter of the femur (*). The iliopsoas muscles are the flexors of the hip. An abdominal X-ray often demonstrates the lateral edge of the psoas muscles as a near straight line. The iliacus muscles are not visible, as they lie over the iliac bones of the pelvis.

Kidneys on abdominal X-ray

Natural contrast between the kidneys and the low density retroperitoneal fat that surrounds them means they are often visible on an X-ray of the abdomen. They lie at the level of T12-L3 and lateral to the psoas muscles. The right kidney is usually slightly lower than the left due to the position of the liver.

Spleen on abdominal X-ray

The spleen lies in the left upper quadrant (LUQ)immediately superior to the left kidney.

Bladder abdominal X-ray The bladder has variable appearance depending on how full it is. It has the same density as other soft tissue structures, due to its water content.

Bones

All bones seen on an abdominal X-ray are better visualized with dedicated images. Nevertheless, it is important to carefully examine the bones visible on an abdominal x-ray because clinically important bone disease may be identified on an abdominal X-ray, either as a significant unexpected finding or as an unsuspected cause of abdominal symptoms.
Bones visible on an abdominal X-ray include the lower ribs, the lumbar spine, the sacrum, coccyx, pelvis and proximal femora.

Key points Systematically examine the bones All bones are better visualized with dedicated images Bones act as landmarks for other structures

Normal bones on abdominal X-ray

The lower ribs, lumbar vertebrae and sacrum are highlighted. Bones can be used as landmarks for invisible soft tissue structures. Note the transverse processes of the lumbar vertebrae act as landmarks for the course of the ureters (arrowheads). The vesico-ureteric junctions(*) are located at the level of the ischial spines (arrows).

Normal bones on abdominal X-ray The sacrum, coccyx, pelvic bones and proximal femora are highlighted. The sacro-iliac joint is formed by the overlapping of the sacrum and iliac bones of the pelvis.

Calcification and artifact

Densities that cannot be explained by anatomical structures are often seen on abdominal X-rays. These may be artifactual, for example due to medical devices, or due to soft tissue calcification.

This calcification may not be pathological, but differentiating significant calcification from that which can be ignored is not always straightforward. The clinical features must be considered whenever abnormal calcification is suspected. Other investigations may be required.

Key points Added densities may be due to artifact or calcified soft tissue

Calcification of soft tissues is not always clinically significant

Differentiating pathological from inconsequential calcification is not always straightforward

Navel jewellery artifact Ideally all jewellery that overlies anatomically important structures should be removed prior to acquiring an X-ray

Vascular calcification and ring pessary

If seen, vascular (aorto-iliac) calcification implies a more generalised atherosclerosis. Note the ring pessary in this elderly patient.

Calcified structures

There are multiple incidental and asymptomatic calcified structures seen on this X-ray. The patient is recovering from an appendicectomy (note surgical clips). Gallstones are seen only if calcified (20% are calcified). Costochondral calcification, calcified mesenteric lymph nodes, and phleboliths (calcified pelvic veins) are rarely clinically significant. Occasionally additional investigations are required to differentiate them from pathological calcium. For example phleboliths may be mistaken for ureteric calculi. Other investigations such as intravenous urogram (IVU) should only be performed if there are typical clinical features of ureteric calculi.

Residual contrast

The large areas of very high density seen in the descending colon and rectum are caused by residual contrast material in this patient who had a Barium enema 10 days previously. Also note costochondral calcification, and phleboliths.

Do not mistake the tips of the transverse processes for ureteric calculi.

Conclusion

A simple system for assessing an abdominal X-ray has been discussed. Although the clinical indications for performing an abdominal X-ray are few, and limited anatomical information can be gained, a knowledge of normal structures may help determine the site of pathology, and help avoid confusion. Remember to assess the bowel gas pattern, soft tissue structures, and bones, and check for abnormal calcification.

Tutorial key points

Check the patient details Assess quality

Systematically review bowel gas, soft tissues, bones and abnormal calcification