PLAIN ABDOMINAL FILMS

The supine abdominal film

The erect chest film
The horizontal-ray abdominal
film:
- Erect
- Left lateral decubitus

The supine abdomen film

Include the diaphragm & the hernial orifices
Asses:
- The preperitoneal fat line:
Blurring of the preperitoneal fat line e.g.
inflammatory
- The psoas outlines:
Obliteration of psoas outlines e.g.
fluid/inflammatory exudate
- Distribution of gas
- The calibre of bowel :
N: Calibre of small bowel is 2.5 cm & colon is 5
cm.
- The thickened of bowel wall
- Displacement of bowel by soft-tissue masses.
- Calculus

Normal Gas Pattern

Stomach
Always

Small Bowel
Two or three loops of nondistended bowel
Normal diameter = 2.5 cm

Large Bowel
In rectum or sigmoid almost
always

Gas in
stomach

Gas in a
few loops
of small
bowel

Gas in
rectum or
sigmoid

Normal Gas Pattern

Normal Fluid Levels

Stomach
Always (except supine film)

Small Bowel
Two or three levels possible

Large Bowel
None normally

Always
air/fluid
level in
stomach

A few
air/fluid
levels in
small
bowel

Erect Abdomen

Large vs. Small Bowel

Large Bowel
Peripheral
Haustral markings don't
extend from wall to wall

Small Bowel
Central
Valvulae extend across
lumen

The erect chest film

The erect chest film can assess :
Small pneumoperitoneum.
Chest conditions may mimic an acute
abdomen.
Acute abdominal conditions may be
complicated by chest pathology,
e.g. pleural effusion frequently
complicate
acute pancreatitis, etc.
8

The erect chest film

Erect
The patients should be in position
for
10 min before the film is taken.
Radiological findings:
- free gas beneath the diaphragm
- chest abnormality

The horizontal-ray abdominal

film
Erect & left lateral decubitus.
The patients should be in position for
10 min before the film is taken.
Radiological findings:
fluid levels & free gas

10

ACUTE ABDOMEN

Perforation
Intestinal obstruction
Paralytic ileus
Acute colitis
Intraperitoneal fluid
Inflammatory conditions
Calcification associated with acute
abdominal conditions
11

Abnormal Gas Patterns

Functional Ileus
Localized (Sentinel Loops)
Generalized adynamic ileus

Mechanical Obstruction
SBO
LBO

Localized Ileus
Key Features

One or two persistently dilated

loops of large or small bowel
Gas in rectum or sigmoid

Supine

Sentinel Loops/Localized ileus

Prone

Cholecystitis

Appendicitis

Sentinel
Loops

Pancreatitis
Ulcer

Diverticulitis
Ulcer
Ureteral
calculus

Localized Ileus
Pitfalls

May resemble
early mechanical
SBO
Clinical course
Get follow-up

Generalized Ileus
Key Features

Gas in dilated small bowel and

large bowel to rectum
Bowel wall Thickening
Long air-fluid levels
Only post-op patients have
generalized ileus

Supine

Generalized Adynamic Ileus

Erect

Ileus Paralitik
20

Is It An Ileus?
Is the patient immediately postop?
Are the bowel sounds absent or
hypoactive?
If no, then it isnt an ileus

Mechanical SBO
Key Features

Dilated small bowel

Bowel wall Thickening
Little gas in colon, especially
rectum
Key: disproportionate dilatation of
SB

SBO

Mechanical SBO
Causes

Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception

Mechanical SBO
Pitfalls

Early SBO may

resemble
localized ileus

Mechanical LBO
Key Features

Dilated colon to point of

obstruction
Multiple air fluid level=Step
Ladder
Herring Bone appearances
Little or no air in rectum/sigmoid
Little or no gas in small bowel,

Ileocecal valve remains competent

Gambaran Step Ladder

27

Ileus Obstruksi

28

Supine

Prone

Large Bowel Obstruction

Mechanical LBO
Causes

Tumor
Volvulus
Hernia
Diverticulitis
Intussusceptio
n

Mechanical LBO
Pitfalls

Incompetent ileocecal valve

Large bowel decompresses into
small bowel
May look like SBO
Follow-up

Supine

Prone

Carcinoma of Sigmoid : Large Bowel Decompressed into

Small Bowel

Air in
biliary
tree

SBO

Gallstone

Gallstone Ileus

Sigmoid Volvulus

Extraluminal Air
Free Intraperitoneal Air

Signs of Free Air

Air beneath diaphragm
Both sides of bowel wall
Falciform ligament sign

Crescent
sign

Free Intraperitoneal Air

Air on both sides

of bowel wall

Riglers Sign

Free Intraperitoneal Air

Football
sign
Free Intraperitoneal Air

Free Air
Causes

Rupture of a hollow viscus

Perforated ulcer
Perforated diverticulitis
Perforated carcinoma
Trauma or instrumentation

Post-op 57 days
NOT perforated appendix

Extraperitoneal Air

PERFORATION
PNEUMOPERITONEUM

Require emergency surgery!

Small pneumoperitoneum (I ml of free
gas)
erect chest/LLD abdominal films.

43

Small pneumoperitoneum

44

Pneumoperitoneum

45

Pneumoperitoneum

46

INTESTINAL OBSTRUCTION
= Dilated loops of bowel proximally
with
non-dilated/collapsed bowel distal to
the presumed point of obstruction.

Gastric Dilatation:

Etiology:
- Mechanical gastric outlet obstruction
- Paralytic ileus
- Gastric volvulus
- Air swallowing
47

Gastric Dilatation

48

Small-Bowel Obstruction:
Etiology:
- Adhesions due to previous surgery
- Strangulated hernias
- Volvulus
- Gallstone ileus
- Intussusception
- Neoplastic, etc.

49

 Radiological appearances:

Plain film changes appear after 3-5 h

(marked after 12 h) (complete
obstruction).
Supine film:
- Small-bowel dilatation with
accumulation
of both gas & fluid.
- A reduction in calibre of the large
bowel.

50

Small-Bowel Obstruction
due to adhesion

Multiple dilated loops of small

bowel

Multiple fluid levels on erect

film
51

Small-Bowel Obstruction
due to gallstone ileus
Multiple dilated loops of
small bowel are seen. A band
of
gas
in
the
right
hypochondrium lies within
the common bile duct.

52

Small-Bowel Obstruction
due to Intussusception

A crescent of air at the apex of an

intussusception
53

 Erect film:
- Multiple fluid levels (Stepladder pattern
- String of beads sign
= small bubbles of gas may be trapped
in rows between the valvulae
conniventes.

54

Stepladder pattern in mechanical

obstruction of the small bowel

55

Small-Bowel Obstruction:
String of beads sign

56

 Ultrasound:
- Dilated fluid-filled loops of small-bowel
obstruction.
- Assessment of the peristaltic activity.

57

 CT:

* CT should be performed whenever

there is a history of previous abd.
malignancy.
* Radiological appearances:
- Bowel calibre change
- Fluid-filled loops
- The level of obstruction
- Peritoneal adhesions

58

LARGE-BOWEL
OBSTRUCTION
Etiology:
- Neoplastic (benign & malignant)
- Volvulus (caecal & sigmoid), etc.
Radiological appearances:
Depends on the state of competence
of the ileocaecal valve:

59

LARGE-BOWEL OBSTRUCTION
due to Sigmoid Volvulus
The hugely dilated ahaustral
loop of sigmoid can be seen
rising out of the pelvis in the
shape of an inverted U.
Haustrated
ascending
&
descending colon separate
from the volved sigmoid loop.

60

LARGE-BOWEL OBSTRUCTION
due to Caecal Volvulus
Distended caecum with its
haustral markings is lying
low in the central abdomen.
There is no significant smallbowel distention.

61

PARALYTIC ILEUS
Generalised paralytic ileus:
Etiology:
- Peritonitis
- Post-operative
- Hypokalaemia
- General debility or infection
- Drugs: morphine
- Congestive cardiac failure, renal colic,
etc.
Radiological appearances:
- Both small & large-bowel dilatation
- Horizontal-ray films: multiple fluid
levels
62

PARALYTIC ILEUS
There
is
generalised
dilatation of both
small
&
large
bowel.

63

Localised ileus:
Etiology:
- Local inflammatory processes:
pancreatitis, cholecystitis, appendicitis, salpingitis
- Trauma:
spine, ribs, hip, retroperitoneum
- Renal colic, etc.
Radiological appearances:
- Non specific (Mimic small/large-bowel obstruction).
- Dilatation of one/two adjacent loops of bowel.

64

Toxic megacolon
A fulminating form of colitis with transmural
inflammation, extensive & deep ulceration &
neuromuscular degeneration.
Involve the transverse colon
Ro. Findings:
Mucosal islands (=pseudopolyps) & dilatation (8
cm)
Common complication:
Perforation in the sigmoid & peritonitis

65

Toxic megacolon

66

INFLAMMATORY
CONDITIONS
Appendicitis
Acute cholecystitis
Emphysematous
cholecystitis
Acute pancreatitis

67

Appendicitis
Signs of acute appendicitis:

- Appendix calculus (0.5-6cm)

- Localised paralytic ileus in RLQ
- Sentinel loop-dilated atonic ileum
containing
a fluid level
- Widening of the preperitoneal fat line
- Blurring of the preperitoneal fat line
- Blurring of the right psoas outlineunreliable
cont

68

Appendicitis
- Scoliosis concave to the right
- Dilated caecum
- Right lower quadrant (RLQ) mass
identing
the caecum on its medial border (abscess
formation)
- RLQ haze due to fluid & oedema
- Gas in the appendix-rare, unreliable.
69

Small bowel obstruction due to

Appendix abscess
Appendix
causing
obstruction.

abscess
small-bowel

A small gas bubble which

lies within the abscess is
seen in the right iliac
fossa.

70

Ultrasound signs of acute

appendicitis :
- Blind-ending tubular structure at the
point
of tenderness:
Non-compressible
Diameter 7 mm
No peristalsis
- Appendicolith casting acoustic shadow
- Surrounding fluid/abscess

71

Acute appendicitis

72

Acute appendicitis

Acute appendicitis with appendicolith.

Abscess formation & appendicolith.

73

Acute cholecystitis
Plain abdominal film:
- Gallstones seen in 20%
- Duodenal ileus
- Ileus of hepatic flexure of colon
- Right hypochondrial mass due to
enlarged
gallbladder
- Gas within the biliary system
- Normal plain films in two-thirds of cases
74

Ultrasound imaging:
- A circumferential halo of low
echogenicity
with thickening of the gallbladder
wall
(8-10mm) in fasting state.
- Indistinct contour to the gallbladder
wall
- Fluid around the fundus of the
gallbladder
- Gallstones casting acoustic shadow
- A distended gallbladder (a stone
obstructing
the cystic duct)
- Echogenic sediment in the lumen
- Positive sonographic Murphy sign

75

Acute cholecystitis

76

CHRONIC CHOLECYSTITIS
Ultrasound imaging:
- A contracted gallbladder
- Sometimes, obliteration of the lumen
- Thickening of the gallbladder wall &
strongly
reflective
- Cholelithiasis

77

CHRONIC CHOLECYSTITIS

78

Acute pancreatitis
Plain chest film:
- A left side pleural effusion
- Basal parenchymal shadowing
- Elevated left hemidiaphragm-unreliable
Plain abdominal film:
- Normal plain films in two-thirds of cases
- Duodenal ileus
Gas in a dilated duodenal loop in the LLD
- A gasless abdomen due to vomiting
cont

79

Acute pancreatitis
- Generalised paralytic ileus
- Dilated loops of bowel (small bowel,
terminal
ileum, ascending & transverse colon)
- Loss of the psoas outline
- Multiple small bubbles within the
pancreas
(pancreatic abscess)
- Pancreatic calcification-unreliable
80

 Ultrasound signs of acute pancreatitis:

- Contours: smooth & well delineated
- Enlargement
- Echotexture: heterogeneous, hypoechoic to
anechoic
& less echogenic than the liver
- Associated signs: venous compression, pleural
effusion, ascites, duodenal
atony

81

ACUTE PANCREATITIS

82

 CT signs of acute pancreatitis:

- Necrosis, haemorrhage, & solid parenchyma

that
enhances with i.v.contrast medium
- Abscess
- Pancreatic pseudocyst
- Extrapancreatic fluid collection
- Ascites

83