The Abdominal X-Ray

ABDOMINAL X-RAY
PROJECTIONS:

•Supine 99%
• Erect
• Lateral decubitus.

Knowledge of the anatomy of the abdomen

allows localization of the abnormalities
observed on the AXR.
FILM SPECIFICS AND TECHNICAL
FACTORS:
The initial assessment of an AXR is the same as
for a CXR:
Film Specifics:
• Name of Patient
• Age & Date of Birth
• Location of Patient
• Date Taken
• Film Number (if applicable)
Film Technical factors:
• Type of projection (Supine is standard)
• Markings of any special techniques used
ASSESS THE FILM IN
DETAIL:

A simple guide to interpretation is shown as

follows:
1. Dark Shadows - Air
2. White Shadows –Soft tissues, air,
3. Grey Shadows
4. Bright white Shadows
Anatomy on the Abdominal X-Ray:
Normal AXR
Liver T12 Gas in
11th stomac Splenic flexure
rib h
Psoas margin
Left kidney
Hepatic Transverse
flexure colon
Iliac Gas in
crest sigmoid
Gas in
caecum SI
joint
Bladd Femoral
er head
7. Sacrum
Gas pattern
What is normal?
 Stomach
 Almost always air in stomach
 Small bowel
 Usually small amount of air in
2 or 3 loops
 Large bowel
 Almost always air in rectum
and sigmoid
 Varying amount of gas in rest of large bowel
Normal fluid levels
 Stomach
 Always (upright, decub)

 Small bowel
 Two or three levels
acceptable (upright, decub)

 Large bowel
 None normally
(functions to remove fluid)
Large vs small bowel

 Large bowel
 Peripheral (except RUQ occupied by liver)
 Haustral markings don’t extend from wall to wall

 Small bowel
 Central
 Valvulae conniventes extend across lumen and are
spaced closer together
Radiographic principles

Series of films for acute abdomen

 Obstruction series/ Acute abdominal series/
Complete abdominal series

 Supine (almost always)

 Upright or left decubitus (almost always)
 Prone or lateral rectum (variable)
 Chest, upright or supine (variable)
 BLACK SHADOWES
‘BLACK SHADOWS’ = GASSES

 Intra-luminal gas can be normal.

• Extra-luminal gas is abnormal.

• However, intra-luminal gas can be abnormal if it is

in the wrong place or if too much is seen.
• The maximum normal diameter of the large bowel
is 55mm.
• Small bowel should be no more than 35mm in
diameter.
 Places to look for abnormal extra-
luminal gas

 Under the diaphragm

 In the biliary system
 Within the bowel wall
 Key to densities in Abdominal X
Ray

 Black: gas
 White: calcified structures
 Grey: soft tissues
 Darker grey: fat
 Intense white: metallic objects
Acute abdominal series
What to look for
VIEW LOOK FOR

SUPINE ABDOMEN Bowel gas pattern

Calcifications
Masses

PRONE ABDOMEN Gas in rectosigmoid

Gas in ascending and
descending colon
UPRIGHT ABDOMEN Free air, air-fluid levels

UPRIGHT CHEST Free air, lung pathology

secondary to intraabdominal
process

Substitutes: Prone Lateral rectum

Upright Left
lateral decub
Obtaining views
• Supine
– Patient on back, x ray beam directed
vertically downward, casette
posterior, x-ray tube anterior (AP)

• Prone
– Patient on abdomen, x-ray beam
directed vertically downward,
cassette anterior, x-ray tube posterior
(PA)

• Upright
– Patient stands or sits, x-ray beam
directed horizontally, cassette
posterior, x-ray tube anterior (AP)

• Upright chest
– Patient stands or sits, horizontal x-ray
beam, cassette anterior, x-ray tube
1900s X-Ray-based fluoroscopy
posterior (PA) machine in which radiation is shot
directly through the patient and
Abnormal Gas Patterns

 Functional ileus
 One or more bowel loops become aperistaltic
usually due to local irritation or inflammation
 Localised “sentinel loops” (one or two loops)
 Generalised (all loops of large and small bowel)

 Mechanical obstruction
 Intraluminal or extraluminal
 Small bowel obstruction
 Large bowel obstruction
3, 6, 9 RULE

Maximum Normal Diameter of bowel

Small bowel 3cm
Large bowel 6cm
Caecum 9cm
 Localised ileus
Key features
 One or two persistently
dilated loops of small or large
bowel (multiple views)
 Often air-fluid levels in
sentinel loops
 Local irritation, ileus in same
anatomical region as
pathology
 Gas in rectum or sigmoid
 May resemble early SBO
Causes of Localised Ileus
by location

SITE OF DILATED LOOPS CAUSE

Right upper quadrant Cholecystitis
Left upper quadrant Pancreatitis
Right lower quadrant Appendicitis
Left lower quadrant Diverticulitis
Mid-abdomen Ulcer or kidney/ureteric calculi
Colon cut off sign
Abrupt cutoff of colonic gas column at the splenic flexure (arrow).
The colon is usually decompressed beyond this point.
Explanation:

Inflammatory exudate in
acute pancreatitis extends
into the phrenicocolic
ligament via lateral
attachment of the transverse
mesocolon

Infiltration of the
phrenicocolic ligament
results in functional spasm
and/or mechanical
 Generalised ileus
Key features
 Entire bowel aperistaltic/hypoperistaltic
 Dilated small bowel and large bowel to rectum
(with LBO no gas in rectum/sigmoid)
 Long air-fluid levels

CAUSE REMARK

*Postoperative Usually abdominal surgery

Electrolyte imbalance Diabetic ketoacidosis

* almost always
 Generalised adynamic ileus

The large and

small bowel are
extensively
airfilled but not
dilated.

The large and

small bowel
"look the same".
Mechanical SBO

 Dilated small bowel

 Fighting loops (visible loops, lying

transversely, with air-fluid levels at different
levels)

 Little gas in colon, especially rectum

SBO Erect SBO Supine

Air fluid levels

Causes of Mechanical SBO

Adhesions
Hernia*
Malignancy
Gallstone ileus*
Intussesception
Inflammatory bowel disease

* May be visible on AXR

Step ladder appearance

 Loops arrange
themselves
from left upper
to right lower
quadrant in
distal SBO
Coil spring sign
 String of pearls sign

Considered diagnostic of obstruction (as opposed to ileus)

and is caused by small bubbles of air trapped in the
valvulae of the small bowel.
Closed loop obstruction

 Two points of same loop of bowel obstructed at

a single location
 Forms a C or a U shape
 Term applies to small bowel, usually caused by
adhesions
 Large bowel, called a volvulus
Crescent Sign

Caused by:

LUQ Soft tissue mass

OR

Head of intussusception in
distal transverse colon
 Double Bubble Sign

Duodenal
Atresia
Mechanical LBO
 Colon dilates from
point of obstruction
backwards

 Little/no air fluid levels

(colon reabsorbs water)

 Little or no air in
rectum/sigmoid
Large bowel obstruction

Bowel loops tend not to

overlap therefore possible
to identify site of
obstruction

Little or no gas in small

bowel if ileocaecal valve
remains competent*

* If incompetent, large bowel

decompresses into small bowel,
may look like SBO
Causes of Mechanical LBO

TUMOUR
VOLVULUS
HERNIA
DIVERTICULITIS
INTUSSUSCEPTION
 Note on volvulus
 Sigmoid colon has its own mesentry therefore
prone to twisting

 Caecum usually retroperitoneal and not prone to

twisting; 20% people have defect in peritoneum
that covers the caecum resulting in a mobile
caecum
Volvulus
A volvulus always extends away from the area of twist.
Sigmoid
volvulus can only move upwards and usually
goes to the right upper quadrant. Caecal volvulus
can go almost anywhere.
Coffee Bean Sign
Sigmoid volvulus

Massively
dilated
sigmoid
loop
Hernia

Lateral decubitus of value

The advantage is that there may be a greater chance of air
entering the herniated bowel because it is the least dependent
part of the bowel in the supine position.
 Apple core sign
 Radiologic manifestation of a
focal stricture of the bowel
usually at contrast material
enema examination. The
stricture demonstrates
shouldered margins and
resembles the core of an
apple that has been partially
eaten. The most common
cause is an annular
carcinoma of the colon.
Thumbprinting

The distance between

loops of bowel is
increased due to
thickening of the
bowel wall.

The haustral folds are

very thick, leading to a
sign known as
'thumbprinting.'
Lead pipe
colon
 Shortening of
colon secondary
to fibrosis
 Loss of
haustration
 Ulcerative colitis
 Extraluminal air
 TYPES
 Pneumoperitoneum/free air/intraperitoneal air

 Retroperintoneal air

 Air in the bowel wall (pneumatosis intestinalis)

 Air in the biliary system (pneumobilia)

Upright film best

 The patient should be positioned sitting

upright for 10-20 minutes prior to acquiring
the erect chest X-ray image.

 This allows any free intra-abdominal gas to

rise up, forming a crescent beneath the
diaphragm. It is said that as little as 1ml of
gas can be detected in this way.
Free Air
Causes
 Rupture of a hollow viscus
 Perforated peptic ulcer
 Trauma
 Perforated diverticulitis (usually seals off)
 Perforated carcinoma

 Post-op 5-7 days normal, should get less with successive

studies *NOT ruptured appendix (seals off)
Signs of free air

 Crescent sign
 Chilaiditis sign
 Riglers (and False Rigler’s)
 Football sign
 Falciform ligament sign
 Triangle sign
 Cupola sign
 Lesser sac sign
Crescent Sign II
Free air under the diaphragm

Best demonstrated
on upright chest x
rays or left lat
decub

Easier to see under

right diaphragm
 Chilaiditis sign
 May mimic air under
the diaphragm
 Look for haustral folds
 Get left lat decub to
confirm

In patients who have

cirrhosis or flattened
diaphragms due to lung
hyperinflation, a void is
created within the upper
abdomen above the liver.
This space may be filled
by bowel. If this bowel is
Rigler’s Sign
Bowel wall visualised on both sides due to intra and
extraluminal air
Usually large amounts of free air
May be confused with overlapping loops of bowel, confirm with
upright view
False Rigler’s Sign

 The Rigler sign can sometimes be simulated

by contiguous loops of bowel, whereby
intraluminal air in one loop of bowel may
appear to outline the wall of an adjacent loop,
which results in a misdiagnosis of free air.

 Measure distance of interface if unsure

Football SIgn

Seen with massive

pneumoperitoneum

Most often in
children with
necrotising
In supine
enterocolitis
position air
collects anterior
to abdominal
viscera
Paediatric Adult
Falciform ligament sign

Normally
invisible.

Supine film,
free air rises
over anterior
surface of
liver
Other patterns of air around
liver

Doge’s Cap
Sign
Inverted V sign

 On the supine radiograph, an inverted "V"

may be seen over the pelvis in a patient with
pneumoperitoneum.

 While in infants this is produced by the

umbilical arteries, in adults it appears to be
created by the inferior epigastric vessels
Continuous diaphragm sign

Sufficient
free air, left
and right
hemi-
diaphragms
appear
continous
 Lesser sac Sign
Cupola Sign
Lesser sac Cupola
sign sign
 (black – (white
arrows) arrows)
The lesser sac is
positioned posterior Air superior to
to the stomach and is left lobe of liver
usually a potential
space. There is free
connection between
the lesser sac and the
greater sac through
the foramen of
Winslow

Double Bubble Sign

Cupola Sign
Air beneath the central tendon of the
diaphragm

The term cupola comes from a dome such as

this famous dome of the Duomo in Florence.
Triangle Sign

 The triangle sign

refers to small
triangles of free gas
that can typically be
positioned between
the large bowel and
the flank
Retroperitoneal Air
 Recognised by:
 Streaky, linear appearance outlining retroperitoneal
structures
 Mottled, blotchy appearance
 Relatively fixed position
 May outline:
 Psoas muscles
 Kidneys, ureters, bladder
 Aorta or IVC
 Subphrenic spaces
Causes of retroperitoneal
air
 Bowel perforation (appendix, ileum, colon)
 Trauma (blunt or penetrating)
 Iatrogenic
 Foreign body
 Gas producing infection
Pneumoretroperitoneum

 This patient has free air in

the retroperitoneal space.
The air is seen surrounding
the lateral border of the
right kidney (white arrow).
There is other evidence of
free gas including Rigler's
sign.

 If you are not confident that

the appearance is
pneumoretroperitoneum,
you can try an erect and
decubitus view to see if the
gas moves. If the gas is seen
to move, it's not in the
retroperitoneum.
Air in the bowel
wall
 Signs

 Best seen in profile producing a linear lucency that

parallels the bowel

 Air en face has a mottled appearance resembling

gas mixed with faeculent material
Causes of air in bowel wall

 Primary Pneumatosis cystoides intestinalis (rare)

 usually affects left colon
 Produces cyst-like collections of air in the submucosa or serosa

 Secondary
 Diseases with bowel wall necrosis
 Obstructing lesions of the bowel that raise intraluminal pressure

 Complications
 Rupture into peritoneal cavity
 Dissection of air into portal venous system
 Pneumatosis intestinalis
 Intramural air,
best
appreciated in
profile
 Air in the biliary tree
 One or two tube-like branching lucencies in the
RUQ, conform to location of major bile ducts
Causes

 “Normal” if Sphincter of Oddi incompetence

 Previous surgery including sphincterotomy or
transplantation of CBD

 Pathology (uncommon)
 Gallstone ileus: gallstone erodes through wall of GB
into the duodenum producing a fistula between the
bowel and the biliary system.
 Stone impacts in small bowel = mechanical SBO.
“ileus” misnomer
Biliary vs Portal Venous Air

 Portal venous air

usually associated
with bowel
necrosis

 Air is peripheral
rather than central

 Numerous
branching
structures
Soft tissue masses
 Organomegaly
 Know normal landmarks

2 ways to identify soft tissue masses/organs:

 Direct visualisation of edges of structure

 Indirect by displacement of bowel

CT, US and MRI have essentially replaced

conventional radiography in the assessment of
organomegaly and soft tissue masses
Abdominal
Calcifications
Location
Pattern
First exclude artefact

Kim Kardashian’s butt – real or artefact?

Location
 Vascular
 Liver
 Gallbladder
 Spleen
 Pancreas
 Lymph nodes
 Adrenals
 Kidneys
 Ureters
 Bladder
 Prostate
 Rim-like
 Calcification that has occurred in the wall of a
hollow viscus

 Cysts
 renal, splenic, hepatic
 Aneurysms
 aortic, splenic, renal artery
 Saccular organs
 Gallbladder
 Urinary bladder

Calcified hydatid
cysts
Linear/Track

 Calcification in walls of tubular structures

Aortoiliac calcification
 Arteries
 Fallopian tubes
 Vas deferens
 Ureter
Chinese Dragon Sign

Calcified splenic
artery
Calcified vas deferens
Floccular, Amorphous,
Popcorn
 Formed in solid organ or tumour
 Pancreas (chronic pancreatitis)
 Leiomyomas of uterus
 Ovarian cystadenomas
 Lymph nodes
 Adenocarcinomas of stomach, ovary, colon
 Metastases
 Soft tissue (previous trauma, crystal deposition)
 Calcified
Calcified
fibroids
enteric
lymph nodes

Calcified
pancreas

Floccular
Lamellar or laminar

 Formed around a nidus inside hollow lumen

 Concentric layers due to prolonged

movement of stone inside hollow viscus
 Renal stones
 Gallstones
 Bladder stones
Bladder calculi

Lamellar
Renal calculi
Pelvicalyceal calcifications
Staghorn Calcification

Renal stones are often small, but if

large can fill the renal pelvis or a
Tubular calyx, taking on its shape which is
likened to a staghorn.
Renal calculi
Parenchymal calcification

Nephrocalcinosis

Uncommonly the renal

parenchyma can become
calcified.

This is known as
nephrocalcinosis, a
condition found in
disease entities such as
medullary sponge
kidney or Flocculent
hyperparathyroidism.
 Putty Kidney
 "Putty kidney" –
sacs of casseous,
necrotic material
(TB)
 Autonephrectomy
– small, shrunken
kidney with
dystrophic
calcification
Flocculent
Calcified gallstones

Lamellar
Conclusion

 Approach to AXR should include gas pattern,

extraluminal air, soft tissue and calcifications

 Named radiological signs are a useful way of

remembering, identifying and reporting on
films
 References
 Herring, W. Learning Radiology 2nd Ed, 2012
 Begg, J. Abdominal X-rays Made Easy, 1999
 http://www.wikiradiography.com
 http://www.radiopaedia.org
 http://www.imagingconsult.com
 Roche, C et al. Radiographics: Selections from the buffet of food signs in Radiology. Nov 2002, RG, 22,
1369-1384
 Young, L. Radiology Cases in Paediatric Emergency Medicine. Vol 1 Ca 2. The Target, Crescent and
Absent Liver Edge Signs.
 Raymond, B et al. Radiographics: Classic signs in uroradiology. RSN 2004
 http://www.swansea-radiology.co.uk Radiology Teaching Site. Introduction to abdominal radiography
 Mussin, R. Postgrad Med J 2011: 87:274-287. Gas patterns on plain abdominal radiographs
 http://www.radiologymasterclass.co.uk/tutorials/abdo/abdo_x-ray_abnormalities
 Mettler: Essentials of Radiology, 2nd Ed, 2005
 http://www.learningradiology.com/radsigns
 Muharram Food signs in radiology. International Journal of Health Sciences Vol 1 No 1. Jan 2007.
THANK YOU
ABDOMINAL X-RAYS:

AXR-3 AXR-4
Small Bowel
 Large bowel

• Colon with barium contrast

Small bowel
Large bowel
Small bowel
Barium meal, stomach, duodenum and jejunum
Assess the Film in Detail:

 Intra-luminal Gas:
 Low Small Bowel Obstruction
 Assess the Film in Detail:

 If bowel obstruction is
observed try to look for
the cause . For example
a hernia as the cause of
obstruction.

Hernia
 Assess the Film in Detail:
 Extra-luminal Gas:
When bowel becomes obstructed, or
any other gas containing structure
perforates , its contain gas becomes
extra-luminal. Extra-luminal gas is
never normal , but may be seen
following intra-abdominal surgery or
endoscopic retrograde cholangio -
pancreatography (ERCP). Extra-luminal gas
seen on erect CXR.
 Causes of Extra-luminal gas:
1. Post Abdominal Surgery/ERCP
2. Perforation of viscous (e.g.. bowel, stomach)
3. Gallstone ileus
4. Cholangitis ( infection with gas forming
organisms)
5. Abscess

 An erect CXR (not AXR) is the best projection

to diagnose a pneumoperitoneum (gas in
the peritoneal cavity).
 WHITE SHADOWS :
WHITE SHADOWS’ = Calcification
Calcified structures are often seen on AXR. The main
question is – does its presence have any important
implications. Calcification can be broadly divided into 3 types:
(1) Calcium that is an abnormal structure - eg. gallstones and
renal calculi
(2) Calcium that is within a normal structure, but represents
pathology - eg. nephrocalcinosis,
(3) Calcium that is within a normal structure, but is harmless -
eg. lymph node calcification.

Bones are normal ‘white’ structures. On the AXR they

comprise mainly those of the thoraco-lumbar spine and pelvis.
Findings are largely incidental as direct bone pathology would
be investigated with specific views.
Renal Stones
Renal Stones
STAGES OF HYDRONEPHROSIS
HYDRONEPHROSIS AND
HYDROURETER
Kidneys ureters and stones
NORMAL IVU
HYDRONEPHROSIS
HYDRONEPHROSIS
 RENAL STONES
Pancreatic Calcification
Splenomegaly
Psoas muscle
Psoas muscle
Psoas Abscess
Hernia
FINALS RADIOLOGY CASES:
ABDOMINAL X-RAY
CASE 1:

This 67 year-old women

presented to the surgical
ward with a distended
abdomen and vomiting.
Present this x-ray
Give a diagnosis and
potential causes
 CASE 1: ANSWER
Radiology Report:
Plain abdominal radiograph.
Multiple dilated loops of small bowel within
the central abdomen. Gas is not seen in the
large bowel. No evidence of hernia or
gallstone to suggest potential cause of
the dilated loops.
These findings are in keep with a low small
bowel obstruction.
I would like to know if the patient has a
history of abdominal surgery as the
commonest cause is surgical
admissions.

The three commonest causes of small bowel obstruction are:

• Surgical adhesions
• Herniae
• Intraluminal mass eg, small bowel lymphoma or gallstone (in gallstone
ileus)
CASE 2:

This 71 year-old gentleman

visits his GP complaining of
in his urine. He has had a
number of UTI’s in recent
years.

Present this x-ray

Give a diagnosis and

potential causes
 CASE 2: ANSWER
Radiology Report:
Plain abdominal radiograph.
Two rounded radio-opacities
measuring 4cm within the pelvis. Both
opacities are smooth in outline,
laminated in nature, have the same
density as bone and project over the
bladder . No other renal tract calcification.
Does the patient have a history of
neurogenic bladder?
Given the size of these stones and history
of UTI’s these are bladder calculi.
Bladder calculi are more common in those with a history of:
•UTI’s
•A neurogenic bladder
•Bladder diverticulum
CASE 3:

This patient was

admitted with poor renal
function.

Present this x-ray

Give a diagnosis and

potential causes
CASE 3: ANSWER

Radiology Report:
Plain abdominal radiograph
Multiple areas of punctuate
calcification project over the renal
outlines bilaterally.
The calcification is within the medulla
of the renal parenchyma. The bones
are normal in appearance.
These findings are consistent with
nephrocalcinosis
Causes of Nephrocalcinosis include:
• Hyperparathyroidism
•Medullary sponge kidney
Systematic approach to viewing an
abdominal film:
1. Start by identifying the name on the film
and the date.
2. What is the projection of the film? Is if PA or
AP? Most are PA.
3. Is the view Supine, Erect or Lateral
Decubitus? Are there erect and supine
films? If so decide which is which.
4. Confirm that an adequate area has been
covered.
5. Check exposure. If the spine is visible most
structures to be seen will be visible.
6. Artefacts may be immediately obvious.
Piercing of the umbilicus is very popular,
especially in young women but genital
piercing is not infrequent. Metallic objects
are obvious. There may be clips or materials
from previous surgery. Occasionally a
retained surgical instrument is seen. Swabs
contain a radio-opaque band.
Solid organs, hollow organs and
bones can be classified as:
 Visible or not visible
 Normal in size, enlarged, or too small
 Distorted or displaced
 Abnormally calcified
 Containing abnormal gas, fluid, or discrete
calculi
Bones Look in a specific order and
keep to your regime:
 Lower Rib Cage
 Lumbar Spine
 Sacrum
 Pelvis
 Hip Joints
Normal Calcification

* Costal cartilage
* Mesenteric lymph nodes
* Pelvic vein phleboliths
* Prostate gland
Abnormal calcification Calcium indicates
pathology in
* Pancreas
* Renal parenchymal tissue
* Blood vessels and vascular aneurysms
* Gallbladder fibroids (leiomyoma)
Calcium is the pathology in

* Biliary calculi
* Renal calculi
* Appendicolith
* Bladder calculi
* Teratoma
• Mesenteric lymph nodes may calcify and
be confused with ureteric calculi. They are
usually oval in shape . The line of the
ureter is along the transverse processes of
the lumbar vertebrae . Phleboliths from
calcified pelvic veins may appear like
bladder stones. Calcification may appear in
the ageing prostate , low down in the
pelvic brim. Prostate calcification may also
occur in malignancy but it is not
diagnostic.
• The pancreas lies at the level of the T9 to T 12
vertebrae . Calcification occurs in chronic
pancreatitis and may show the whole outline
of the gland.
• Between the levels of T12 and L2,
nephrocalcinosis may be seen. Calcification of
the renal parenchyma indicates pathology
including hyperparathyroidism, renal tubular
acidosis, and medullary sponge kidney.
• Renal calculi tend to obstruct at certain sites,
especially the pelviureteric junction, brim of
the pelvis, and vesicoureteric junctions.
• Calcification of blood vessels usually affects
the arteries and can be quite striking. The
whole vessel may be outlined by calcium.
Extensive calcification may indicate
widespread atheroma, especially in diabetes.
• Abdominal aortic aneurysms are usually
below the 2nd lumbar vertebra. Calcification
may make them obvious and can give a rough
indication of the internal diameter.
• Abdominal ultrasound is required for
accurate assessment , and to determine the
need for surgery or follow up.
• Gallstones are visible in only 10 to 20% of
cases. Ultrasound is vastly superior but
plain abdominal x-ray is often the initial
investigation in patients with abdominal
pain . The gallbladder may become
calcified after repeated episodes of
cholecystitis . This is called a porcelain
gallbladder and 11% will become
malignant11.
 In the pelvic region bladder calculi may
occasionally be seen. Bladder stones are
usually quite large and often multiple.
Calcification of a bladder tumor may also
occur . Schistosomiasis may produce
calcification of the bladder wall.
 Uterine fibroids can become calcified
 Sometimes ovarian teratoma may show a
tooth. This is of passing interest although
such an ovarian tumour can undergo
torsion
Systematic approach to viewing an
abdominal film with contrast:
• When we examine x.ray abdomen
with contrast the following steps should
followed:
1. Which organ is examined?
2. Which type of contrast?
3. Is there a pathology or not?
4. The position and view of examiantion?
Types of contrast examinations

1. Esophagus
2. Stomach
3. Small intestine
4. Large intestine
5. Kidney, ureters and urinary bladder
Contrast examination of the
esophagus
 Barium swallow
 We see if there is
narrowing or
dilatation .
 if there is filling
defect in the
lumen of
esophagus.
 We see if contrast reached the stomach
Contrast examination of stomach
 We see if contrast reached the stomach and
fill it completely.
 We check contrast and air in the stomach to
detect the position of the patient during
examination.
 We see the wall of the stomach if the is
ulcer or tumor.
 There are two types of contrast positive and
negative we identify them. We see whether
the exam is with double or single contrast.
Ba meal with double contrast

Patient is in supine position

Ba meal with single contrast
Gass in the fandus
Narrowing in the stomach

Patient is standing
Ulcer in the wall of the stomach
Barium meal with single and double contrast in
prone position
Barium meal and follow through
 The patient drinks a contrast medium
containing barium sulfate.
 X-ray images are taken as the contrast
moves through the intestine, commonly at
0 minutes, 20 minutes, 40 minutes and 90
minutes.
Barium meal and follow through
Barium meal and follow through
Barium meal and follow through

 Crohn 's disease of distal ileum with stricturing and

sacculation on the antimesenteric aspect ( curved
arrows), and fissure ulcers ( small arrows ). Open arrow
points to ileo-caecal valve.
Barium meal and follow through

 Aphthoid ulceration of terminal ileum (small arrows)-

Note also "cobblestoning" (larger arrows).
Barium meal and follow through

• Chronic ileocaecal tuberculosis. The caecum and

ascending colon are retracted craniad and are fibrotic .
scarred and saccilated (curved arrows). The terminal ileum
in this patient is relatively patulous (straight arrows) and
probably nodular. v=ileocaecal valve.
 Small Bowel Enema

 Enteroclysis examination demonstrates a segment

of ileum in the right iliac fossa with wall
thickening, destruction of the normal fold pattern
and aneurysmal ulceration (arrowed) and mass effect
 Small Bowel Enema

 Multiple moderate-sized and large diverticula

present.
Barium Enema
 Plain x-ray abdomen (erect film) showing multiple air fluid
levels in the loops of jejunum due to small gut
obstruction.
 Plain x-ray abdomen showing marked dilatation
of the large gut from caecum to splenic flexure
due to large gut obstruction.
 Plain x-ray abdomen showing dilatation of
large gut due to twisted and obstructed
caecum and ascending colon due to volvulus
of caecum
 Plain x-ray abdomen showing air fluid level
under the right dome of diaphragm due to
presence of gas in the right subphrenic abscess
Surgical Clips
Extra-luminal gas seen on erect CXR.
 renal calculi

„80% radioopaque
 „ca2+ oxalate,
phosphate
 „struvite
 „20% radiolucent
 „uric acid (+ve on CT)
 „cystine (+ve on CT)
 „HIV indinavir (-ve on
CT)
 LBO
 „Colorectal Carcinoma
 „Diverticular Stricture
 „Volvulus
 „Hernias
 colitis
 thumbprinting
 „bowel wall edema
 „DDx (4 I’s)
 „ischemia
 „infectious colitis „
 „inflammatory
(UC/IBD)
 „Infiltrative (ie:
lymphoma)
 „other: edema, Rn,
tumor, hemorrhage
Ct scan of portal venous gas
 sigmoid volvulus „flips into RUQ
 „midline crease – mesenteric vessels
 cecal volvulus
 cecal volvulus
flips into LUQ „
kidney bean
shaped
 „midline crease –
mesenteric
vessels
 c„ ecal volvulus
coffee bean