VOLUME 10April 2002
The abdominal radiograph is one of themost commonly requested images, and allmedical students should have a knowledgeof common radiological interpretations. This article covers the radiology of normalfindings. Subsequent parts of the series willcover abnormal intraluminal gas, abnormalextraluminal gas, calcification, bone andsoft tissue abnormalities, and iatrogenic,accidental, and incidental objects. The standard abdominal radiograph(AXR) taken is a supine projection:
raysare passed from front to back (anteroposte-rior projection) of a patient lying down onhis or her back. In some circumstances anerect AXR is requested: its advantage over asupine film is the visualisation of air-fluid lev-els. A decubitus film (patient lying on his or her side) is also of use in certain situations. Although an AXR is a plain radiograph, it has a radiation dose equivalent to 50 pos-teroanterior chest
rays or six months of standard background radiation. As with any plain radiograph, only fivemain densities are seen, four of which arenatural: black for gas, white for calcifiedstructures, grey representing a host of soft tissue with a slightly darker grey for fat (as it absorbs slightly fewer
rays). Metallic objectsare seen as an intense bright white. The clar-ity of outlines of structures depends, there-fore, on the differences between thesedensities. On the chest radiograph, this iseasily shown by the contrast between lung and ribs—black air against the white calciumcontaining bones. These differences aremuch less apparent on the AXR as most structures are of similar density—mainly soft tissue.
It is important, as with any image, that thetechnical details of an AXR are assessed. The date the film was taken and the name,age, and sex of the patient are all worth not-ing. This ensures you are interpreting thecorrect film with the correct clinical infor-mation and it also may aid your interpreta-tion. You would be a little concerned if yousaw what appeared to be a calcified fibroidon an AXR when holding the notes of Mr John Brown.Next ask what type of AXR is it: supine,erect, or decubitus? Unless specificallylabelled the film is taken to be supine. The best way to appreciate normality is tolook at as many films as possible, with anawareness of anatomy in mind (fig 1).
Begin by looking at the amount and distri- bution of gas in the bowels (intraluminalgas). There is considerable normal variationin distribution of bowel gas. On the erect AXR, the gastric gas bubble in the left upper quadrant of the film is a normal find-ing. Gas is also normally seen within thelarge bowel, most notably the transversecolon and rectum (fig 2).Importantcharacteristicsofbowelloopsto bearinmindaretheirsizeanddistribution(wheretheyaresituatedinrelationtoother structures).Normalsmallbowelshouldmeas-urelessthan3cmindiameter,whereasnor-malcolonshouldmeasurelessthan5cmindiameter.Thediameterofthecaecummaybegreater,butifitisgreaterthan9cmitisabnor-mal.Largebowelshouldlieattheperipheryofthefilm,withsmallboweldistributedcen-trally.Smallandlargebowelcanalsobedistin-guished,mosteasilywhendilated,bytheir differentmucosalmarkings.Smallbowelhas valvulaeconniventesthattransversethefull widthofthebowel;largebowelhashaustrathatcrossonlypartofthebowelwall(figs3and4).Thesefeaturesareimportantinthenextpartofthisseries,whichconsidersabnor-malintraluminalgas.Occasionally,fluidlevelsinthesmallbowelareanormalfinding.
Faecal matter in the bowel gives a “mot-tled” appearance (fig 5). This is seen as amixture of grey densities representing a gas-liquid-solid mixture.
Gas outside the bowel lumen is invariablyabnormal. The largest volume of gas youmight see is likely to be under the right diaphragm: this occurs after a viscus has
rays made easy:normal radiographs
Figure 1. Normal filmFigure 2. Rectal gas filmFigure 3. Valvulae conniventes
ray films is something that all clinical studentsshould get to grips with. Starting out as a doctor, you will not needto be an expert but you will need to know the basics.
present the first part of a new series on interpretingplain abdominal radiographs