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Abdominal x rays made easy

normal radiographs
Understanding x ray films is something that all clinical students
should get to grips with. Starting out as a doctor, you will not need
to be an expert but you will need to know the basics. Ian Bickle
and Barry Kelly present the first part of a new series on interpreting
plain abdominal radiographs

The abdominal radiograph is one of the large bowel, most notably the transverse
most commonly requested images, and all colon and rectum (fig 2).
medical students should have a knowledge Important characteristics of bowel loops to
of common radiological interpretations. bear in mind are their size and distribution
This article covers the radiology of normal (where they are situated in relation to other
findings. Subsequent parts of the series will structures). Normal small bowel should meas-
cover abnormal intraluminal gas, abnormal ure less than 3 cm in diameter, whereas nor-
extraluminal gas, calcification, bone and mal colon should measure less than 5 cm in
soft tissue abnormalities, and iatrogenic, diameter. The diameter of the caecum may be
accidental, and incidental objects.
The standard abdominal radiograph
(AXR) taken is a supine projection: x rays
are passed from front to back (anteroposte-
rior projection) of a patient lying down on
his or her back. In some circumstances an
erect AXR is requested: its advantage over a
supine 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 x rays or six months of
standard background radiation. Figure 1. Normal film
As with any plain radiograph, only five
main densities are seen, four of which are
natural: black for gas, white for calcified erect, or decubitus? Unless specifically
structures, grey representing a host of soft labelled the film is taken to be supine. Figure 3. Valvulae conniventes
tissue with a slightly darker grey for fat (as it The best way to appreciate normality is to
absorbs slightly fewer x rays). Metallic objects look at as many films as possible, with an
are seen as an intense bright white. The clar- awareness of anatomy in mind (fig 1). greater, but if it is greater than 9 cm it is abnor-
ity of outlines of structures depends, there- mal. Large bowel should lie at the periphery
fore, on the differences between these of the film, with small bowel distributed cen-
densities. On the chest radiograph, this is Intraluminal gas trally. Small and large bowel can also be distin-
easily shown by the contrast between lung Begin by looking at the amount and distri- guished, most easily when dilated, by their
and ribs—black air against the white calcium bution of gas in the bowels (intraluminal different mucosal markings. Small bowel has
containing bones. These differences are gas). There is considerable normal variation valvulae conniventes that transverse the full
much less apparent on the AXR as most in distribution of bowel gas. On the erect width of the bowel; large bowel has haustra
structures are of similar density—mainly soft that cross only part of the bowel wall (figs 3
tissue. and 4). These features are important in the
next part of this series, which considers abnor-
mal intraluminal gas. Occasionally, fluid levels
Technical features in the small bowel are a normal finding.Valvu-
It is important, as with any image, that the lae conniventes and haustra films
technical details of an AXR are assessed. Faecal matter in the bowel gives a “mot-
The date the film was taken and the name, tled” appearance (fig 5). This is seen as a
age, and sex of the patient are all worth not- mixture of grey densities representing a gas-
ing. This ensures you are interpreting the liquid-solid mixture.
correct film with the correct clinical infor-
mation and it also may aid your interpreta- Figure 2. Rectal gas film
tion. You would be a little concerned if you Extraluminal gas
saw what appeared to be a calcified fibroid Gas outside the bowel lumen is invariably
on an AXR when holding the notes of Mr AXR, the gastric gas bubble in the left abnormal. The largest volume of gas you
John Brown. upper quadrant of the film is a normal find- might see is likely to be under the right
Next ask what type of AXR is it: supine, ing. Gas is also normally seen within the diaphragm: this occurs after a viscus has

102 STUDENT BMJ VOLUME 10 April 2002
Key to densities in AXRs
● Black—gas
● White—calcified structures
● Grey—soft tissues
● Darker grey—fat
● Intense white—metallic objects

appearance of what looks like a soft tissue
mass in the region of the stomach is more
often than not actually a gastric pseudotu-
mour. This is a normal finding on the supine
film and represents gastric fluid lying within
the fundus (fig 6).
The assessment of bones entails evaluat-
ing the spine and pelvis for evidence of bony
pathology. Osteoarthritis frequently affects
the vertebral bodies, as well as the femoral
and the acetabular components of the hip
Figure 4. Haustra films Figure 5. Faecal mottling joint. Paget’s disease may also be identified,
commonly along the iliopectineal lines of
the pelvis. Your bone survey should also
Presenting the AXR Places to look for abnormal check for fractures, especially subtle femoral
neck fractures in elderly people. The spine
This is the supine abdominal radiograph extraluminal gas
and pelvis are also common locations for
of a 42 year old women taken yesterday. ● Under the diaphragm metastatic deposits. In the spine this is classi-
It is technically satisfactory. The amount ● In the biliary system cally seen as “the absent pedicle.”
and distribution of gas within the bowel ● Within the bowel wall
is normal. There is no bowel dilatation.
There is no evidence of extraluminal air. Artefacts
Soft tissue outlines of the psoas muscles most commonly phleboliths. Part 4 of this You should be able to identify “man made”
series is dedicated to calcification on AXR. structures correctly. These may be iatro-
and kidneys are seen. The kidneys are
genic (put there by health professionals),
normal in size and shape. There are no accidental (put there by the patient or
apparent bony lesions or abnormal calci- other), or projectional (lying in front of or
fication. Incidentally, sterilisation clips behind the abdomen but spuriously pro-
can be seen within the pelvis indicating jected within it on the AXR). Examples of
previous gynaecological intervention. iatrogenic structures would be surgical
clips, an interuterine contraceptive device,
renal or biliary stent, an endoluminal aortic
been perforated. This gas within the peri- stent, or inferior vena cava filter. Accidental
toneal cavity is termed pneumoperitoneum. findings include bullets or a per rectum
Gas in the right upper quadrant within object. Projectional findings include pyjama
the biliary tree is a “normal” finding after buttons, coins in pockets, or body piercings
sphincterotomy or biliary surgery, but it can (see part 6 of the series).
indicate the presence of a fistula between the Figure 6. Gastric pseudotumour
biliary tree and the gut. Ian C Bickle final year medical student, Queen’s
Beware of gas in the portal vein, as this University, Belfast
can look very similar to biliary air. Gas in the Soft tissues and bone
portal vein is always pathological and fre- A review of the soft tissues entails evaluating Barry Kelly consultant radiologist Royal Victoria
quently fatal. It occurs in ischaemic states, the outlines of the major abdominal organs. Hospital, Belfast
such as toxic megacolon, and it may be Observing these structures is made easier by
accompanied by gas within the bowel wall the “fatty” rim (properitoneal fat lines) sur-
(intramural gas). rounding them. In fact, the loss of these fat Next month: Abnormal intraluminal gas
planes may indicate an ongoing pathological
process, such as peritonitis. Look at the size Review points
Calcification and position of the liver and spleen. Look at
Calcium is visible in a variety of structures, the position and size of the kidneys, lateral to ● Technical specifics of the radiograph
both normal and abnormal, and becomes the midline in the region of the T12-L2 verte- ● Amount and distribution of gas
more common with advancing age. How- brae (a useful way of identifying vertebrae: ● Extraluminal gas
ever, review the following areas in particu- the lowest one to give off a rib is T12 and ● Calcification
lar for evidence of calcification: cartilage of serves as a reference point). The renal outline
● Soft tissue outlines and bony struc-
ribs, blood vessels (chiefly the aortoiliac and is usually three to three and a half vertebral
splanchnic arteries), pancreas, kidneys, the bodies in length. Also, look for the clear out-
right upper abdominal quadrant for gall- line of the psoas muscle shadow(s). Finally, ● Iatrogenic, accidental, and incidental
bladder calculi, and the pelvis, which may try to identify the outline of the bladder, seen objects
contain a variety of calcified structures, more clearly if full, within the pelvis. The

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