RADIOLOGI o air may be visible di left upper

quadrant abdomen
Approach to AXR o lowest part of stomach crosses
1. Pre-peritoneal fat line midline
2. Bowel gas pattern  Small bowel :
3. Extraluminal air o 2 atau 3 level masih gakpapa
4. Soft tissue masses (upright, decub)
5. Calcification o central position di abdomen
o valvulae conniventes  mucosal
Pre-peritoneal fat line fold yang melewati lebar bowel
 Lemak yang melapisi dinding peritoneum (yg ditunjuk)
 Lemak hilang  tanda inflamasi  o space close together
curiga peritonitis

 Large bowel :
Bowel gas pattern
 Normal : ada udara dilambung
 Bedain small & large bowel :
o Small  ada valvula ceriventes &
lebih ke central
o Large  ada haustrae & faeces &
lebih ke perifer
 Stomach  hampir selalu ada udara
 Small bowel  biasanya sedikit di 2 atau
3 loops
 Large bowel  selalu ada udara di
rectum & sigmoid, banyaknya beda-beda
o normalnya gak ada (functions to
remove fluid)
o posisi perifer (transverse &
sigmoid colon occupy variable
positions)  kecuali right upper
quadrant : diisi oleh liver
o haustra (yang ditunjuk)  don’t
extend from wall to wall
o berisi feses

Maximum Normal Diameter of Bowel

 Small bowel : 3 cm
 Large bowel : 6 cm
 Caecum : 9 cm

Extraluminal air Soft Tissue Masses

 Stomach:  Provide limited detail dari organ
o always (upright, decub) abdomen
 Yang kelihatan : liver, spleen, kidney,  Bone
psoas muscle, bladder (dalam pelvis),
dan lung bases (dalam thorax)
 Liver :

Calcification
o RUQ
o Bland (lunak) area warna abu-abu
o Superior edge  membentuk
right hemi-diafragma countour
o Breast shadow  overlies the
liver
o Marking lung  keliatan di blkg
liver
o Gallbladder jarang keliatan
o Clip mark  cholecystectomy

 Lung base

 Psoas edge

Radiographic principle
 Series of film for acute abdomen :
o Obstruction series
o Acute abdominal series
 Kidney & Spleen o Complete abdominal series
 Posisi :
o Supine (always)
o Upright or left decubitus (always)
o Prone (variable)
o Chest, upright or supine
(variable)
 Vesica urinaria
Acute abdominal series  Long air fluid level
 Cause :

 Generalised adynamic ileus :

o Large & small bowel extensively
airfilled tapi tidak dilatasi
o Large & small bowel kelihatan
sama
Abnormal gas pattern Mechanical Small Bowel Obstruction (SBO)
 Functional ileus  Dilatasi small bowel
o 1 atau lebih bowel loops menjadi
 Fighting loops  visible loops, lying
aperistaltic  biasanya karena
transversely, with air-fluid level at
local iritasi atau inflamasi
different level
o Localized “sentinel loops” : 1/2
 Sedikit gas di kolon, terutama rectum
loops
 Causes : * = visible on AXR
o Generalised (semua loops dari
bowel)
 Mechanical obstruction
o Intraluminal atau extraluminal
o Small bowel obstruction (SBO)
o Large bowel obstruction (LBO)

Localised Ileus  Step ladder (anak tangga) appearance :

 1 atau lebih persistently dilatasi loops
dari small atau large bowel (multiple
views)
 often air fluid levels in sentinel loops
 iritasi local, ileus in same anatomical
region as pathology
 gas di rectum atau sigmoid
 menggambarkan early SBO
 Causes based on location : o Loops arrange dari LUQ to RLQ di
distal SBO
 Coil spring sign (per) :

Generalised Ileus
 Seluruh bowel aperistaltic/
hypoperistaltic
 Dilatasi small & large bowel ke rectum
(dgn LBO  tidak ada gas di
rectum/sigmoid)
  String of pearls sign :  Causes :
o Tumor
o Volvulus :

 Closed loop obstruction :

 Coffee bean sign
 Sigmoid colon rentan
melilit karena punya
mesentry sendiri
o 2 point dari loop yang sama
 Caecum biasanya
obstruksi di 1 lokasi
retroperitoneal & tidak
o Membentuk bentu C atau U
rentan mililit  defect di
o Term ini applies to small bowel
peritoneum that cover
(kalau large bowel : volvulus)
cecum  movile cecum
o Caused by : adhesion
o Hernia
 Crescent sign (bulan sabit) :
o Caused by : LUQ soft tissue mass,
head of intussusception di distal
transverse colon
 Double bubble sign :
 Lateral decubitus of value
o Diverticulitis
o Intussuception
 Apple core sign :

o Intestinal atresia

Mechanical Large Bowel Obstruction (LBO)

 Dilatasi dari kolon dari titik obstruksi
backwards o Manifestasi dari focal stricture of
 Sedikit/tidak ada air fluid level (colon the bowel
reabsorbs water) o Common cause : annular
carcinoma of colon
 Sedikit/tidak ada udara di
rectum/sigmoid  Thumbprinting :
o Jarak antara loops bowel
 Bowel loops tend not to overlap 
meningkat karena penebalan dari
memungkinka untuk identifikasi temat
dinding
obstruksi
o Haustral folds sangat tebal 
 Sedikit/tidak ada udara di small bowel
leading to thumbprinting sign
jika ileocaecal valve remain competent
 kalau incompetent : large bowel
decompress into small bowel, mirip SBO
  Lead pipe colon :  Chilaiditis sign :
o Pemendekan dari kolon karena
fibrosis
o Hilangnya haustration
o Ulcerative colitis

Free Air
 Types :
o Mimic udara dibawah diafragma
o Pneumoperitoneum/free
o Cari haustral folds
air/intraperitoneal air
o Get lateral decubitus untuk
o Retroperitoneal air
memastikan
o Air in the bowel wall
o Chirrosis atau flattened
(pneumatosis intestinalis)
diafragma karena lung
o Air in the biliary system
hyperinflation  upper abdomen
(penumobilia)
above liver
 Upright film best
 Rigler’s sign :
o Pasien duduk tegak 10-20 menit
sebelum chest x-ray berdiri
o Menyebabkan free intra-
abdominal gas naik ke atas 
membentuk crescent dalam
diafragma
o Dengan cara ini 1 ml gas dapat
dideteksi
o Bowel wall terlihat di both sides
 Causes : karena intra & extraluminal air
o Rupture dari hollow viscus o Biasanya banyak udara bebas
 Perforasi peptic ulcer o Confirm with upright view
 Trauma
 Football sign :
 Perforasi diverticulitis
(biasanya menutup)
 Perforasi carcinoma
o Post-op  5-7 hari normal
 Crescent sign :

o Terlihat dgn massive

pneumoperitoneum
o Free air under diafragma
o Sering di anak-anak dgn
o Best terlihat di upright chest xray
necrotizing enterocolitis
atau left lateral decubitus
o Pada posisi supine : air collects
o Lebih mudah diliat dibawah
anterior to abdominal viscera
diafragma kanan
 Falciform ligament sign :  Pneumatosis intestinalis :

o Normally invicible
o Supine flm  free air rises over
anterior surface of liver
 Continous diaphragm sign :
o Intramural air
o Best appreciated in profile
 Air in the biliary tree :

o 1 atau 2 tube like branching

lucencies di RUQ
o confirm to location of major bile
o Sufficient fre air
ducts
o Left & right hemidiaphragm
appear continuous
Soft Tissue Masses
 Cupola sign :
 Organomegaly  know normal
landmarks
 Indetifikasi :
o Direct visualization dari tepi
struktur
o Air superior to left lobe liver o Indirect dengan displacement of
o Air di dalam central tendon bowel
diafragma  Sekarang untuk lihat udah diganti pakai
o Mirip dome  CT, USG, MRI
 Triangle sign :  Lokasi :
o Vascular
o Liver
o Gallbladder
o Spleen
o Pancreas
o Lymph nodes
o Adrenals
o Kidney
o Segitiga kecil dari free gas yg o Ureter
terletak diantara large bowel & o Bladder
flank o Prostate
Calcification  Floccular, Amourphous, Popcorn
 Rim-like : o Formed in solid organ
atau tumor
 Pancreas
 Leiomyoma uterus
 Ovarian cyst
 Lymph nodes
 AdenoCa stomach,
ovary, colon
o Kalsifikasi di dinding  Metastases
hollow viscus  Soft tissue (prev
o Cyst  renal, splenic, trauma, crystal
hepatic deposition)
o Aneurysm  aortic,  Lamellar or Laminar
splenic, renal artery o Terbentuk disekeliling
o Saccular organ  nidus di dalam hollow
gallbladder, urinary lumen
bladder o Concentric layers karena
 Linear/Track : perpanjangan pergerakan
batu didalam hollow
viscus
 Renal stone
 Gallstones
 Bladder stones

o Kalsifikasi di dinding
tubular structure
o Arteries
o Tuba falopi
o Vas deferens
o Ureter  Renal calculi
 Chinese dragon sign : o Pelvicalyceal calcification

o Kalsifikasi splenic artery

 Calcified vas deferens
o Staghorn calcification
(tubular)

o Parenchymal calcification
(flocculent)

 Nephrocalcinosis
 Uncommon
 Ditemukan pada
penyakit :
medullary sponge
kidney atau
hiperparatiroidism
o Calsified gallstones
(lamellar)