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William Herring, M.D.

2002

Plain Films
Of the Abdomen
An Approach

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What to Examine
Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
GESC

Normal Gas Pattern


Stomach
Always

Small Bowel
Two or three loops of non-distended bowel
Normal diameter = 2.5 cm = 1 US quarter

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


Maximum diameter of 2"

Complete Abdomen
Obstruction Series

Supine
Prone or lateral rectum
Erect or left decubitus
Chest - erect or supine

Complete Abdomen
Supine

Looking for
Scout film for gas

pattern
Calcifications
Soft tissue
masses
Substitute none

Complete Abdomen
Prone

Looking for
Gas in

rectum/sigmoid
Gas in ascending and
descending colon
Substitute lateral

rectum

Complete Abdomen
Erect

Looking for
Free air
Air-fluid levels

Substitute left

lateral decubitus

Complete Abdomen
Erect Chest

Looking for
Free air
Pneumonia at bases
Pleural effusions

Substitute supine

chest

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

Prone

Sentinel Loops
Cholecystitis

Pancreatitis
Ulcer

Appendicitis

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


Long air-fluid levels
Only post-op patients have
generalized ileus

Supine

Generalized Adynamic Ileus

Erect

Is It An Ileus?

Is the patient immediately post-op?


Are the bowel sounds absent or

hypoactive?
If no, then it isnt an ileus

Patients

dont present to the ER with


a generalized adynamic ileus!

Mechanical SBO
Key Features

Dilated small bowel


Fighting loops
Little gas in colon, especially rectum
Key: disproportionate dilatation of SB

SBO

Mechanical SBO
Causes

Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception

*Cause may be visible on plain film

Mechanical SBO
Pitfalls

Early SBO may

resemble localized
ileus -get F/O

Mechanical LBO
Key Features

Dilated colon to point of

obstruction
Little or no air in rectum/sigmoid
Little or no gas in small bowel, if
Ileocecal valve remains competent

Prone

Supine

LBO

Mechanical LBO
Causes

Tumor
Volvulus
Hernia
Diverticulitis
Intussusception

Mechanical LBO
Pitfalls

Incompetent ileocecal valve


Large bowel decompresses into small

bowel
May look like SBO
Get BE or follow-up

Supine

Carcinoma of Sigmoid LBO


Decompressed into SB

Prone

Aunt Minnie Diagnoses

Air in
biliary
tree

SBO

Gallstone

Gallstone Ileus

Post-op C-section
Adynamic Ileus

Sigmoid Volvulus

Cecal Volvulus

Mesenteric Occlusion

Abnormal Gas Patterns


Ileus and Obstruction

Localized ileus
Generalized ileus
Mechanical SBO
Mechanical LBO

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

Falciform
Ligament
Sign

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

Air in Lesser Sac

Extraperitoneal Air

Soft Tissue Masses

Soft Tissue Masses


Hepatosplenomegaly
Plain films

poor for judging liver

size
Tumor or cyst
Bowel displacement
Paucity of

gas

Pad sign
Extrinsic

compression of bowel

Splenomegaly

Myomatous Uterus

Hours
later

Bladder Outlet Obstruction pre- and post- cath

Mass in Cologastric Space - Pancreatic Pseudocyst

Right Renal Cyst

RLQ Abscess

Free Peritoneal Fluid- Bladder Ears

Abdominal
Calcifications

Abdominal Calcifications
Patterns

Rimlike
Linear or track-like
Lamellar
Cloudlike

Rimlike Calcification

Wall of a hollow viscus


Cysts
Renal cyst

Aneurysms
Aortic

aneurysm

Saccular organs e.g. GB


Porcelain Gallbladder

Renal Cyst

Gallbladder Wall

Linear or Track-like
Walls of a tube
Ureters
Arterial walls

Atherosclerosis

Calcification Vas Deferens

Lamellar or Laminar

Formed in lumen of a hollow viscus


Renal stones
Gallstones
Bladder stones

Stone in Ureterocoele

Staghorn Calculi

Cloudlike, Amorphous, Popcorn


Formed in a solid organ or tumor
Leiomyomas of uterus
Ovarian cystadenomas

Nephrocalcinosis

Myomatous Uterus

What to Examine
Gas pattern
Extraluminal air
Soft tissue masses
Calcifications

The End