INTERPRETATION OF

ABDOMINAL X-RAYS
Dr Fahad Saadi
FY2 in General Surgery
fsaadi01@qub.ac.uk
Altnagelvin Hospital, Western Trust
• Normal bowel gas pattern
• Normal bowel gas has very variable appearance.
• In this example the wavy 'ruggae' of the stomach wall can be seen.
• A short segment of the colon is prominent, but is not frankly dilated.
• Faecal material is visible in the right hemi-colon.
• Small bowel obstruction
• Features of small bowel obstruction include the central position of gas-filled
and distended loops of bowel.
• The white lines passing across the full width of the bowel are 'valvulae
conniventes' - these are only found in the small bowel.
• Small bowel obstruction
• The clinical history will often give a clue to the cause of obstruction.
• Abdominal X-rays sometimes provide evidence of the cause of obstruction,
as in this patient who had a history of previous surgery (cholecystectomy).
Adhesions were found at time of surgery.
• Small bowel obstruction?
• This image demonstrates distention of gas-filled loops of small bowel. This
does not necessarily mean that the obstruction is in the small bowel.
• In this patient a colonic mass was found to be obstructing the proximal large
bowel.
• Much of the small bowel is not visible in this image because it contains fluid
and not gas.
• Post-operative ileus
• This post operative patient was intolerant of food, but did not have clinical
features of obstruction.
• The X-ray features of post-operative ileus are often indistinguishable from
those of small bowel obstruction.
• Large bowel obstruction
• The colon is gas-filled and dilated down to the level of the sigmoid colon.
• The dilated colon is abruptly 'cut-off' at the level of obstruction (X).
• The cause of obstruction in this patient was found to be a diverticular
stricture.
• Dilated small and large bowel
• The entire large bowel is dilated down into the pelvis.
• Dilated loops of small bowel are also visible. This indicates incompetence of
the ileocaecal valve, which allows gas to build up in the small bowel as well
as in the large bowel.
• The obstruction was found to be due to an obstructing tumour of the sigmoid
colon which was treated using a colonic stent (see image below).
• Sigmoid volvulus - 'coffee bean' sign
• Sigmoid volvulus is due to a twist at the base of the sigmoid mesentery which
is in a fixed position (asterisk) in the left iliac fossa.
• This results in the appearance of a giant 'coffee bean', the typical sign of
sigmoid volvulus.
• Sigmoid volvulus - 'coffee bean' sign
• Here is another example of the 'coffee bean' sign of sigmoid volvulus.
• Caecal volvulus
• This patient has a caecum which is not retroperitoneal and is therefore
'mobile' and susceptible to twisting or folding. The 'volvulus' (twist/fold) has
resulted in dilatation of the caecum.
• Caecal volvulus
• The caecum is grossly dilated and is no longer located in its anatomical
position, the right iliac fossa (RIF), which is occupied by small bowel in this
example.
• Radiology Masterclass 'Caecal Embryo Sign'
• In caecal volvulus, the dilated caecum takes on a shape similar to a
mammalian embryo. That is, the formation of a large dilated caecal pole
(head), with one or two further 'segments' (body and tail). This is seen in all
the images on this page.
• Pneumoperitoneum - Erect chest X-ray
• An erect chest X-ray can show even a very small volume of free abdominal
gas.
• Reference to the clinical setting is required to determine if this is a potentially
life-threatening perforation.
• This patient had undergone laparoscopic surgery earlier in the day. The free
gas under the diaphragm is insufflated carbon dioxide, an acceptable post-
surgical finding.
• A careful check should be made for free gas under the diaphragm on every
chest X-ray.
• Perforation - Erect Chest X-ray
• If perforation is suspected then an erect chest X-ray should be performed as
well as an abdominal X-ray.
• This image shows a very large volume of gas under the diaphragm due to
bowel perforation
• Rigler's sign
• If there is free intra-abdominal gas adjacent to a gas-filled loop of bowel
then both sides of the bowel wall are well-defined. This is known as 'Rigler's
sign'.
• Ulcerative colitis - Thumbprinting
• Abdominal X-rays are often entirely normal in inflammatory bowel disease.
Occasionally there are signs of acute inflammation indicated by bowel wall
thickening.
• This image demonstrates extensive bowel wall thickening throughout the
entire colon. Thickening of the haustral folds results in a 'thumbprinting'
appearance (arrowheads).
• Ulcerative colitis - Toxic megacolon
• This patient's colon is very dilated and there are extensive 'mucosal islands'
indicating bowel wall inflammation.
 REFERENCES
• https://www.radiologymasterclass.co.uk/gallery/galleries