PLAIN FILM

OF THE
ABDOMEN
Edi Yanuarto Hidayat
 INTRODUCTION
 Plain films of the abdomen are used
primarily to asses calcifications and
intestinal obstruction or perforation.
 In case of acute abdomen, plain film of the
abdomen should be made in 3 positions
(Supine, upright or semi-upright, left
lateral decubitus) + chest x-ray.
SUPINE
ERECT / UPRIGHT
LEFT LATERAL
DECUBITUS
 WHAT TO EXAMINE
 Gas pattern
 Extraluminal air / Free air
 Soft tissue masses
 Calcifications
 NORMAL GAS PATTERN
 Stomach
– Almost always
 Small bowel
– Two or three loops of non-distended bowel
– Normal diameter ≤ 3,0 cm
 Large bowel
– In rectum or sigmoid – almost always
– Normal diameter ≤ 5,0 cm
 NORMAL GAS PATTERN
Gas in stomach

Gas in a few
Loops of
Small bowel

Gas in rectum
or sigmoid
NORMAL GAS PATTERN
A. Gaster
B. Colon Descenden
C. Fleksura hepatica
D. Psoas Line kiri
E. Fleksura lienalis
F. Hepar
G. Caecum
H. Sacrum
I. Os iliaca
J. Caput Femoris
 THE 3,6,9 RULE
Maximum Normal
Diameter
Small bowel 3 cm
Large bowel 5 – 6 cm
Caecum 9 cm

It is a very useful guide to determine whether the bowel

is dilated or not.
 NORMAL FLUID LEVELS
 Stomach
– Always
 Small bowel
– Two or three levels possible
 Large bowel
– None normally
 NORMAL AIR-FLUID
LEVELS

Always air-fluid
level
in stomach
A few
Air-fluid level
in small bowel

Upright Abdomen
LARGE VS SMALL BOWEL
Characteristic Large Bowel Small Bowel

Position Circumferential – the Central

large bowel tends to
frame the small bowel

Contents Faeces of variable Fluid like and air

consistency

Mucosal / Wall Haustral folds Encircling valvulae

Pattern interspaced with plica conniventes
semilunaris

Size Up to 5 - 6 cm, 9 cm Up to 3 cm
for the caecum
LARGE VS SMALL BOWEL

Plica semilunaris and Valvulae Conniventes

Haustra
SMALL BOWEL
 NORMAL GAS PATTERN
IN THE NEWBORN
 Gas in the stomach
 10 – 15 minutes after birth
 Gas in the proximal small bowel
 30 – 60 minutes after birth
 Gas in the distal small bowel
 6 hours after birth
 Gas in the colon and rectum
 within 12 - 24 hours after birth
ABNORMAL GAS
PATTERNS
 ABNORMAL GAS
PATTERNS
A. Paralytic Ileus (Adynamic)
B. Mechanical obstruction
– Small Bowel Obstruction (SBO)
– Large Bowel Obstruction (LBO)
C. Localized Ileus
 PARALYTIC ILEUS
 Definition:
Ileus that results from hypomotility of the gastrointestinal
tract in the absence of mechanical bowel obstruction.
 Symptoms & Clinical findings:
– Abdominal distention
– Nausea and vomiting are variably present
– The bowel sounds absent or hypoactive
 PARALYTIC ILEUS

 Etiology:
A. Abdominal Trauma
B. Abdominal Surgery (i.e Laparatomy)
C. Serum electrolyte abnormality
• Hypokalemia
• Hyponatremia
• Hypomagnesemia
• Hypermagnesemia
 PARALYTIC ILEUS

 Etiology:
D. Inflammation
• Intrathoracic (Pneumonia, Myocardial Infarction)
• Intraabdominal (Appendicitis, Diverticulitis,
Nephrolithiasis, Cholecystitis, Pancreatitis,
Perforated duodenal ulcer)
E. Intestinal ischemia
F. Medications
• Narcotics, phenothiazines, diltiazem or verapamil,
clozapine, anticholinergic.
 PARALYTIC ILEUS
 Radiologic findings:
– Gas in dilated small bowel and large bowel to rectum
– Long air-fluid levels
– Bowel wall thickening
PARALYTIC ILEUS
 PARALYTIC ILEUS
 Differential diagnosis:
– Mechanical obstruction (Ileus obstruction)
– Bowel pseudoobstruction / Ogilvie Syndrome
 MECHANICAL
OBSTRUCTION
 Definition:
A mechanical obstruction of the bowel, preventing the
normal transit of the products of digestion.
 It classifies into:
– Small Bowel Obstruction (if the obstruction
occur in the level of small bowel).
– Large Bowel Obstroction (if the obstruction
occur in the level of large bowel)
 SMALL BOWEL
OBSTRUCTION
 Symptoms & Clinical Findings:
– Severe, colicky abdominal pain
– Billious emesis
– Mild abdominal distention
– Bowel sounds:
• Early: high pitched, hyperactive bowel sounds
• Later: hypoactive or absent bowel sounds
 SMALL BOWEL
OBSTRUCTION
 Etiology:
– Adhesions
– Hernia
– Neoplasms
– Small bowel volvulus
– Intussuception
– Congenital anomalies (in pediatric): small
bowel atresia, small bowel stenosis, meconium
ileus
 SMALL BOWEL
OBSTRUCTION
 Key Concept:
– Bowel distention proximal to obstruction
– Bowel collapsed distal to obstruction
 Radiologic findings:
– Dilated small bowel > 3,0 cm in diameter
– Little gas in colon
– Multiple air fluid level (step ladder appearance) in
upright / LLD position
– String of pearls / String of beads appearance
– Coiled spring appearance
SMALL BOWEL
OBSTRUCTION
STRING OF PEARLS
APPEARANCE

- It can be seen in upright /

LLD position
- It caused by small bubbles of
air trapped in the valvulae
conniventes
STEP LADDER
APPEARANCE

White arrow is a string of

pearl appearance
COILED SPRING
APPEARANCE

It only occurs in the

dilated air-filled small
bowel
 LARGE BOWEL
OBSTRUCTION
 Symptoms & Clinical findings:
– Emesis may occur and is brown and fecculent
– Significant abdominal distention
– Stool passage may be present in the early / partial
obstruction.
– Obstipation in complete obstruction
– Bowel sounds:
• Initial: high pitched, hyperactive bowel sounds
• Later: hypoactive or absent bowel sounds
 LARGE BOWEL
OBSTRUCTION
 Etiology:
– Infectious / inflammatory
– Neoplastic
– Mechanical pathology
• Volvulus
• Incarcerated hernia
• Stricture
• Obstipation
• In neonates: imperforate anus, meconium ileus,
hirschprung disease.
 LARGE BOWEL
OBSTRUCTION
 Radiologic findings:
– Dilated colon to point of obstruction
– Little or no air in rectum / sigmoid
– Multiple air fluid level = step ladder appearance
– Herring-bone appearance
– Little or no gas in small bowel if ileocecal valve
remains competent.
– May look like SBO, large bowel decompresses into
small bowel if ileocecal valve incompetent.
LARGE BOWEL
OBSTRUCTION
HERRING BONE
APPEARANCE
 LOCALIZED ILEUS
 May resemble early
SBO
SENTINEL LOOP

Supine Prone
 SUMMARY FOR ABNORMAL
GAS PATTERNS
Air in rectum Air in small Air in large
or sigmoid bowel bowel

Paralytic Ileus Yes Multiple Yes – distended

distended loops

SBO No Multiple No
distended loops

LBO No None Yes – dilated

Unless ileocecal
valve
incompetent
Localized Ileus Yes 2 – 3 distended Air in rectum or
loops sigmoid
 WHAT TO EXAMINE
 Gas pattern
 Extraluminal air
 Soft tissue masses
 Calcifications
 EXTRALUMINAL AIR
 Signs of pneumoperitoneum:
– Anterior subhepatic space air
– Doges Cap Sign (free air in Morisson’s pouch)
– Rigler’s sign on supine plain abdominal film
– Falciform ligament sign
– Footbal sign
– The cupola (Air accumulation beneath the central
tendon of diaphragm)
– The triangle (Air trapped between three loops of
bowel)
 EXTRALUMINAL AIR
 Signs of pneumoperitoneum (cont.):
– Air under diaphragm on upright chest x-ray
– Air outlined against liver / flank on decubitus position
 ETIOLOGY
 Rupture of a hollow viscus
– Perforated ulcer
– Perforated diverticulitis
– Perforated carcinoma
– Trauma or instrumentation
 Post-op 5-7 days
ANTERIOR SUBHEPATIC
SPACE AIR
DOGES CAP SIGN

Doges cap sign refers to free air

in Morisson’s pouch
DECUBITUS ABDOMEN
SIGN
 Patient in LLD
 There is evidence of free
air between the
abdominal wall and the
liver (white arrow).
 There is also evidence of
free fluid in the
peritoneum (black arrow).
CRESCENT SIGN
RIGLER’S SIGN
 The sign refer to the
appearance of the bowel
wall on the plain film
when it is outlined by
intraluminal and
extraluminal air.
 The extraluminal is the
free peritoneal gas.
FOOTBALL SIGN
FOOTBALL SIGN

Massive pneumoperitoneum and

could reasonably be said to display
football sign

There is also falciform ligament sign,

Rigler’s sign and air in the scrotum.
FALCIFORM LIGAMENT
SIGN

If there’s enough free air to outline

the falciform ligament, there is
usually enough air to also provide
Rigler’s sign
 CONTINUOUS
DIAPHRAGM SIGN
 Massive
pneumoperitoneum
CUPOLA AND LESSER SAC
GAS SIGN
 White arrow: cupola sign
 Black arrow: lesser sac
gas sign
 There is free connection
between the lesser sac
and the greater sac
through the foramen of
winslow.
 WHAT TO EXAMINE
 Gas pattern
 Extraluminal air
 Soft tissue masses
 Calcifications
 SOFT TISSUE MASSES
 Hepatosplenomegaly
 Tumor or cyst
– Bowel displacement
– Paucity of gas
SPLENOMEGALY
 WHAT TO EXAMINE
 Gas pattern
 Extraluminal air
 Soft tissue masses
 Calcifications
 CALCIFICATIONS
 Etiology:
– Gallstones or renal calculi
– Lymph node calcifications
Staghorn calculi
Urolithiasis
 REFERENCES
 www.emedicine.com
– Large bowel obstruction, 2004
– Colonic Obstruction, 2004
– Small bowel obstruction, 2004
– Bowel obstruction in the newborn, 2010
– Ileus differential diagnose, 2011
 Baker, R., Fischer, J., LBO, Mastery of Surgery, fourth edition, pp 1405-1407
 Haubrich, W., Schaffner, F., 1995, Gastroenterology, LBO, pp 1189
 www.learningradiology.com
– Plain film of the abdomen
– Sign in Radiology
 Paul C. Nevitt. The String of Pearl Sign. Radiology 2000;214:157-158
 BOWEL
PSEUDOOBSTRUCTION
 Symptoms and clinical findings:
Marked abdominal distention without pain or tenderness.
Usually in elderly bedridden patient.
 Etiology:
dismolity due to loss of the migrating motor complex and
bacterial overgrowth.
 Radiologic findings:
isolated, proximal large bowel dilatation.
limited to colon only.
 BOWEL
PSEUDOOBSTRUCTION