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7.abdomen Xray
7.abdomen Xray
Suzanne O’Hagan
Lightbulb moment
a moment of sudden inspiration, revelation, or recognition
Approach to AXR
• Bowel gas pattern
• Extraluminal air
• Calcifications
Normal AXR
Liver Gas in
stomach Splenic flexure
11th rib T12
Psoas margin
Left kidney
Hepatic flexure
Transverse colon
Iliac crest
Gas in sigmoid
Sacrum
Gas in caecum
SI joint
Bladder
Femoral head
Gas pattern
What is normal?
• Stomach
– Almost always air in stomach
• Small bowel
– Usually small amount of air in
2 or 3 loops
• Large bowel
– Almost always air in rectum
and sigmoid
– Varying amount of gas in rest of large bowel
Normal fluid levels
• Stomach
– Always (upright, decub)
• Small bowel
– Two or three levels
acceptable (upright, decub)
• Large bowel
– None normally
(functions to remove fluid)
Large vs small bowel
• Large bowel
– Peripheral (except RUQ occupied by liver)
– Haustral markings don’t extend from wall to wall
• Small bowel
– Central
– Valvulae conniventes extend across lumen and are
spaced closer together
Radiographic principles
• Prone
– Patient on abdomen, x-ray beam directed
vertically downward, cassette anterior, x-
ray tube posterior (PA)
• Upright
– Patient stands or sits, x-ray beam directed
horizontally, cassette posterior, x-ray tube
anterior (AP)
• Upright chest
– Patient stands or sits, horizontal x-ray
beam, cassette anterior, x-ray tube
posterior (PA)
• Mechanical obstruction
– Intraluminal or extraluminal
• Small bowel obstruction
• Large bowel obstruction
3, 6, 9 RULE
Explanation:
* almost always
Generalised adynamic ileus
• Loops arrange
themselves from
left upper to
right lower
quadrant in
distal SBO
Coil spring sign
String of pearls sign
Caused by:
OR
Head of intussusception
in distal transverse colon
Double Bubble Sign
Duodenal Atresia
Mechanical LBO
• Colon dilates from point
of obstruction
backwards
• Little or no air in
rectum/sigmoid
Large bowel obstruction
Bowel loops tend not to
overlap therefore
possible to identify site
of obstruction
TUMOUR
VOLVULUS
HERNIA
DIVERTICULITIS
INTUSSUSCEPTION
Note on volvulus
• Sigmoid colon has its own mesentry therefore
prone to twisting
Massively
dilated
sigmoid loop
Hernia
– Retroperintoneal air
Best demonstrated on
upright chest x rays or
left lat decub
Paediatric
Adult
Falciform ligament sign
Normally
invisible.
Sufficient
free air, left
and right
hemi-
diaphragms
appear
continous
Lesser sac Sign Cupola Sign
Lesser sac Cupola
sign sign
– (black – (white
arrows) arrows)
The lesser sac is
positioned Air superior to
posterior to the left lobe of
stomach and is liver
usually a potential
space. There is
free connection
between the lesser
sac and the
greater sac
through the
foramen of
Winslow Double Bubble Sign
Cupola Sign
Air beneath the central tendon of the diaphragm
• Secondary
– Diseases with bowel wall necrosis
– Obstructing lesions of the bowel that raise intraluminal pressure
• Complications
– Rupture into peritoneal cavity
– Dissection of air into portal venous system
Pneumatosis intestinalis
• Intramural air,
best
appreciated in
profile
Air in the biliary tree
• One or two tube-like branching lucencies in
the RUQ, conform to location of major bile
ducts
Causes
• “Normal” if Sphincter of Oddi incompetence
• Previous surgery including sphincterotomy or
transplantation of CBD
• Pathology (uncommon)
– Gallstone ileus: gallstone erodes through wall of GB into
the duodenum producing a fistula between the bowel and
the biliary system.
– Stone impacts in small bowel = mechanical SBO. “ileus”
misnomer
Biliary vs Portal Venous Air
• Portal venous air
usually associated
with bowel necrosis
• Air is peripheral
rather than central
• Numerous
branching
structures
Soft tissue masses
• Organomegaly
– Know normal landmarks
– Cysts
• renal, splenic, hepatic
– Aneurysms
• aortic, splenic, renal artery
– Saccular organs
• Gallbladder
• Urinary bladder
Calcified pancreas
Floccular
Lamellar or laminar
• Formed around a nidus inside hollow lumen
Lamellar
Renal calculi
Pelvicalyceal calcifications
Staghorn Calcification
Nephrocalcinosis
Uncommonly the renal
parenchyma can become
calcified.
This is known as
nephrocalcinosis, a condition
found in disease entities such
as medullary sponge kidney
or hyperparathyroidism.
Flocculent
Putty Kidney
• "Putty kidney" –
sacs of casseous,
necrotic material
(TB)
• Autonephrectomy
– small, shrunken
kidney with
dystrophic
calcification
Flocculent
Calcified gallstones
Lamellar
Conclusion
• Approach to AXR should include gas pattern,
extraluminal air, soft tissue and calcifications