•X-RAY DISCUSSION

Dr.Jini Joseph
Junior Resident
SGMC and RF
Trivandrum
 ACUTE ABDOMEN
⦿Series of films required :
⮚ Supine Abdomen –
1.Bowel gas pattern
2.Calcifications
3.Masses-obliteration of fat lines (psoas ouline).
⮚ Erect abdomen –
1.Free air
2.Free air-fluid levels.
⮚ Chest erect- to detect small pneumoperitoneum.
 3,6,9 RULE
⦿Maximum normal diameter of bowel
❑ Small bowel 3 cm
❑ Large bowel 6 cm
❑ Cecum 9 cm.
CLASSIFICATION OF INTESTINAL
OBSTRUCTION

⦿Localised versus Generalised ileus

⦿Dynamic versus Adynamic (paralytic) ileus.

CAUSES OF LOCALISED ILEUS

SITE OF DILATED LOOPS CAUSE

Right Upper Quadrant Cholecystitis

Left Upper Quadrant Pancreatitis

Right Lower Quadrant Appendicitis

Left lower quadrant Diverticulitis

Mid abdomen Ulcer/ kidney or ureteric calculus

 GENERALISED ILEUS
⦿Entire bowel aperistaltic /hypoperistaltic
⦿Dilated small bowel or large bowel ; In LBO ,no
gas in rectum.

⦿Causes :
⮚ Postoperative
⮚ Electrolyte imbalance - DKA
GENERALISED ADYNAMIC
ILEUS
⦿The large and small bowel are extremely air
filled but not dilated.
⦿It is pseudoobstruction ,without mechanical
obstruction ( Ogilvie syndrome), or toxic
megacolon.
⦿Can be characterized by diffuse small- and
large-bowel dilatation without a transition point.
Dynamic /Mechanical SBO
⦿Causes :
Adhesions
Hernia
Malignancy
Gallstone ileus
Intussusception
IBD

⦿Dilated small bowel ; Little gas in

colon,especially rectum.
Mechanical LBO
⦿Colon dilates from point of obstruction
backwards.
⦿Little / no air fluid levels
⦿Little / no air in rectum / sigmoid.
⦿Little /no gas in small bowel if ileocecal valve
remains competent

⦿Causes : Tumour
Volvolus, Hernia
Diverticulitis , Intussusception.
DISTINCTION BETWEEN SMALL AND
LARGE BOWEL OBSTRUCTION
FEATURES SMALL BOWEL LARGE BOWEL

1.Haustra Absent Present

2.Valvulae conniventes Present in jejunum Absent

3.Number of loops Many Few

4.Distribution of loops Central Peripheral

5.Radius of curvature of Small Large

loops

6.Diameter of loop < 3 cm < 5 cm

7.Solid faeces Absent May be present

>5 cm
>3 cm
 Radiographic signs
⦿Presence of > 2 air fluid levels.
⦿Air fluid levels wider than 2.5 cm.
⦿Air fluid levels differing > 2 cm in height within
the same small bowel loop.
Stretch sign
SMALL BOWEL OBSTRUCTION

X-RAY ABDOMEN ERECT AND SUPINE

LARGE BOWEL OBSTRUCTION
PSEUDOOBSTRUCTION
PNEUMOPERITONEUM

X-RAY ABDOMEN ERECT

 PNEUMOPERITONEUM
⦿ Free gas within peritoneal cavity
⦿ Chest radiograph-
1.Subdiaphragmatic free gas (Erect)
2.Cupola sign /Saddle bag /Moustache sign (Supine) –
Gas trapped below central tendon of diaphragm.
⦿ Abdominal radiograph –
⮚ Bowel related signs ----
1.Double wall sign/ Rigler’s sign /Bas relief sign- Air
outling the serosal and luminal surface of bowel wall with
patient in supine postion(requires >1000 ml of free
intraperitoneal gas +intraperitoneal fluid).
2.Tell tale triangle sign –Triangular air pocket between 3
loops of bowel.
⮚ Peritoneal ligament related signs ---
1.Football sign- Large pneumoperitoneum
outlining entire abdominal cavity.
2.Falciform ligament sign –Long vertical line to
the right of midline from lig teres notch to
umbilicus.
3.Lateral umbilical ligament sign(Inverted V
sign)- Outline of both lateral umbilical ligaments.
4.Urachus sign – Outline of middle umbilical
ligament .
⮚ Right upper quadrant signs ---
1.Cupola sign
2.Ligamentum teres sign –Air outlining fissure of
ligamentum teres hepatis (posterior free edge of
falciform ligament ).
3.Hepatic edge sign – Cigar shaped pocket of free
air in subhepatic region.
4.Lucent liver sign – Single large area of
hyperlucency over liver.
5.Morrison Pouch sign (Doges cap sign )-
Triangular collection of gas in morrison pouch/
posterior hepatorenal space.
6.Periportal free gas sign
CONTINUOUS
DIAPHRAGM RIGLER’S SIGN
FOOTBALL SIGN
SIGN
TELL TALE TRIANGLE URACHUS SIGN
SIGN INVERTED V SIGN
 CUPOLA SIGN

FALCIFORM LIGAMENT SIGN

DOGES CAP SIGN

 HEPATIC EDGE SIGN

LUCENT LIVER SIGN

SIGMOID DIVERTICULOSIS
DIFFERENCE BETWEEN POLYPS AND
DIVERTICULUM
POLYPS DIVERTICULUM

1.Bowler’s hat sign- dome towards 1.Dome points away from the lumen.
bowel axis.

2.Meniscus sign –inner margin well 2.Outer margin well defined,fades

defined, fades outwards. inwards

3.Negative Filling defects in barium pool 3.Protrusions out of the lumen.

4.Mexican hat sign- Barium around the

stalk is surrounded by a second ring of
barium around the dome of the polyp
(Pedunculated polyp).

5.Stalk sign - A linear filling defect in a

barium pool
POLYP VERSUS DIVERTICULUM
INTESTINAL MALROTATION
Intestinal malrotation -Any deviation from the normal 270° counterclockwise rotation of the midgut during
embryologic development.
 Imaging features
⦿ X-Ray abdomen –
- Right-sided jejunal markings
-Absence of a stool-filled colon in the right lower quadrant .
⦿ Upper GI barium series-
Frontal view
- Duodenal—jejunal ( DJ ) junction fails to cross the midline to the
left of the left-sided vertebral body pedicle
- DJ junction lies inferior to the duodenal bulb
Lateral view
- D2 and D3 segments of the duodenum not located posteriorly in a
retroperitoneal position
- DJJ corkscrew appearance in volvolus.
⦿ Contrast enema - Malposition of the right colon, but the cecum may
assume a normal location in up to 20% of patients.
⦿ SMA-SMV inversion - Deviation from the normal relationship between
the superior mesenteric artery (SMA) and superior mesenteric vein
(SMV) (vertical relationship or left—right inversion ). 
• THANK YOU
 SIGMOID VOLVOLUS
⦿ A cause of large bowel obstruction and occurs when the 
sigmoid colon twists on its mesentery, the 
sigmoid mesocolon.
⦿ Differentiated from a caecal volvulus by its ahaustral wall and
the lower end pointing to the pelvis.
⦿ Plain radiograph
1.Large, dilated loop of the colon with a few air-fluid levels.
Specific signs include:
2.Coffee bean sign-
3.Frimann Dahl sign - 3 dense lines converge towards the
site of obstruction
4. Absent rectal gas
⦿ Fluoroscopy
⦿ Beak sign (or bird beak sign) -.
CAECAL VOLVOLUS