The Abdominal Radiograph

Aims
 Indication for AxR
 Assessment
 Normal Appearances
 Common Pathology
 Rarer Pathology
 Abdominal Radiograph (AXR)
 Readily available
 Cheap
 Low dose cf CT
 Gives large amount of information
 Indications for AXR
 Non-specific abdominal pain
 ? Small bowel obstruction
 ? Large bowel obstruction
 Palpable mass
 Renal colic (KUB)
 Colitis
 Position of foreign objects
 AXR
 Lacks symmetry of chest
 Normal appearances highly variable
 Several solid and hollow organs visible
 Solid organs
 Liver- may see lower edge

 Kidneys- L1- L4, outlines may be

obscured by bowel content

 Bladder- outlined by fat

 Spleen- rarely seen unless enlarged

 Invisible:normal pancreas, adrenal,

uterus, ovaries
 Small vs Large Bowel
 Small Bowel Large Bowel
Position Central Peripheral

Size <3cm 6cm, (caecum

can be up to
9)
Pattern Valvulae Haustrae
conniventes do not
traverse traverse
Content Fluid, Air Air , Stool
Large Bowel
Small Bowel
 Assessment- ABC’s
 A- adequacy, air
 B- bowel
 C- calcification
 D- densities
 E- edges
 F- fat planes
 S- skeleton
 Adequacy
 Standard- AP view, supine
 Erect CXR if ?Perforation; may show
chest pathology and fluid levels
 Film should include: pubic symphisis,
hernial orifices, properitoneal fat
Inguinal Hernia
 Air
 Free air implies perforation unless recently
post op
 Riglers sign- air on both sides of the bowel
wall
 May see falciform ligament, liver edge
outlined by air.
 Retroperitoneal free gas will outline structures
here (kidney, psoas)
 Erect CXR if any doubt - air rises
 Extraluminal Air Causes
 Recent laparotomy/laparoscopy
 Perforated peptic ulcer
 Perforated colonic/other diverticulum
 Perforated tumour
 Obstruction complicated by perforation
 Trauma
 Intramural Air
 Implies infarction, either due to
inflammation or ischemia
 May be associated with wall thickening
 Air may track into mesenteric veins and
portal vein- RIP (adult)
 Other Sites for Air
 Biliary tree- post ERCP/ stent
placement/ gallstone ileus
 Portal vein- mesenteric infarction
 Abscess- may cause air fluid level
 Renal tract- infection
Aerobilia
Subphrenic abscess
 Calcification
 Many causes of calcification on the
AXR:
 Costal cartilage- commoner in elderly,
incidental
 Phleboliths- veins in pelvis, can be
mistaken for ureteric calculi
 Vascular- curvilinear
 Calcification continued
 Renal tract- 90% calculi radio- opaque
 Cholelithiasis- 10% radio-opaque
 Mesenteric lymph node (incidental)
 Pancreas- punctate, nodular- indicates
chronic pancreatitis
 Spleen - sickle cell,previous trauma or
infection
 Calcification continued
 Appendix- appendicoliths can cause
appendicitis
 Bladder wall- infections, e.g. TB,
schistomiasis
 Seminal vesicles- diabetics
 Uterus- fibroids
 Ovaries - dermoids
Phleboliths
Gallstones+ Costal Cartilage
Bladder Wall Calcification
Appendicolith
Faecoliths+Gallstones
Fibroids
Teeth in Ovarian Dermoid
Pancreatic calcification
Nephrocalcinosis
 Densities
 Foreign bodies- almost anything can be
ingested or inserted!!
 Tablets, IUCD, Stents, Filters etc
 Fat Planes
 Psoas- usually visible
 Asymmetry or displacement may imply
retroperitoneal or spinal pathology
 Skeleton
 Fractures in trauma should suggest
possible intra-abdominal injury
 But AXR not indicated in routine
trauma- do U/S and/or CT
 Bony metastases may be seen
 Common Abnormalities
 Small bowel dilatation
 Large bowel dilatation
 Extraluminal air
 Small Bowel Dilatation
 Causes- small bowel obstruction and
paralytic ileus
 Small bowel obstruction- adhesions
(75%), hernias, volvulus,
intussusception and masses and
inflammation
 Small Bowel Obstruction
 Loops dilated >3cm
 Large bowel collapsed (cf ileus)
 Erect film - several air fluid levels may
be seen
 Increasing duration - string of beads
 CT indicated
Small Bowel Obstruction
String of Beads (chronic/sub-acute)
 Dilated Large Bowel
 Large bowel obstruction
 Causes include neoplasm, volvulus
(sigmoid/ caecal), and strictures e.g
inflammatory / radiotherapy
 Paralytic ileus / pseudo-obstruction
 Toxic Megacolon
 Large Bowel Obstruction
 Risk of perforation especially if caecum
>9 cm
 Remainder of bowel >5cm
 CT (preferably)or water soluble contrast
enema indicated
Large Bowel Obstruction
Pseudo-obstruction
 Large Bowel Volvulus
 Long mesentery
 Caecum rotates to lie in RUQ
- causes small bowel obstruction
 Sigmoid rotates to lie in LUQ
- causes large bowel obstruction
Caecal Volvulus
Sigmoid Volvulus
 Toxic Megacolon
 Severe colitis including UC, Crohns,
infective
 Thickened wall with mucosal oedema-
“thumbprinting”
( also in ischaemic colitis)
 Dilatation implies perforation imminent
 Surgical emergency
Thumb-printing
Quiz