Abdominal X-ray Radiological Signs

Approach to AXR
• Pre-peritoneal fat line

• Bowel gas pattern

• Extraluminal air

• Soft tissue masses

• Calcifications
Pre-peritoneal fat line
 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
 Gas in stomach

Gas in a few
loops of small
bowel

Gas in rectum
or sigmoid

Normal Gas Pattern

 Normal fluid levels
• Stomach
– Always (upright, decub)

• Small bowel
– Two or three levels
acceptable (upright, decub)

• Large bowel
– None normally
(functions to remove fluid)
 Always air/fluid
level in stomach

A few air/fluid
levels in small
bowel

Erect Abdomen
• Normal Stomach
• If the stomach contains
air it may be visible in
the left upper quadrant
of the abdomen. The
lowest part of the
stomach crosses the
midline
• Normal small bowel
• Central position in
the abdomen
• Valvulae conniventes
- mucosal folds that
cross the full width of
the bowel (arrowheads)
• Normal large bowel
• Peripheral position in
the abdomen (the
transverse and sigmoid
colon occupy very
variable positions)
• Haustra
(arrowheads)
• Contains faeces
 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
 3, 6, 9 RULE

Maximum Normal Diameter of bowel

Small bowel 3cm
Large bowel 6cm
Caecum 9cm
 Soft Tissue

• Although plain radiographs of the abdomen provide

limited detail of the abdominal organs, occasionally
a knowledge of their normal appearance will allow
identification of abnormalities.
• Visible soft tissue organs visible on abdominal X-
rays include the liver, spleen, kidneys, psoas
muscles, bladder (within pelvis), and lung bases
(within thorax).
Liver on abdominal X-ray
• Liver on abdominal X-ray
• The liver lies in the right upper quadrant
(RUQ) and is seen as a bland area of
grey on an abdominal X-ray.
• The superior edge of the liver forms the
right hemi-diaphragm contour
(arrowhead).
• In this patient the breast shadow (red
line) overlies the liver, and markings of
the right lung are visible behind the liver.
• The gallbladder is only rarely visible on
an abdominal X-ray. Its position is very
variable. This patient has had a
cholecystectomy. The clips mark the
previous location of the gallbladder.
VESICA URINARIA
Bone
Calcification
 Radiographic principles

Series of films for acute abdomen

• Obstruction series/ Acute abdominal series/
Complete abdominal series

– Supine (almost always)

– Upright or left decubitus (almost always)
– Prone (variable)
– Chest, upright or supine (variable)
 Acute abdominal series
What to look for
VIEW LOOK FOR

SUPINE ABDOMEN Bowel gas pattern

Calcifications
Masses

PRONE ABDOMEN Gas in rectosigmoid

Gas in ascending and
descending colon
UPRIGHT ABDOMEN Free air, air-fluid levels

UPRIGHT CHEST Free air, lung pathology

secondary to intraabdominal
process
 Abnormal Gas Patterns
• Functional Ileus
– One or more bowel loops become aperistaltic usually
due to local irritation or inflammation
• Localised “sentinel loops” (one or two loops)
• Generalised (all loops of large and small bowel)

• Mechanical Obstruction
– Intraluminal or extraluminal
• Small bowel obstruction
• Large bowel obstruction
 Localised Ileus
Key features
• One or two persistently dilated
loops of small or large bowel
(multiple views)
• Often air-fluid levels in sentinel
loops
• Local irritation, ileus in same
anatomical region as pathology
• Gas in rectum or sigmoid
• May resemble early SBO
 Causes of Localised Ileus
by location

SITE OF DILATED LOOPS CAUSE

Right upper quadrant Cholecystitis
Left upper quadrant Pancreatitis
Right lower quadrant Appendicitis
Left lower quadrant Diverticulitis
Mid-abdomen Ulcer or kidney/ureteric calculi
 Generalised ileus
Key features
• Entire bowel aperistaltic/hypoperistaltic
• Dilated small bowel and large bowel to rectum
(with LBO no gas in rectum/sigmoid)
• Long air-fluid levels
CAUSE REMARK

*Postoperative Usually abdominal surgery

Electrolyte imbalance Diabetic ketoacidosis

* almost always
 Generalised adynamic ileus

The large and

small bowel are
extensively airfilled
but not dilated.

The large and

small bowel "look the
same".
 Mechanical SBO
• Dilated small bowel

• Fighting loops (visible loops, lying transversely,

with air-fluid levels at different levels)

• Little gas in colon, especially rectum

SBO Erect SBO Supine

Air fluid levels

 Causes of Mechanical SBO
Adhesions
Hernia*
Malignancy
Gallstone ileus*
Intussesception
Inflammatory bowel disease

* May be visible on AXR

 Step ladder appearance

• Loops arrange
themselves from
left upper to
right lower
quadrant in
distal SBO
Coil spring sign
 String of pearls sign

Considered diagnostic of obstruction (as opposed to ileus)

and is caused by small bubbles of air trapped in the
valvulae of the small bowel.
 Closed loop obstruction
• Two points of same loop of bowel obstructed
at a single location
• Forms a C or a U shape
– Term applies to small bowel, usually caused by
adhesions
– Large bowel, called a volvulus
Crescent Sign

Caused by:

LUQ Soft tissue mass

OR

Head of intussusception
in distal transverse colon
Double Bubble Sign
 Mechanical LBO
• Colon dilates from point
of obstruction
backwards

• Little/no air fluid levels

(colon reabsorbs water)

• Little or no air in
rectum/sigmoid
Large bowel obstruction
Bowel loops tend not to
overlap therefore possible
to identify site of
obstruction

Little or no gas in small

bowel if ileocaecal valve
remains competent*

* If incompetent, large bowel

decompresses into small bowel, may look
like SBO
Causes of Mechanical LBO

TUMOR
VOLVULUS
HERNIA
DIVERTICULITIS
INTUSSUSCEPTION
 Note on volvulus
• Sigmoid colon has its own mesentry therefore
prone to twisting

• Caecum usually retroperitoneal and not prone

to twisting; 20% people have defect in
peritoneum that covers the caecum resulting
in a mobile caecum
 Volvulus
A volvulus always extends away from the area of twist.
Sigmoid volvulus can only move upwards and usually
goes to the right upper quadrant. Caecal volvulus
can go almost anywhere.
 Coffee Bean Sign
Sigmoid volvulus

Massively
dilated
sigmoid loop
 Hernia

Lateral decubitus of value

The advantage is that there may be a greater chance of air entering the herniated
bowel because it is the least dependent part of the bowel in the supine position.
 Apple core sign
• Radiologic manifestation of a
focal stricture of the bowel
usually at contrast material
enema examination. The
stricture demonstrates
shouldered margins and
resembles the core of an apple
that has been partially eaten.
The most common cause is an
annular carcinoma of the colon.
Thumbprinting

The distance between loops

of bowel is increased due to
thickening of the bowel wall.

The haustral folds are very

thick, leading to a sign known
as 'thumbprinting.'
 Lead pipe
colon

• Shortening of
colon secondary
to fibrosis
• Loss of
haustration
• Ulcerative colitis
 Extraluminal air
• TYPES
– Pneumoperitoneum/free air/intraperitoneal air

– Retroperintoneal air

– Air in the bowel wall (pneumatosis intestinalis)

– Air in the biliary system (pneumobilia)

 Upright film best
• The patient should be positioned sitting
upright for 10-20 minutes prior to acquiring
the erect chest X-ray image.

• This allows any free intra-abdominal gas to

rise up, forming a crescent beneath the
diaphragm. It is said that as little as 1ml of gas
can be detected in this way.
 Free Air
Causes

• Rupture of a hollow viscus

– Perforated peptic ulcer
– Trauma
– Perforated diverticulitis (usually seals off)
– Perforated carcinoma

• Post-op 5-7 days normal, should get less with successive

studies *NOT ruptured appendix (seals off)
 Signs of free air
• Crescent sign
• Chilaiditis sign
• Riglers
• Football sign
• Falciform ligament sign
• Triangle sign
• Cupola sign
Crescent Sign II
Free air under the diaphragm

Best demonstrated on
upright chest x rays or
left lat decub

Easier to see under

right diaphragm
 Chilaiditis sign
• May mimic air under
the diaphragm
• Look for haustral folds
• Get left lat decub to
confirm
In patients who have cirrhosis or
flattened diaphragms due to lung
hyperinflation, a void is created
within the upper abdomen above
the liver. This space may be filled
by bowel. If this bowel is air filled
then it may mimic free gas.
 Rigler’s Sign
Bowel wall visualised on both sides due to intra and extraluminal air
Usually large amounts of free air
May be confused with overlapping loops of bowel, confirm with upright view
 Football SIgn
Seen with massive
pneumoperitoneum

Most often in children

with necrotising
enterocolitis

In supine position air

collects anterior to
abdominal viscera

Paediatric
Adult
Falciform ligament sign

Normally
invisible.

Supine film, free

air rises over
anterior surface
of liver
 Continuous diaphragm sign

Sufficient
free air, left
and right
hemi-
diaphragms
appear
continous
Cupola Sign
Cupola
sign
– (white
arrows)

Air superior to
left lobe of liver
 Cupola Sign
Air beneath the central tendon of the diaphragm

The term cupola comes from a dome such as

this famous dome of the Duomo in Florence.
 Triangle Sign
• The triangle sign
refers to small
triangles of free gas
that can typically be
positioned between
the large bowel and
the flank
 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
 Soft tissue masses
• Organomegaly
– Know normal landmarks

2 ways to identify soft tissue masses/organs:

– Direct visualisation of edges of structure

– Indirect by displacement of bowel

CT, US and MRI have essentially replaced conventional

radiography in the assessment of organomegaly and soft
tissue masses
Abdominal Calcifications
Location Pattern
 Location
• Vascular
• Liver
• Gallbladder
• Spleen
• Pancreas
• Lymph nodes
• Adrenals
• Kidneys
• Ureters
• Bladder
• Prostate
 Rim-like
• Calcification that has occurred in the wall of a
hollow viscus

– Cysts
• renal, splenic, hepatic
– Aneurysms
• aortic, splenic, renal artery
– Saccular organs
• Gallbladder
• Urinary bladder

Calcified hydatid cysts

 Linear/Track
• Calcification in walls of tubular structures
Aortoiliac calcification
– Arteries
– Fallopian tubes
– Vas deferens
– Ureter
Chinese Dragon Sign

Calcified splenic artery

Calcified vas deferens
 Floccular, Amorphous, Popcorn
• Formed in solid organ or tumour
– Pancreas (chronic pancreatitis)
– Leiomyomas of uterus
– Ovarian cystadenomas
– Lymph nodes
– Adenocarcinomas of stomach, ovary, colon
– Metastases
– Soft tissue (previous trauma, crystal deposition)
Calcified enteric Calcified fibroids
lymph nodes

Calcified pancreas

Floccular
 Lamellar or laminar
• Formed around a nidus inside hollow lumen

• Concentric layers due to prolonged movement

of stone inside hollow viscus
– Renal stones
– Gallstones
– Bladder stones
 Bladder calculi

Lamellar
 Renal calculi
Pelvicalyceal calcifications
 Staghorn Calcification

Renal stones are often small, but if large can fill

the renal pelvis or a calyx, taking on its shape
Tubular which is likened to a staghorn.
Renal calculi
Parenchymal 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
 Calcified gallstones

Lamellar
 Conclusion
• Approach to AXR should include gas pattern,
extraluminal air, soft tissue and calcifications

• Named radiological signs are a useful way of

remembering, identifying and reporting on
films
• THANK YOU
CASES
Supine Prone
Supine Erect
 Supine Prone

LBO
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
 Correct

There are multiple air-containing

and dilated loops of small bowel
with little or no gas in the colon.
The findings are those of a
mechanical small bowel
obstruction. The patient had
undergone prior surgery and the
cause of this obstruction was
adhesions form the prior surgery.

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
 Correct

There is a dilated colon to

the splenic flexure/ Little or
no gas is seen in the rectum
or in the small bowel. The
findings are those of a
mechanical large bowel
obstruction. The cause was
an annular constricting
carcinoma at the splenic
flexure.

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
 Correct

There are several air-containing

and slightly dilated loops of small
bowel in the LLQ. These were
persistent. The findings are those
of a localized ileus (sentinel loops)
and their location would suggest
diverticulitis. The patient had
appendicitis. The sentinel loops do
not always correspond to the area
of inflammation.

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
 Correct

All of the bowel is dilated. There

is air in the rectum. The patient
was post-op abdominal surgery
and the bowel sounds were
absent. This is a generalized
adynamic ileus as is seen
sometimes after abdominal
surgery.

Go Back Go ahead
Can you find the soft tissue mass?
The answer’s on the next slide.
Splenomegaly
You can see the edge of the spleen projecting well below the 12 th rib. The
enlarged spleen displaces the stomach to the right.
Can you find the soft tissue mass?
The answer’s on the next slide.
 Calcifications

Myomatous Uterus
The huge uterus displaces bowel upwards out of the pelvis and lower
abdomen. The amorphous calcifications suggest fibroids.
This is an 82 year-old male.
What do you think the “mass” represents?
 Hours
later

Bladder outlet obstruction-after catheterization, the dilated bladder returns to

normal size. The bowel gas returns to the pelvis.
Can you find the soft tissue mass?
The answer’s on the next slide.
There is an abnormal curvilinear density that forms the mass’s inferior
margin. This was a pancreatic pseudocyst.
Can you find the soft tissue mass?
The answer’s on the next slide.
This one is difficult to see. There is an abnormal curvilinear density superimposed
on the liver. This was a renal cyst (see CT).
What kind of calcification is this and what might it be?

Rim-like

Track-like

Laminar

Amorphous

Right Upper Quadrant

Go ahead
 Correct

This is a rim-like
calcification implying
calcification in the wall of a
hollow viscous. Since this is
the RUQ, the gallbladder is
the most likely organ. This
is called a “porcelain
gallbladder” because of the
gross appearance of the
calicification.

Right Upper Quadrant

What kind of calcification is this and what might it be?

Rim-like

Track-like

Laminar

Amorphous

Left Upper Quadrant Go ahead

Correct

This is amorphous or
cloud-like calcification.
That implies calcification in
a solid organ or tumor. In
the left upper quadrant
the organ that has this
shape is the pancreas. This
is calcification in chronic
pancreatitis.
What kind of calcification is this and what might it be?

Rim-like

Track-like

Laminar

Amorphous

Right Upper Quadrant Go ahead

Correct

These are laminar or

lamellated calcifications. This
implies they formed within a
hollow viscous. In the right
upper quadrant, that would
be the gallbladder. These are
gallstones.
What kind of calcification is this and what might it be?

Rim-like

Track-like

Laminar

Amorphous

Left Upper Quadrant

Go ahead
Correct

This is track-like
calcification which
implies calcification in
the wall of a tubular
structure like an artery
or the ureter. In the
LUQ, this is the splenic
artery, calcified and
tortuous from
atherosclerosis.