Abdominal X-Rays for Phase 4

A Systematic Approach…

…with the clinical context always in mind…

…avoids pitfalls!

General Approach

Date of Film Patient Name Patient Age Sex Adequate area covered

Topics Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film

Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film

Normal Intraluminal Gas Stomach : Always Small Bowel : Two or three loops of non-distended bowel Normal diameter < 3.5 cm (jejunum) Normal diameter < 2.5 cm (ileum) Large Bowel : Almost always in rectum/sigmoid Normal diameter < 5 cm (colon) Normal diameter < 9 cm (caecum)

Stomach gas Gas in ascending colon Gas in a few loops of small bowel Gas in rectum

Large or small bowel? Large Bowel Peripheral Only a few loops Centrally placed Narrow angle of curvature Multiple loops Mucosal folds cross the full width of the bowel (valvulae conniventes) Large Bowel Peripheral Only a few loops Mucosal folds only cross part of the bowel width (haustra)

Mucosal folds go all the way across Small Bowel Obstruction Mucosal folds go all the way across

Mucosal folds only partly cross bowel wall Peripheral loop of caecum

Large Bowel Obstruction

Some reflux of air into terminal ileum

Where is the level of obstruction?

Distal descending colon cancer proven at barium enema

32 year old patient, poorly controlled ulcerative colitis, presenting with bloody diarrhoea and severe abdominal pain

Very dilated transverse colon (>6cm)

Oedematous mucosa descending colon (“thumbprinting”)

Toxic Megacolon SURGICAL EMERGENCY

Haustral folds do not cross all the way across Very dilated large bowel Haustral folds do not cross all the way across

Normal gas pattern in ascending colon and caecum

Apex of loop in left upper quadrant Sigmoid Volvulus

Very dilated large bowel

Normal descending colon

Apex of loop centrally / left upper quadrant

Caecal Volvulus

Management of Volvulus Sigmoid Trial of flatus tube / sigmoidoscopy Caecal Surgical

Faecal Material Mottled appearance Wide range of normal amount Within large bowel

Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film

Extraluminal Gas Invariably abnormal Exceptions Recent laparotomy / laparoscopy (<5 days) Gas in biliary tree after biliary intervention Only seen if large (>1 litre) amount of gas

Gas outlining peritoneal cavity Can see both sides of the bowel wall Gas outlining peritoneal cavity

Pneumoperitoneum

Erect Chest X-ray is the best initial test for excluding perforation

Pneumoperitoneum Free gas under diaphragm

Pneumoperitoneum

Lateral decubitus view

Free intraperitoneal gas

Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film

Normal structures that calcify Abnormal structures containing calcium Costal cartilage Pancreas Mesenteric lymph nodes Blood vessels/aneurysms Pelvic vein clots (phleboliths) Uterine fibroids Prostate gland Calculi: Biliary Bladder Renal

Gallstones

Renal Calcification

Calculi also within left ureter

BLADDER STONES

BLADDER STONES Bladder stones

Calcified Aortic Aneurysm

Pancreatic calcification

Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film

Soft Tissues AXR relatively insensitive unless very large enlargement May see bowel displacement

Bowel loops displaced Large pelvic mass

2 hours later ….after bladder catheterisation

Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film

…abnormalities may be coincidental Bone pathology Generalised problem Osteopaenia Paget’s disease Ankylosing spondylitis Localised problem Fractures Osteoarthritis Metastatic deposits …abnormalities may be coincidental

Clue : 77 year old with known colon cancer and lower back pain Lytic sacral met Clue : 77 year old with known colon cancer and lower back pain

Sacral metastasis Lytic sacral met

Fused sacro-iliac joints Ankylosing Spondylitis Bamboo spine Fused sacro-iliac joints

Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects

toothbrush lightbulbs

Other foreign objects Sterilisation Clips Surgical Clips Should both lie in the pelvis Surgical Clips Cholecystectomy Hip prostheses Retained swabs / needles very rare

Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of Film

Periphery of Film Lung bases Hernial orifices Subcutaneous tissues

Strangulated right inguinal hernia Small and large bowel obstruction Strangulated right inguinal hernia

Summary Clinical context is very important Remember to have a systematice approach

CXR Tutor …series of 9 self-directed learning presentations on Medi-CAL site Includes tubes and lines, lung cancer, pneumothorax, interstitial lung disease and a quiz

The End