1. The Abdominal X-Ray

2. The Abdominal X-Ray: The abdominal x-ray (AXR) has a much more limited value in diagnosis than a chest x-ray. The radiation exposure of an AXR compared to a CXR is also considerably higher. One AXR is equivalent to 35 CXRs. The AXR is of most use in the patient with an acute abdomen. It may guide further imaging with other imaging modalities. As with a CXR, an appreciation of normal structures is vital.

3. Abdominal X-Ray Projections: Supine 99% Erect Lateral decubitus. Knowledge of the anatomy of the abdomen allows localization of the abnormalities observed on the AXR.

4. Anatomy on the Abdominal X-Ray:

5. Abdominal X-Rays:

6. Film Specifics and Technical Factors: Film Specifics: Name of Patient Age & Date of Birth Location of Patient Date Taken Film Number (if applicable ) Film Technical factors: Type of projection (Supine is standard) Markings of any special techniques used The initial assessment of an AXR is the same as for a CXR :

7. Assess the Film in Detail: A simple guide to interpretation is shown as follows: 1.Dark Shadows 2.White Shadows 3.Grey Shadows 4.Bright white Shadows

8. BLACK SHADOWES ‘BLACK SHADOWS’ = GASSES Intra-luminal gas can be normal. Extra-luminal gas is abnormal. However, intra-luminal gas can be abnormal if it is in the wrong place or if too much is seen. The maximum normal diameter of the large bowel is 55mm. Small bowel should be no more than 35mm in diameter.

9. Places to look for abnormal extra-luminal gas Under the diaphragm In the biliary system Within the bowel wall

10. Key to densities in Abdominal X Ray Black: gas White: calcified structures Grey: soft tissues Darker grey: fat Intense white: metallic objects

11. Assess the Film in Detail: Natural presence of gas within the bowel allows assessment of caliber - although the amount varies between individuals. The caecum is not said to be dilated unless wider than 80mm. Large and small bowel may be distinguished by looking at bowel wall markings, as shown in the box below.

12. The haustra of the large bowel extend only a third of the way across the bowel from each side, whereas the valvulae conniventes of the small bowel transverse the complete distance.

13. It is usual to see small volumes of gas throughout the GI tract and the absence in one region may in itself represent pathology. For example, if gas is seen to the level of the splenic flexure and nothing is seen beyond this, a site of the obstruction at this site – a ‘cut off’ point is noted.

14. Abdominal X-Rays: AXR-3 AXR-4

15. Small Bowel

16. Colon with barium contrast Large bowel

17. Small bowel

18. Large bowel

19. Small bowel

20. Barium meal, stomach, duodenum and jejunum

21. Assess the Film in Detail: Intra-luminal Gas: Low Small Bowel Obstruction

22. Assess the Film in Detail: If bowel obstruction is observed try to look for the cause. For example a hernia as the cause of obstruction. Hernia

23. Assess the Film in Detail: Extra-luminal Gas: When bowel becomes obstructed, or any other gas containing structure perforates, its contain gas becomes extra-luminal. Extra-luminal gas is never normal, but may be seen following intra-abdominal surgery or endoscopic retrograde cholangio - pancreatography (ERCP). Extra-luminal gas seen on erect CXR.

24.  Causes of Extra-luminal gas: 1. Post Abdominal Surgery/ERCP 2. Perforation of viscous (e.g.. bowel, stomach) 3. Gallstone ileus 4. Cholangitis ( infection with gas forming organisms) 5. Abscess An erect CXR (not AXR) is the best projection to diagnose a pneumoperitoneum (gas in the peritoneal cavity).

25. WHITE Shadows : WHITE SHADOWS’ = Calcification Calcified structures are often seen on AXR. The main question is – does its presence have any important implications. Calcification can be broadly divided into 3 types: (1)Calcium that is an abnormal structure - eg. gallstones and renal calculi (2)Calcium that is within a normal structure, but represents pathology - eg. nephrocalcinosis, (3)Calcium that is within a normal structure, but is harmless - eg. lymph node calcification. Bones are normal ‘white’ structures. On the AXR they comprise mainly those of the thoraco-lumbar spine and pelvis. Findings are largely incidental as direct bone pathology would be investigated with specific views.

26. Renal Stones

28. STAGES OF HYDRONEPHROSIS

29. HYDRONEPHROSIS AND HYDROURETER

30. Kidneys ureters and stones

31. NORMAL IVU

32. HYDRONEPHROSIS

34. RENAL STONES

35. Pancreatic Calcification

36. GREY SHADOWS: ‘GREY SHADOWS’ = Soft Tissues Soft tissues represent most of the contents of the abdomen and feature heavily in the AXR. However, these tissues are poorly seen when compared to other imaging techniques such as ultrasound or CT. The kidneys, spleen, liver and bladder (if filled) can be seen in addition to psoas muscle shadows and abdominal fat. Rarely would action be taken on the basis of this imaging alone.

37. Splenomegaly

38. Psoas muscle

40. Psoas Abscess

41. BRIGHT WHITE SHADOWS: ‘BRIGHT WHITE BITS’ = Foreign Bodies Foreign Bodies represent an interesting final observation. Objects that may be seen include ingested foreign bodies, items in the path of the x-ray beam such as belt buckles, dress buttons and jewelry. Other objects may have been deliberately placed for example an aortic stent, an inferior vena cava filter or a suprapubic urinary catheter. Sterilization clips and an intra-uterine device are common findings in women.

42. Assess the Film in Detail: Sterilisation and Surgical Clips Intra-abdominal foreign bodies

43. Hernia

45. Finals Radiology Cases: Abdominal X-Ray

46. Case 1: This 67 year-old women presented to the surgical ward with a distended abdomen and vomiting. Present this x-ray Give a diagnosis and potential causes

47. Case 1: Answer Radiology Report: Plain abdominal radiograph. Multiple dilated loops of small bowel within the central abdomen. Gas is not seen in the large bowel. No evidence of hernia or gallstone to suggest potential cause of the dilated loops. These findings are in keep with a low small bowel obstruction. I would like to know if the patient has a history of abdominal surgery as the commonest cause is surgical admissions. The three commonest causes of small bowel obstruction are: Surgical adhesions Herniae Intraluminal mass eg, small bowel lymphoma or gallstone (in gallstone ileus)

48. Case 2: This 71 year-old gentleman visits his GP complaining of in his urine. He has had a number of UTI’s in recent years. Present this x-ray Give a diagnosis and potential causes

49. Case 2: Answer Radiology Report: Plain abdominal radiograph. Two rounded radio-opacities measuring 4cm within the pelvis. Both opacities are smooth in outline, laminated in nature, have the same density as bone and project over the bladder. No other renal tract calcification. Does the patient have a history of neurogenic bladder? Given the size of these stones and history of UTI’s these are bladder calculi. Bladder calculi are more common in those with a history of: UTI’s A neurogenic bladder Bladder diverticulum

50. Case 3: This patient was admitted with poor renal function. Present this x-ray Give a diagnosis and potential causes

51. Case 3: Answer Radiology Report: Plain abdominal radiograph Multiple areas of punctuate calcification project over the renal outlines bilaterally. The calcification is within the medulla of the renal parenchyma. The bones are normal in appearance. These findings are consistent with nephrocalcinosis Causes of Nephrocalcinosis include: Hyperparathyroidism Medullary sponge kidney

52. Systematic approach to viewing an abdominal film: 1. Start by identifying the name on the film and the date. 2. What is the projection of the film? Is if PA or AP? Most are PA. 3. Is the view Supine, Erect or Lateral Decubitus? Are there erect and supine films? If so decide which is which. 4. Confirm that an adequate area has been covered.

53. 5. Check exposure. If the spine is visible most structures to be seen will be visible. 6. Artefacts may be immediately obvious. Piercing of the umbilicus is very popular, especially in young women but genital piercing is not infrequent. Metallic objects are obvious. There may be clips or materials from previous surgery. Occasionally a retained surgical instrument is seen. Swabs contain a radio-opaque band.

54. Solid organs, hollow organs and bones can be classified as: Visible or not visible Normal in size, enlarged, or too small Distorted or displaced Abnormally calcified Containing abnormal gas, fluid, or discrete calculi

55. Bones Look in a specific order and keep to your regime: Lower Rib Cage Lumbar Spine Sacrum Pelvis Hip Joints

56. Check bones for: Cortical Outline Joint and Disc Space Trabecular Pattern General Bone Density Lysis, Fracture, Sclerosis Epiphyseal Lines

57. Solid organs Liver – There is soft tissue density in the right upper quadrant that displaces any bowel from this area. Spleen - Soft tissue mass in the left upper quadrant about the size of a fist. It may be clear or obscured but usually is not seen at all. Kidneys – A shadow may be visible. The left kidney is higher than the right. The upper poles tilt medially. They should be about 3 vertebrae in size.

58. Psoas Muscles - Form straight lines extending infero-laterally from the lumbar spine to the lesser trochanter of the femur. Bladder - If the bladder is full, it will appear as a soft tissue density in the pelvis. Uterus - Sits on top of and may indent the bladder. It is often not seen on plain films. Prostate - Sits deep in the pelvis. Usually only seen if calcified

59. Hollow organs Stomach - When supine, air in stomach will rise anteriorly and fluid will pool posteriorly. Small Bowel - Gas will be seen in polygonal shapes due to perstalsis. Normal small bowel is 2.5 to 3.0 cm in diameter. Valvulae may be seen crossing the entire lumen. Often little small bowel is seen on a plain film.

60. Appendix - Occasionally an appendicolith is seen. Less commonly barium from an old study, or ingested foreign bodies appear in the appendix. Colon - Start in the right iliac fossa with the caecum that may show fluid levels. Follow it up to the hepatic flexure, over to the splenic flexure, and down into the pelvis. It may be filled with air or faeces. Shape may altered by redundant bowel. The colon is in the periphery of the abdomen.

61. Normal Calcification * Costal cartilage * Mesenteric lymph nodes * Pelvic vein phleboliths * Prostate gland

62. Abnormal calcification Calcium indicates pathology in * Pancreas * Renal parenchymal tissue * Blood vessels and vascular aneurysms * Gallbladder fibroids (leiomyoma)

63. Calcium is the pathology in * Biliary calculi * Renal calculi * Appendicolith * Bladder calculi * Teratoma

64. Mesenteric lymph nodes may calcify and be confused with ureteric calculi. They are usually oval in shape. The line of the ureter is along the transverse processes of the lumbar vertebrae. Phleboliths from calcified pelvic veins may appear like bladder stones. Calcification may appear in the ageing prostate, low down in the pelvic brim. Prostate calcification may also occur in malignancy but it is not diagnostic.

65. The pancreas lies at the level of the T9 to T 12 vertebrae. Calcification occurs in chronic pancreatitis and may show the whole outline of the gland. Between the levels of T12 and L2, nephrocalcinosis may be seen. Calcification of the renal parenchyma indicates pathology including hyperparathyroidism, renal tubular acidosis, and medullary sponge kidney. Renal calculi tend to obstruct at certain sites, especially the pelviureteric junction, brim of the pelvis, and vesicoureteric junctions.

66. Calcification of blood vessels usually affects the arteries and can be quite striking. The whole vessel may be outlined by calcium. Extensive calcification may indicate widespread atheroma, especially in diabetes. Abdominal aortic aneurysms are usually below the 2nd lumbar vertebra. Calcification may make them obvious and can give a rough indication of the internal diameter. Abdominal ultrasound is required for accurate assessment, and to determine the need for surgery or follow up.

67. Gallstones are visible in only 10 to 20% of cases. Ultrasound is vastly superior but plain abdominal x-ray is often the initial investigation in patients with abdominal pain. The gallbladder may become calcified after repeated episodes of cholecystitis. This is called a porcelain gallbladder and 11% will become malignant11.

68. In the pelvic region bladder calculi may occasionally be seen. Bladder stones are usually quite large and often multiple. Calcification of a bladder tumor may also occur. Schistosomiasis may produce calcification of the bladder wall. Uterine fibroids can become calcified Sometimes ovarian teratoma may show a tooth. This is of passing interest although such an ovarian tumour can undergo torsion

69. Systematic approach to viewing an abdominal film with contrast: When we examine x.ray abdomen with contrast the following steps should followed: 1.Which organ is examined? 2.Which type of contrast? 3.Is there a pathology or not? 4.The position and view of examiantion?

70. Types of contrast examinations 1.Esophagus 2.Stomach 3.Small intestine 4.Large intestine 5.Kidney, ureters and urinary bladder

71. Contrast examination of the esophagus Barium swallow  We see if there is narrowing or dilatation.  if there is filling defect in the lumen of esophagus.  We see if contrast reached the stomach

72. Contrast examination of stomach We see if contrast reached the stomach and fill it completely. We check contrast and air in the stomach to detect the position of the patient during examination. We see the wall of the stomach if the is ulcer or tumor. There are two types of contrast positive and negative we identify them. We see whether the exam is with double or single contrast.

73. Ba meal with double contrast Patient is in supine position

74. Ba meal with single contrast

75. Gass in the fandus

76. Narrowing in the stomach Patient is standing

77. Ulcer in the wall of the stomach

78. Barium meal with single and double contrast in prone position

79. Barium meal and follow through The patient drinks a contrast medium containing barium sulfate. X-ray images are taken as the contrast moves through the intestine, commonly at 0 minutes, 20 minutes, 40 minutes and 90 minutes.

80. Barium meal and follow through

82. Crohn 's disease of distal ileum with stricturing and sacculation on the antimesenteric aspect ( curved arrows), and fissure ulcers ( small arrows ). Open arrow points to ileo-caecal valve.

83. Barium meal and follow through Aphthoid ulceration of terminal ileum (small arrows)- Note also "cobblestoning" (larger arrows).

84. Barium meal and follow through Chronic ileocaecal tuberculosis. The caecum and ascending colon are retracted craniad and are fibrotic. scarred and saccilated (curved arrows). The terminal ileum in this patient is relatively patulous (straight arrows) and probably nodular. v=ileocaecal valve.

85. Small Bowel Enema Enteroclysis examination demonstrates a segment of ileum in the right iliac fossa with wall thickening, destruction of the normal fold pattern and aneurysmal ulceration (arrowed) and mass effect

86. Small Bowel Enema Multiple moderate-sized and large diverticula present.

87. Barium Enema

88. Plain x-ray abdomen (erect film) showing multiple air fluid levels in the loops of jejunum due to small gut obstruction.

89. Plain x-ray abdomen showing marked dilatation of the large gut from caecum to splenic flexure due to large gut obstruction.

90. Plain x-ray abdomen showing dilatation of large gut due to twisted and obstructed caecum and ascending colon due to volvulus of caecum

91. Plain x-ray abdomen showing air fluid level under the right dome of diaphragm due to presence of gas in the right subphrenic abscess

92. Surgical Clips

93. Extra-luminal gas seen on erect CXR.