1. Positioning Considerations of the Abdomen

2. Evaluation Criteria Structures shown Position/projection
Collimation/central ray
Exposure criteria
Acceptable and unacceptable abdominal images based on errors i.e.:
Motion
Collimation
Positioning
Exposure factors
Side markers and patient demographic information
RADIATION PROTECTION FOR MALES, FEMALE REPRODUCTIVE ORGANS ARE IN THE AREA OF INTEREST.
Every time a radiographer completes an image, an evaluation must be made to determine whether the image is diagnostically optimal for the radiologist to provide an accurate diagnosis. A radiologist should NEVER have to return an image for repeat if proper evaluation of the image is done by the radiographer.
Here are five basic criteria for radiographic evaluations and critique. These should be used every time a radiographic image is performed.

3. Abdominal Quadrants and Regions
I don’t have images 5-7 and 5-8
The abdominopelvic cavity is subdivided into the abdominal and pelvic cavities. The abdominopelvic cavity contains many vital organs and body systems, i.e. gastrointestinal, genitourinary, and hepatobiliary systems. Abdominal organs and structures are difficult to visualize because their densities are similar to those of surrounding structures. The abdomen is divided into a quadrant system to localize the organs contained in the abdominal pelvic cavities. <Image #5-7> Then the abdomen is further divided into the nine regions. (Image #5-8) Contrast media must frequently be used to visualize the various organs and structures.
The routine positions/projections of the abdomen include
AP supine/KUB
AP upright
PA chest upright
These three positions/projections make up the acute abdominal series
Alternative positions/projections consist of the PA
Lateral decubitus
Lateral abdomen

4. AP Supine/KUB Abdomen Basics
<images >
The AP supine/KUB abdomen often serves as a scout image for various radiologic exams (e.g., GI, GU). It is valuable for visualizing abdominal masses, calcifications, foreign bodies, and intestinal obstructions. The AP projection also provides a general survey of the abdominal gas pattern, soft tissue shadows organ configuration and skeletal structures.

5. AP Supine/KUB Abdomen Criteria
Technical Considerations
Grid
kVp range, 70-80
SID: 40 inches (100cm)
IR: 14X17 inch (35x43 cm) lengthwise
Radiation Protection
Females are generally not shielded because the female reproductive organs lie in the area of interest.
Patient Position
Laying supine (face up) on the table
Part Position
Midsagittal plane of the body is centered to the midline of the table
Shoulders adjusted to lie in the same transverse plane with arms laying at the patient’s side, away from the body
Pelvis adjusted so that it is not rotated (distance from anterior superior iliac spine and tale top is the same on both sides)
Knees flexed for patient comfort
Central Ray (CR)
IR positioned so that the lower border is at the level of the greater trochanter (symphysis pubis)
CR perpendicular to midpoint of the IR (centered at the level of the iliac crests).
Patient Instructions
“Take in a deep breath, let your breath out. Don’t breathe or move.”
Evaluation Criteria
Pelvis and abdomen should not be rotated as evidenced by:
Symmetrical iliac alae
Spinous processes in center of vertebral bodies
Vertebral column is in center of radiograph
A portion of the symphysis pubis must be included on the bottom portion of the image
Density should be sufficient to demonstrate bony anatomy of pelvis and soft tissue structures of the abdomen
Additional Information
When imaging a hypersthenic (large and wide) patient, two 14x17in. (35x43 cm) image receptors (IR) should be used to cover the entire abdominal area.
Click each button for more information about AP supine/KUB abdomen imaging.
Guidelines
Evaluation Criteria
Additional Information

6. Knowledge Check < (Image(s) 4-2 Answers 4-1)
Label the radiographic anatomy:
Liver, 12th rib, Edge of psoas major muscle, Sacrum, Coccyx, Symphysis pubis, Transverse Process L4, Left iliac crest
<Image 4-3>
1.What is the principle reason this AP supine abdomen image needs to be repeated?
Good image no repeat,
Image underexposed
Symphysis pubis not included
Patient rotated

7. AP Upright Abdomen Basics
<Images 2 and 3-4>
The AP upright projection of the abdomen is most valuable for demonstrating free intraperitoneal air and air/fluid levels. It is also good for visualization of soft tissue structures, bowel gas patterns, and skeletal structures.

8. AP Upright Abdomen Criteria
Technical Considerations
Grid
kVp range 75-85
SID: 40 inches (100 cm)
IR: 14x17 inch (35x43 cm) lengthwise
Radiation Protection
Females are generally not shielded because of the female reproductive organs lie in the area of interest.
Patient Position
Erect with the patient’s back against the upright IR.
Part Position
Midsagittal plane of the body should be centered to the midline of the upright IR
Patient’s weight should be equally distributed on both feet
Central Ray (CR)
To include the diaphragm on the image, center 2 to 3 inches (5-8 cm) above the level of the iliac crests
CR is perpendicular to the midpoint of the IR
Patient Instructions
“Take in a deep breath, let your breath out. Don’t breathe or move.”
Evaluation Criteria
The patient should be standing straight as evidenced by spine vertically aligned on image
Pelvis and abdomen should not be rotated as evidenced by:
Symmetrical iliac alae
Spinous processes in center of vertebral bodies
Diaphragm should be included at top of image and demonstrate NO motion
Density should be sufficient to demonstrate bony anatomy of pelvis and soft tissue structures of the abdomen
Additional Information
Patient should be erect for a minimum of 5 minutes before the exposure is made.
Mark the image as upright with appropriate markers.
If using a radiographic table, the table may be tilted if the patient has difficulty standing. Compression bands on the chest and legs may also be used to help support the patient. The CR remains horizontal (no angle).
The AP upright projection may be replaced by the left lateral decubitus if the patient has difficulty standing.
Click each button for more information about the AP upright projection.
Guidelines
Evaluation Criteria
Additional Information

9. Knowledge Check
1. To demonstrate the diaphragm on an AP upright abdomen, where should the CR be directed in relation to the iliac crests?
At the level of the iliac crests
2 inches (5 cm) superior to the iliac crests
At the level of the symphysis pubis
At the level of the greater trochanter

10. Lateral Abdomen Basics
Lateral Position
<Images 3-7, 3-8 & 5-1>
The lateral position of the abdomen is useful for demonstration of calcifications of the abdominal aorta and blood vessels and aneurysms.
Dorsal Decubitus
Position

11. Lateral Abdomen Criteria
Technical Considerations
Grid
kVp range: 75-85
SID: 40 inches (100 cm)
Radiation Protection
Females are generally not shielded because of the female reproductive organs lie in the area of interest.
Patient Position
Patient lying on left side.
Part Position
Knees may be bent for patient support; arms and elbows toward head so that they are not in the area of interest, shoulders and pelvis should be in the true lateral position.
Central Ray (CR)
CR perpendicular to the midpoint of the IR at the level of the iliac crests approximately 2 inches (5 cm) anterior to the midsagittal plane.
Patient Instructions
“Take in a deep breath, let your breath out. Don’t breathe or move.”
Evaluation Criteria
Pelvis and lumbar spine are not rotated
Density is sufficient to demonstrate soft tissue structures of the abdomen
Anterior portion of abdomen is demonstrated
Additional Information
Centering light should extend to the anterior margin of the abdomen
Lateral abdomen can also be performed with the patient lying supine and the CR directed horizontal
The position is called the DORSAL DECUBITUS.
Click each button for more information about lateral abdominal imaging.
Guidelines
Evaluation Criteria
Additional Information

12. Knowledge Check <Image 3-9>
What image criteria is not met in this lateral abdomen image? (mark all that apply)
No markers on image
CR is centered above the iliac crests
Image is overexposed
CR is centered lower than the iliac crests

13. Lateral Decubitus Abdomen Basics
The lateral decubitus position of the abdomen is useful for demonstrating air/fluid levels or free intraperitoneal air in cases of bowel obstruction or perforation of the viscus. It also demonstrates abdominal masses and soft tissue structures of the abdomen. The left lateral decubitus is usually performed when the patient is unable to stand for an upright abdomen image.
Image 3-6 & 5-2

14. Lateral Decubitus Abdomen Criteria
Technical Considerations
Grid
kVp range: 70-80
SID: 40 inches (100cm)
Radiation Protection
(for males) Females are generally not shielded because the female reproductive organs lie in the are of interest.
Patient Position
Patient lying on left side on top of a radiolucent support
Part Position
Patient knees slightly flexed for patient support;
Arms and elbows moved toward head to that they are not in the area of interest;
Shoulders and pelvis should be in true lateral position.
If the patient is on a radiolucent support, move the IR below the level of the support to include both sides. If both sides cannot be imaged, include the elevated side to demonstrate free air or include the dependent side to visualize fluid.
Central Ray (CR)
CR is directed horizontal, perpendicular to the midpoint of the IR.
Centered 2-3 inches (5-8 cm) above the level of the iliac crests and aligned to the midsagittal plane of the patient.
Patient Instructions
“Take in a deep breath. Let your breath out. Don’t breathe or move.”
Evaluation Criteria
Pelvis and abdomen should not be rotated as evidenced by:
Symmetrical iliac alae
Spinous process in center of vertebral bodies
Density should be slightly less than for supine abdomen to enable visualization of air/fluid levels and any free intra-abdominal air.
Diaphragm should be included and demonstrated without breathing motion
Additional Information
Lateral decubitus abdomen can be performed in either in the AP or PA position/projection
Always mark the image appropriately to demonstrate the side up
Click each button for more information about lateral decubitus abdominal imaging.
Guidelines
Evaluation Criteria
Additional Information

15. Knowledge Check
Which of the following is the correct breathing instruction for all abdominal images?
Inspiration
Breathing technique
Expiration
No breathing instructions necessary
<Image #4 Answers Image #5-6>
2. Label the anatomy:
Left iliac wing, Intestinal gas, Dome of the diaphragm, Pedicle of the lumbar spine, Spinous process of the lumbar spine, NG tube.

16. Summary
For all positions and projections of the abdomen, the patient should disrobe from the waist down and put a patient gown on without snaps. Any tubes, e.g., nasogastric (NG) should be carefully moved from the radiographic image area. Abdominal imaging provides valuable information to the physician when a patient presents with abdominal distress.