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Abdominal X-Rays for Phase 4
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A Systematic Approach…
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Date of Film Patient Name Patient Age Sex Adequate area covered
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Topics Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film
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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)
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Stomach gas Gas in a few loops of small bowel Gas in rectum Gas in ascending colon
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Large or small bowel? Small Bowel 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)
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Some reflux of air into terminal ileum
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Where is the level of obstruction?
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Distal descending colon cancer proven at barium enema
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32 year old patient, poorly controlled ulcerative colitis, presenting with bloody diarrhoea and severe abdominal pain
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Very dilated transverse colon (>6cm)
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Oedematous mucosa descending colon (“thumbprinting”)
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Normal gas pattern in ascending colon and caecum
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Sigmoid Volvulus Apex of loop in left upper quadrant
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Caecal Volvulus
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Management of Volvulus Sigmoid Trial of flatus tube / sigmoidoscopy Caecal Surgical
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Faecal Material Mottled appearance Wide range of normal amount Within large bowel
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Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film
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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
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Pneumoperitoneum
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Erect Chest X-ray is the best initial test for excluding perforation
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Free gas under diaphragm Pneumoperitoneum
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Lateral decubitus view
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Free intraperitoneal gas
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Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film
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Gallstones
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Bladder stones
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Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film
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Soft Tissues AXR relatively insensitive unless very large enlargement May see bowel displacement
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2 hours later ….after bladder catheterisation
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Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of film
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Clue : 77 year old with known colon cancer and lower back pain
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Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects
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Other foreign objects Sterilisation Clips –Should both lie in the pelvis Surgical Clips –Cholecystectomy Hip prostheses Retained swabs / needles very rare
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Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects Periphery of Film
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Lung bases Hernial orifices Subcutaneous tissues
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Summary Clinical context is very important Remember to have a systematice approach
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