1. Abdominal X-Rays for Phase 4

2. A Systematic Approach…

3. Date of Film Patient Name Patient Age Sex Adequate area covered

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

5. 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)

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

7. 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)

10. Some reflux of air into terminal ileum

11. Where is the level of obstruction?

12. Distal descending colon cancer proven at barium enema

13. 32 year old patient, poorly controlled ulcerative colitis, presenting with bloody diarrhoea and severe abdominal pain

14. Very dilated transverse colon (>6cm)

15. Oedematous mucosa descending colon (“thumbprinting”)

17. Normal gas pattern in ascending colon and caecum

18. Sigmoid Volvulus Apex of loop in left upper quadrant

20. Caecal Volvulus

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

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

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

24. 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

26. Pneumoperitoneum

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

29. Free gas under diaphragm Pneumoperitoneum

31. Lateral decubitus view

32. Free intraperitoneal gas

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

35. Gallstones

38. Bladder stones

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

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

44. 2 hours later ….after bladder catheterisation

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

46. Clue : 77 year old with known colon cancer and lower back pain

47. Intraluminal gas Extraluminal gas Calcification Soft tissues Bones Foreign objects

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

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

51. Lung bases Hernial orifices Subcutaneous tissues

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