The ACUTE ABDOMEN

The role of the Plain Film Abdominal

Series
MI Zucker, MD

A dr Z Lecture

The Abdominal Series

For all acute abdominal complaints where
plain film imaging is indicated, get a
COMPLETE abdominal series
Exceptions: Suspected renal calculus or
foreign body, where a single view is OK
CT and ultrasound are often performed
after plain films

Abdominal Series
Indications:
Highest yield: Presentations suggestive of
free air or obstruction
Not very good for masses, ascites,
organomegaly, biliary tract disease, GI
bleeding and vague abdominal complaints
Yield is higher in the elderly

The Abdominal Series

Erect chest, AP supine and erect abdomen
Or, if patient unable to sit/stand:
supine chest, supine and left lateral
decubitus abdomen
For calculus or foreign body: AP supine
abdomen

The Erect Chest

Best for free air
To evaluate for intrathoracic abnormalities
presenting with abdominal complaints,
especially pneumonia (more common in
kids)

Supine Abdomen
Best for abdominal detail: Organs, bones
and joints, calcifications, fat and gas pattern

Erect Abdomen
For air-fluid levels and little else

Left Lateral Decubitus Abdomen

Substitute for erect chest (free air) and erect
abdomen (air-fluid levels) in a patient
unable to sit or stand

Indications for a single erect

abdomen film ONLY
NONE
None
None
None

The Check List

Bones and joints

Calcifications
Organs
Fat
Gas: In bowel and outside of bowel

A memory aid

First organs, bones, and stones,

Then masses, fat, and gas.
Dont forget the corner zones,
And youll always cover yoursubject

The Normal Abdominal Series

Chest
Supine abdomen
Erect abdomen
Left lateral decubitus abdomen

Chest

Supine Abdomen

Erect Abdomen

Left Lateral Decubitus Abdomen

Dont forget to look for

pneumonia

GAS
In the gut, and elsewhere

PNEUMOPERITONEUM
FREE AIR: Perforated Gut

Free Air
Best views: Erect chest and left lateral
decubitus abdomen
Erect abdomen is less sensitive
Supine abdomen is insensitive

How Sensitive?
Plain films are 85% sensitive for free air
Theoretical threshold is 2 cc
CT is much more sensitive and is the Gold
Standard

Free Air: Erect Chest

Air under the diaphragm
Usually on the right
Occasionally only seen on the left

Free Air: Erect Chest

Free Air: Erect Chest

Free Air: Erect Chest

Free Air: Left Lateral Decubitus

Right side up, left side down
Patient who cant sit or stand
Air under right abdominal wall

Free Air: Left Lateral Decubitus

Free Air: Supine Abdomen

Double bowel wall sign
Falciform ligament sign

Double Wall sign

Falciform Ligament sign

Pneumoretroperitoneum
From perforation of posterior
extraperitoneal portions of duodenum or
colon
Extension from or through the mediastinum

Pneumoretroperitoneum

Air in Biliary System

Bile ducts
Gall bladder

Air in Biliary System

Usually secondary to surgery on bile ducts
Can be due to biliary-bowel fistula from
infection or neoplasm
Rarely, can be due to infection

Air in Bile Ducts

Air in Gall Bladder

Portal Venous Air

A sign of dead or dying bowel

Portal Venous Air

The GUT
Gas and Fluid
Too Much and Too Little

The Gas Pattern

Can be specific for obstruction
Often, nonspecific: General ileus, focal
ileus, ischemia, or obstruction
A paucity of gas may be due to vomiting or
fluid-filled bowel

OBSTRUCTION
Small bowel
Colon

OBSTRUCTION
Small bowel obstruction much more
common than colon: 70:30

Small Bowel Obstruction:

Causes
Adhesions 80%
Hernia 15%
Tumors, intussusception, midgut volvulus,
etc.

Small Bowel Obstruction:

Findings
Step-ladder dilated bowel loops on supine
view
Step-ladder air-fluid levels on
erect/decubitus views
Stretch sign on supine view
String-of-pearls sign on erect/decubitus
views

How Big is Big?

In an adult, any visible small bowel is
abnormal, but small amounts often not
significant. Kids normally have small
amounts.
Jejunum over 3 cm and ileum over 2 cm
diameter is very abnormal, but not specific
for obstruction

Air, Fluid or Both?

Small bowel can be distended by either air
or fluid or both
Fluid-filled bowel may be more significant
than air-filled bowel, but often the
significance is the same

Air Filled Small Bowel

Fluid Filled Small Bowel

Air-Fluid Levels
Always abnormal in small bowel, but not
specific; often normal in colon
The height of the fluid levels, same or
different, is NOT helpful in distinguishing
ileus from obstruction

Small Bowel Air-Fluid Levels

What is Dilated?
If small bowel and colon dilated equally,
probably not small bowel obstruction:
nonspecific ILEUS
If small bowel significantly more dilated
than colon, suggests SBO
Some gas in colon does NOT exclude SBO

Ileus

Classic Small Bowel Obstruction,

Supine

Classic Small Bowel Obstruction,

Erect

Stretch Sign: Supine

String-of-Pearls Sign: Erect

SBO: Hernia

COLON Obstruction
Causes

Carcinoma of the colon 80%

Volvulus 5%
Diverticulitis 5%
Fecal impaction 5%
Everything else 5%

Colon Obstruction: Carcinoma

Colon Obstruction: Volvulus

5% of total
80% sigmoid
20% cecum

Volulus: Sigmoid

Volvulus: Cecum

Colon Obstruction:
Measurements
The cecum is the most distensible part of
the colon
A cecum of 9 cm diameter is cause for
concern
A cecum of 11 cm is impending perforation

Distended Cecum

Other Emergency Conditions of

the Gut
Toxic megacolon: Crohn, UC; 5cm
transverse colon is impending perforation
Enterocolitis: C. diff. and other microbes
Ischemia

Toxic Megacolon

A word on Thumbprinting
It means thickened bowel wall
It can occur acutely in C. diff. or ischemia
or hemorrhage
Chronically, it can be seen in inflammatory
bowel disease and neoplasm and a few other
less common diseases

C. diff. Enterocolitis

Ischemic Bowel Disease

Arterial emboli: A. fib., MI

Arterial thrombi: ASCVD
Venous thrombi: Hypercoag., neoplasm
Non-occulsive mesenteric ischemia: Low
flow states

Ischemia: Findings

Normal gas pattern

Non-specific ileus
Thumbprinting
Gas in bowel wall
Gas in portal vein system
Free air

Ischemia: Thumbprinting

Ischemia: CT

ACUTE APPENDICITIS

Acute Appendicitis: Findings

Normal
Focal ileus
Appendicolith
Mass
Free air is very rare

Focal Ileus

Appendicolith

Acute Appendicitis: CT

Acute Appendicitis: CT

Gall Bladder Disease

Cholelithiasis

Cholelithiasis: Ultrasound

PANCREATITIS
Acute

PANCREATITIS: Findings
Normal
General nonspecific ileus
Focal ileus: Sentinel loop, colon cut-off
sign
Pancreatic calculi are found in CHRONIC
pancreatitis, not acute

Focal Ileus

Chronic Pancreatitis

Abdominal Aortic Aneurysm

AAA
Plain films are not sensitive, but can be
diagnostic
Calcified walls of aorta can allow
measurement of lumen
AAA if over 3 cm AP diameter
Ultrasound and CT are much more sensitive

AAA

AAA: CT

A few more
The odd and the interesting

Echinococcus cyst

Ascariasis

Ascariasis

Foreign Body: Battery

Foreign Body: Battery

Tongue Ornament Misadventure

Body Packer or Mule

Customer of Body Packer

???

GOODBYE

Copyright 2004
MI Zucker, MD