1

PLAIN ABDOMINAL FILMS

The supine abdominal film
The erect chest film
The horizontal-ray abdominal film:
- Erect
- Left lateral decubitus

The supine abdomen film

Include the diaphragm & the hernial orifices
Asses:
- The preperitoneal fat line:
Blurring of the preperitoneal fat line e.g. inflammatory
- The psoas outlines:
Obliteration of psoas outlines e.g. fluid/inflammatory
exudate
- Distribution of gas
- The calibre of bowel :
N: Calibre of small bowel is 2.5 cm & colon is 5 cm.
- The thickened of bowel wall
- Displacement of bowel by soft-tissue masses.
- Calculus
3

Normal Gas Pattern

Stomach
Always

Small Bowel
Two or three loops of non-distended
bowel
Normal diameter = 2.5 cm

Large Bowel
In rectum or sigmoid almost always

Gas in
stomach

Gas in a few
loops of
small bowel

Gas in
rectum or
sigmoid

Normal Gas Pattern

Normal Fluid Levels

Stomach
Always (except supine film)

Small Bowel
Two or three levels possible

Large Bowel
None normally

Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen

Large vs. Small Bowel

Large Bowel
Peripheral
Haustral markings don't
extend from wall to wall

Small Bowel
Central
Valvulae extend across
lumen

The erect chest film

The erect chest film can assess :
Small pneumoperitoneum.
Chest conditions may mimic an acute
abdomen.
Acute abdominal conditions may be
complicated by chest pathology,
e.g. pleural effusion frequently complicate
acute pancreatitis, etc.

The erect chest film

Erect
The patients should be in position for
10 min before the film is taken.
Radiological findings:
- free gas beneath the diaphragm
- chest abnormality

10

The horizontal-ray abdominal film

Erect & left lateral decubitus.
The patients should be in position for
10 min before the film is taken.
Radiological findings:
fluid levels & free gas

11

ACUTE ABDOMEN

Perforation
Intestinal obstruction
Paralytic ileus
Acute colitis
Intraperitoneal fluid
Inflammatory conditions
Calcification associated with acute
abdominal conditions
12

Abnormal Gas Patterns

Functional Ileus
Localized (Sentinel Loops)
Generalized adynamic ileus

Mechanical Obstruction
SBO
LBO

Localized Ileus
Key Features
One or two persistently dilated loops of
large or small bowel
Gas in rectum or sigmoid

Supine

Sentinel Loops/Localized ileus

Prone

Sentinel Loops
Cholecystitis

Appendicitis

Pancreatitis
Ulcer

Diverticulitis
Ulcer
Ureteral calculus

Localized Ileus
Pitfalls

May resemble early

mechanical SBO
Clinical course
Get follow-up

Generalized Ileus
Key Features

Gas in dilated small bowel and large

bowel to rectum
Bowel wall Thickening
Long air-fluid levels
Only post-op patients have generalized
ileus

Supine

Generalized Adynamic Ileus

Erect

Ileus Paralitik
21

Is It An Ileus?
Is the patient immediately post-op?
Are the bowel sounds absent or
hypoactive?
If no, then it isnt an ileus

Mechanical SBO
Key Features

Dilated small bowel

Bowel wall Thickening
Little gas in colon, especially rectum
Key: disproportionate dilatation of SB

SBO

Mechanical SBO
Causes

Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception

Mechanical SBO
Pitfalls

Early SBO may

resemble localized
ileus

Mechanical LBO
Key Features

Dilated colon to point of obstruction

Multiple air fluid level=Step Ladder
Herring Bone appearances
Little or no air in rectum/sigmoid
Little or no gas in small bowel,
Ileocecal valve remains competent

Gambaran Step Ladder

28

Ileus Obstruksi
29

Supine

Prone

Large Bowel Obstruction

Mechanical LBO
Causes

Tumor
Volvulus
Hernia
Diverticulitis
Intussusception

Mechanical LBO
Pitfalls

Incompetent ileocecal valve

Large bowel decompresses into small
bowel
May look like SBO
Follow-up

Supine

Prone

Carcinoma of Sigmoid : Large Bowel Decompressed into Small Bowel

Air in
biliary
tree

SBO

Gallstone

Gallstone Ileus

Sigmoid Volvulus

Extraluminal Air
Free Intraperitoneal Air

Signs of Free Air

Air beneath diaphragm
Both sides of bowel wall
Falciform ligament sign

Crescent
sign

Free Intraperitoneal Air

Air on both sides of

bowel wall Riglers

Sign

Free Intraperitoneal Air

Football sign
Free Intraperitoneal Air

Free Air
Causes

Rupture of a hollow viscus

Perforated ulcer
Perforated diverticulitis
Perforated carcinoma
Trauma or instrumentation

Post-op 57 days
NOT perforated appendix

Extraperitoneal Air

PERFORATION
PNEUMOPERITONEUM
Require emergency surgery!

Small pneumoperitoneum (I ml of free gas)

erect chest/LLD abdominal films.

44

Small pneumoperitoneum

45

Pneumoperitoneum

46

Pneumoperitoneum

47

INTESTINAL OBSTRUCTION
= Dilated loops of bowel proximally with
non-dilated/collapsed bowel distal to the
presumed point of obstruction.

Gastric Dilatation:
Etiology:
- Mechanical gastric outlet obstruction
- Paralytic ileus
- Gastric volvulus
- Air swallowing
48

Gastric Dilatation

49

Small-Bowel Obstruction:
Etiology:
- Adhesions due to previous surgery
- Strangulated hernias
- Volvulus
- Gallstone ileus
- Intussusception
- Neoplastic, etc.

50

 Radiological appearances:

Plain film changes appear after 3-5 h

(marked after 12 h) (complete obstruction).
Supine film:
- Small-bowel dilatation with accumulation
of both gas & fluid.
- A reduction in calibre of the large bowel.

51

Small-Bowel Obstruction
due to adhesion

Multiple dilated loops of small bowel

Multiple fluid levels on erect film

52

Small-Bowel Obstruction
due to gallstone ileus
Multiple dilated loops of small
bowel are seen. A band of gas in
the right hypochondrium lies
within the common bile duct.

53

Small-Bowel Obstruction
due to Intussusception

A crescent of air at the apex of an intussusception

54

 Erect film:
- Multiple fluid levels (Stepladder pattern).
- String of beads sign
= small bubbles of gas may be trapped
in rows between the valvulae conniventes.

55

Stepladder pattern in mechanical

obstruction of the small bowel

56

Small-Bowel Obstruction:
String of beads sign

57

 Ultrasound:
- Dilated fluid-filled loops of small-bowel
obstruction.
- Assessment of the peristaltic activity.

58

 CT:

* CT should be performed whenever

there is a history of previous abd.
malignancy.
* Radiological appearances:
- Bowel calibre change
- Fluid-filled loops
- The level of obstruction
- Peritoneal adhesions

59

LARGE-BOWEL OBSTRUCTION
Etiology:
- Neoplastic (benign & malignant)
- Volvulus (caecal & sigmoid), etc.
Radiological appearances:
Depends on the state of competence
of the ileocaecal valve:

60

LARGE-BOWEL OBSTRUCTION
due to Sigmoid Volvulus
The hugely dilated ahaustral loop
of sigmoid can be seen rising out
of the pelvis in the shape of an
inverted U. Haustrated ascending
& descending colon separate from
the volved sigmoid loop.

61

LARGE-BOWEL OBSTRUCTION
due to Caecal Volvulus
Distended caecum with its
haustral markings is lying low in
the central abdomen. There is no
significant
small-bowel
distention.

62

PARALYTIC ILEUS
Generalised paralytic ileus:
Etiology:
- Peritonitis
- Post-operative
- Hypokalaemia
- General debility or infection
- Drugs: morphine
- Congestive cardiac failure, renal colic, etc.
Radiological appearances:
- Both small & large-bowel dilatation
- Horizontal-ray films: multiple fluid levels
63

PARALYTIC ILEUS
There is generalised
dilatation
of
both
small & large bowel.

64

Localised ileus:
Etiology:
- Local inflammatory processes:
pancreatitis, cholecystitis, appendicitis, salpingitis
- Trauma:
spine, ribs, hip, retroperitoneum
- Renal colic, etc.
Radiological appearances:
- Non specific (Mimic small/large-bowel obstruction).
- Dilatation of one/two adjacent loops of bowel.

65

Toxic megacolon
A fulminating form of colitis with transmural inflammation,
extensive & deep ulceration & neuromuscular
degeneration.
Involve the transverse colon
Ro. Findings:
Mucosal islands (=pseudopolyps) & dilatation (8 cm)
Common complication:
Perforation in the sigmoid & peritonitis

66

Toxic megacolon

67

INFLAMMATORY CONDITIONS

Appendicitis
Acute cholecystitis
Emphysematous cholecystitis
Acute pancreatitis

68

Appendicitis
Signs of acute appendicitis:

- Appendix calculus (0.5-6cm)

- Localised paralytic ileus in RLQ
- Sentinel loop-dilated atonic ileum containing
a fluid level
- Widening of the preperitoneal fat line
- Blurring of the preperitoneal fat line
- Blurring of the right psoas outline-unreliable
cont
69

Appendicitis
- Scoliosis concave to the right
- Dilated caecum
- Right lower quadrant (RLQ) mass identing
the caecum on its medial border (abscess
formation)
- RLQ haze due to fluid & oedema
- Gas in the appendix-rare, unreliable.

70

Small bowel obstruction due to

Appendix abscess
Appendix abscess causing
small-bowel obstruction.
A small gas bubble which lies
within the abscess is seen in
the right iliac fossa.

71

 Ultrasound signs of acute appendicitis :

- Blind-ending tubular structure at the point
of tenderness:
Non-compressible
Diameter 7 mm
No peristalsis
- Appendicolith casting acoustic shadow
- Surrounding fluid/abscess

72

Acute appendicitis

73

Acute appendicitis

Acute appendicitis with appendicolith.

Abscess formation & appendicolith.

74

Acute cholecystitis
Plain abdominal film:
- Gallstones seen in 20%
- Duodenal ileus
- Ileus of hepatic flexure of colon
- Right hypochondrial mass due to enlarged
gallbladder
- Gas within the biliary system
- Normal plain films in two-thirds of cases

75

 Ultrasound imaging:
- A circumferential halo of low echogenicity
with thickening of the gallbladder wall
(8-10mm) in fasting state.
- Indistinct contour to the gallbladder wall
- Fluid around the fundus of the gallbladder
- Gallstones casting acoustic shadow
- A distended gallbladder (a stone obstructing
the cystic duct)
- Echogenic sediment in the lumen
- Positive sonographic Murphy sign
76

Acute cholecystitis

77

CHRONIC CHOLECYSTITIS
Ultrasound imaging:
- A contracted gallbladder
- Sometimes, obliteration of the lumen
- Thickening of the gallbladder wall & strongly
reflective
- Cholelithiasis

78

CHRONIC CHOLECYSTITIS

79

Acute pancreatitis
Plain chest film:
- A left side pleural effusion
- Basal parenchymal shadowing
- Elevated left hemidiaphragm-unreliable
Plain abdominal film:
- Normal plain films in two-thirds of cases
- Duodenal ileus
Gas in a dilated duodenal loop in the LLD
- A gasless abdomen due to vomiting
cont
80

Acute pancreatitis
- Generalised paralytic ileus
- Dilated loops of bowel (small bowel, terminal
ileum, ascending & transverse colon)
- Loss of the psoas outline
- Multiple small bubbles within the pancreas
(pancreatic abscess)
- Pancreatic calcification-unreliable

81

 Ultrasound signs of acute pancreatitis:

- Contours: smooth & well delineated
- Enlargement
- Echotexture: heterogeneous, hypoechoic to anechoic
& less echogenic than the liver
- Associated signs: venous compression, pleural
effusion, ascites, duodenal atony

82

ACUTE PANCREATITIS

83

 CT signs of acute pancreatitis:

- Necrosis, haemorrhage, & solid parenchyma that

enhances with i.v.contrast medium
- Abscess
- Pancreatic pseudocyst
- Extrapancreatic fluid collection
- Ascites

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85

BLUNT HEPATIC TRAUMA

The third most common organ injured in the
abdomen.
The need for surgery is determined by the size
of the laceration, the amount of hemoperitoneum,
& the patients clinical status.
Ultrasound findings:
- Laceration (3%) (right lobe > left lobe)
86

- Intrahepatic hematoma:
* Hyperechoic in the first 24 hours
* Hypoechoic & sonolucent thereafter
- Subcapsular hematoma:
* Unilateral, along the area of laceration
* Anechoic, hypoechoic, septated lenticular,
or curvelinear (DD/ascitic fluid)
- Capsular disruption
- Intraperitoneal fluid
87

Ultrasound findings

A crescent-shaped hyperechoic collection along the right lateral aspect of the liver
consistent with subcapsular hematoma.

88

BLUNT HEPATIC TRAUMA

89

BLUNT HEPATIC TRAUMA

90

BLUNT HEPATIC TRAUMA

91

SUBACUTE SUBCAPSULAR
HAEMATOMA OF THE LIVER

92

BLUNT HEPATIC TRAUMA

93

HEPATIC CONTUSION WITH

HAEMATOMA

94

SPLENIC INJURY
Most commonly injured
Ultrasound findings:
- Splenomegaly, with progressive enlargement
- Irregular splenic border
- Intrasplenic hematoma
take longer
- Contusion (splenic inhomogeneity)
- Subcapsular and pericapsular fluid collections
- Free intraperitoneal blood (disappear 2-4 weeks)
- Left pleural effusion
- When the spleen returns to normal small irregular
foci /normal parenchyma
95

SPLENIC INJURY

96

SPLENIC INJURY

97

HAEMOPERITONEUM
(FRAGMENTED SPLEEN)

98

BLUNT PANCREATIC INJURY

99

BLUNT PANCREATIC INJURY

100

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