Abdominal X-ray Interpretation

DG Mahiswara
Departemen Radiologi FK Udayana / RSUP Sanglah
Denpasar
Objectives
• To review the anatomy relevant to abdominal x-rays.
• To learn a systematic approach to x-ray interpretation.
• To apply this approach to interpreting abdominal x-rays.
• To identify some common pathologies detectable by
abdominal x-ray.
 ABDOMINAL X-RAY (AXR)

• Nilai diagnosisnya lebih terbatas dibanding CXR.

• Standar AXR diambil dalam posisi telentang dimana sinar-x berada
pada proyeksi AP.
• Bisa juga dilakukan dengan pasien di posisi lateral atau tegak lurus
untuk memvisualisasikan tingkat cairan udara.
• AXR paling banyak digunakan pada pasien dengan abdomen akut.
Indications for plain abdominal radiograph
• Suspected bowel obstruction.
• Suspected perforation.
• Suspected foreign body.
• Moderate to severe undifferentiated abdominal pain with
provisional diagnosis of:
Toxic megacolon in acute IBD.
Bowel ischemia.
Metals (mercury).
• Renal tract calculi follow-up.
Surface anatomy of the abdomen
 1, 11th rib.
X -Ray anatomy of the abdomen
2, Vertebral body (TH 12).
3, Gas in stomach.
4, Gas in colon (splenic flexure).
5, Gas in transverse colon.
6, Gas in sigmoid.
7, Sacrum.
8, Sacroiliac joint.
9, Femoral head.
10, Gas in cecum
11, Iliac crest.
12, Gas in colon (hepatic
flexure).
13, Psoas margin.
 RADIOGRAF

ANTERIOR POSTERIOR
Plain films
1.Black- gas
2.Dark grey- fat
3.Grey- Fluid /soft tissue
4.White- calcified structures
5.Intense bright white- metalli objects
The right film for the right person
Is this the right patient?
– Name
– DOB
– Hospital number
Is this the right film?
– Date of x-ray
– Time of x-ray
 1
3
2
PERHATIKAN IDENTITAS PASIEN
DAN NOMER REKAM MEDIS à
SESUAI ATAU TIDAK.
PERHATIKAN TANDA R (RIGHT)
DAN L (LEFT) à POSISI FOTO
RONTGEN SUDAH BENAR.
 Abdominal X ray
1. Commonly taken in supine position
2. Anterio - posterior direction
ANTERIOR
3. Abdominal plain films have radiation
dose equivalent to 35 CXR (or 4
months background radiation)

POSTERIOR
 Staghorn calculi.
Gallbladder stones.
 Gas pattern
What is normal?
• Stomach
– Almost always air in stomach
• Small bowel
– Usually small amount of air in 2 or 3 loops
• Large bowel
– Almost always air in rectum and sigmoid
– Varying amount of gas in rest of large bowel
Pathology

ABCDE approach:
• A-Air in a wrong place.
• B-Bowel loops.
• C-Calcifications.
• D-Dense structures like soft tissue and bones densities.
• E-Everything as foreign bodies.
Pneumoperitoneum is pneumatosis (abnormal presence of air
or other gas) in the peritoneal cavity, a potential space within
the abdominal cavity.
Causes
Perforated duodenal ulcer – The most common cause of rupture in the abdomen.
Perforated peptic ulcer
Bowel obstruction
Ruptured diverticulum
Penetrating trauma
Ruptured inflammatory bowel disease (e.g. megacolon) Necrotizing
enterocolitis/Pneumatosis coli.
Bowel cancer
Ischemic bowel
Steroids
After laparotomy and laparoscopy
Breakdown of a surgical anastomosis
Bowel injury after endoscopy
Peritoneal dialysis (PD).
Vaginal insufflation (air enters via the fallopian tubes). Colonic or peritoneal infection
From chest (e.g. bronchopleural fistula).
Pneumoretroperitoneum.
• Clinical
The most common cause of pneumoretroperitoneum is perforation of
the second, third, or fourth portion of the duodenum or
retroperitoneal colon secondary to trauma, diverticulitis, or
ulceration.
Post-surgical(Post-urology or adrenal surgery).
• Radiological findings
Pneumoretroperitoneum is most often seen on the right side where
the air can outline the right kidney and the undersurface of the liver.
In contrast to pneumoperitoneum, air in the retroperitoneum does
not move freely with change in position. The gas can extend up into
the mediastinum or neck because there is no barrier between them.
Pneuombilia
• Clinical
Gas in the biliary tree is most commonly secondary to surgical procedures
such as choledochoenterostomy or sphincterotmy of the sphincter of Oddi.
It may also arise in the setting of trauma, infection by gas producing
organisms (i.e. emphysematous cholecystitis), fistulas connecting the
biliary system and the intestinal tract (i.e. from dudodenal ulcers, or
gallstones), malignant involvement of the ampulla of Vater, or as a
congenital anomaly.
• Radiological findings
Ultrasound is the modality of choice for visualizing gas in the biliary tree.
Air in the bile ducts generally causes bright linear or globular reflections
with shadowing and ring-down artifacts. The gas will move with patient
positioning. On plain film, biliary gas may be seen outlining the bile ducts
but it is important to be cautious in making this diagnosis as normal
periductal fat that surrounds and parallels the course of the bile ducts may
give the appearance known as pseudopneumobilia.
Bowel loops pathology.
Dilatasi Gaster
Ileus

• Ileus Obstruksi
q Letak tinggi
qLetak rendah
• Ileus Fungsional / Paralitik
qIleus lokal ( sentinel loop )
qIleus generalisata ( ileus paralitik )
Ileus Obstruksi
Small Bowel
– Dilated loops> 3cm
– Air/fluid levels
– Non-distended colon
Large Bowel
– As above
– Distended colon/non-distended rectum
Penyebab Ileus Obstruksi
Small Bowel
– Adhesions – most common
– Hernia
– Intussusception
Large Bowel
– Mass/tumor - most common
– Volvulus
– Hernia
– Inflammation
Gambaran Radiologi:
• Gambaran air fliud level biasanya sedikit, o.k colon berfungsi
u/reabsorbsi cairan
• Udara directum tidak ada
• Gambaran coiled spring
• Gambaran Herring bone
Herring bone app
Ileus Fungsional / Paralitik
Localized
Adjacent inflammatory process causing local
irritation/dilation
Pancreatitis, appendicitis, diverticulitis, ulcer

Generalized
Gas in small and large bowel, symmetric nair/fluid levels
Post-operative
Gambaran Radiologi
• Gambaran udara tampak pada seluruh usus à usus halus – colon
• Air fluid level lebih sedikit , kalau ada à biasanya memanjang.
Intra-abdominal calcification is common and the causes may
be classified into four broad groups based on morphology:
Stones: renal stones, ureteric stones, bladder stones, gallstones
pancreatic ductal calcification
nodal calcification: most commonly from treated lymphoma, tuberculosis or
histoplasmosis
Phlebolith, appendicolith, calcified granuloma
failed renal transplant
encapsulating peritoneal sclerosis
Conduit calcification
Calcification within the walls of any fluid-filled hollow tube:
abdominal aorta, pancreatic duct, ductus deferens, large veins
Cystic calcification
Calcification in the wall of a mass such as a cyst, pseudocyst or aneurysm. simple serous
cysts, Aneurysms, echinococcal cysts, hematoma, 'porcelain' gallbladder, calcified
appendiceal mucocele
Solid mass calcification
mesenteric nodes, adrenal calcifications, uterine fibroids
Primary tumours, e.g. ovarian dermoid, metastases, adenoma
Spleen (autosplenectomy in sickle cell disease)
Renal tuberculosis with autonephrectomy