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22]

Original Article
Assessment of Image Quality of Plain Abdominal Radiographs at a
Northwestern Nigeria Tertiary Hospital

Abstract Hassan Maidugu

Musa, without optimal image
Background: Image quality has a significant effect on the accuracy of radiographic diagnosis, and
quality many vital information might be missed and that will affect patient Suleiman Lawal, management negatively. This
work is aimed at assessing the image quality of plain abdominal
Aliyu Galadima,
radiographs, which is one of the most frequent emergency radiographic examinations done, using the radiographic technical
parameters and the guidelines of image quality criteria set by the European Abubakar G.
Commission (EC) as the measuring criteria for the development of quality assurance program. Mathew1,
Materials and Methods: A prospective survey of anteroposterior erect and supine plain abdominal Aliyu Sadiya Musa,
radiographs of adult patients produced at Ahmadu Bello University Teaching Hospital from August Halimat Shadiat A. 2019
to October 2019 was conducted assessing its quality based on the radiographic technical
Umar, parameters
and the guideline set by the EC for assessing image quality using a data capture sheet.
Results: Plain abdominal radiographs of 92 adults comprising, 55.4% male, 44.6% female, 42.4% Chibuike Onyesoh erect, and
57.6% supine, were evaluated. The finding of the study revealed that image quality criteria Department of Radiology, on radiographic
technical parameters were optimal in 2%, suboptimal in 50%, and poor in 48%. The Ahmadu Bello University image quality based on the
EC guideline result shows that only 3% of the reviewed plain abdominal Teaching Hospital, Zaria,
radiograph were optimum, 63.0% were suboptimal, and 34% were poor. Furthermore, the study 1
Department of Medical
Radiography, University of
proves that gender has no significant effect (P = 0.985) on the image quality based on radiographic
Maiduguri, Maiduguri, Nigeria
technical parameter, whereas image quality based on the EC guideline is significantly influenced by gender ( P = 0.023). Conclusion:
The quality of plain abdominal radiographs produced at this center during this period was abysmal; hence, rigorous quality control
programs, familiarization of the radiographers with the guidelines for assessing image quality, and total replacement of obsolete
equipment need to be instituted.

Introduction of people and the specific intended

purpose. It can be studied physically
Plain abdominal radiograph is among the Submitted:
(objectively) or by intuition
common radiographic examination that 17-May-2020
(subjectively). For instance, a radiologist
forms a part of medical assessment, Revised: 30-May-2020
observing a radiograph may be concerned
particularly in accident and emergency
chiefly in its diagnostic worth; the Accepted:
departments. Plain abdominal
radiographer, on the other hand, may only 22-Jun-2020
radiographs play a vital role in assessing
the level of patient preparation for concentrate on how well the radiograph Published:
contrast-based examinations involving represents the various 25-Sep-2020
the gastrointestinal tract and urogenital anatomical structures.[4,5]
system; it is also used in demonstrating Imaging process, characteristics of Address for
kidney stones and other forms of
equipment, and imaging system variables correspondence:
calcifications.[1,2] Dr. Suleiman Lawal,
selected by the operator determine the
Department of Radiology,
Plain abdominal radiography can be image quality of a radiograph.[6] Thus, an Ahmadu Bello University
readily accessed in low-income countries ideal set of guidelines and parameters to Teaching Hospital, Zaria,
such as Nigeria within a short time, describe image quality is expected to Nigeria.
E-mail:
thereby assisting the referring physician talksuleiman@yahoo.
in having com
Keywords: Abdomen, image quality, radiographs

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Musa, et al.: Assessment of image quality

measure the effectiveness with which a

a clue of the disease or even arrive at a
[3] radiograph can be used for its intended
definitive diagnosis. purpose.[5-7] Studies of image quality are Access this article online

Image quality is a broad term and its essential for optimization of the radiography definition Website: www.jrmt.org
depends on different categories processes in any clinical settings.[7,8,9] DOI: 10.4103/JRMT.JRMT_4_20

Quick Response Code:

How to cite this article: Musa HM, Lawal S,

Galadima A, Mathew AG, Musa AS, Umar HS, et al.
Assessment of image quality of plain abdominal
radiographs at a northwestern Nigeria tertiary
hospital.
J Radiat Med Trop 2020;1:33-7.

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© 2020 Journal of Radiation Medicine in the Tropics | Published by Wolters Kluwer - Medknow
According to the American College of Radiology (ACR)
guidelines on assessing the quality of abdominal
radiography, all abdominal radiographs that are performed
should include the pubic symphysis and both
hemidiaphragms and extend sufficiently laterally to ensure
that the entire bowel is included as well as both flanks.[10]
In general, high-quality radiographs provide maximum
diagnostic information by improving the chance for correct
diagnosis and ultimately contribute to quality patient care.
[9,11]
Guidelines have been set by the European Commission
(EC) that defines the diagnostic requirements for a normal
basic radiograph, specifying anatomical image criteria and
important image details.[12] The objectives of this study are
to assess the quality of plain abdominal radiographs
produced at Ahmadu Bello University Teaching Hospital
(ABUTH), Zaria, based on radiographic technical
parameters and the guidelines set by the EC on assessing
image quality and to determine relationship between gender
and image quality. This center as it stands now has no
quality assurance program in place. Furthermore, no prior
research in this area has been documented, hence
necessitating the need for baseline data or reference point
for feature quality assurance program or as guide for future
studies. This study is therefore an initial program intended
to verify the quality of abdominal radiographs in this
facility and then its subsequent management.
Research hypothesis
Ho = Gender has no effect on the quality of plain abdominal
image based on radiographic technical parameters and the
guidelines set by the EC.
H1= Gender has an effect on the quality of plain abdominal
image based on radiographic technical parameters and the
guidelines set by the EC.
Materials and Methods
This prospective survey was conducted at ABUTH,
northwestern Nigeria, involving plain abdominal
radiographs of 92 adults, assessing the image quality based
on radiographic technical parameters and the guidelines set
by the EC for assessing image quality. The radiographs
were obtained using General Electric Medical System X-ray
machine, Model: MS-18S Manufactured: October 2004,
Japan and Fujifilm Computed Radiography Model:
CR-IR392 Manufactured: October 2015, Tokyo-Japan.
Ethical clearance was obtained from the health research
ethics committee of the institution.
Data capture sheet includes patients sex, radiographic
position, radiographic technical parameters (i.e presence of
full patient identification, correct placement of anatomical
marker, evidence of adequate collimation including both
hemidiaphragms, pubic symphysis, and flanks laterally,
evidence of no rotation to one side and artifacts), EC
guidelines for assessment of image quality (i.e visualization
of kidney, liver and psoas muscles outlines, area of
coverage, image centralization and visually sharp
reproduction of bones).
A radiograph is considered to be optimal if all the 5
radiographic technical parameters are met, suboptimal if 3–
4 of the radiographic technical parameters are met, and poor
if <3 of the radiographic technical parameters are met.
Moreover, a radiograph is considered to be optimal if all the
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Musa, et al.: Assessment of image quality

6 parameters of EC guideline for image quality criteria are
met, suboptimal if 3–5 of the criteria are met, and poor if
only <3 of the criteria are met. AP supine radiograph can be
performed as a standalone projection or as part of an acute
abdominal series, depending on the clinical question posed,
local protocol, and the availability of other imaging
modalities. Pearson’s Chi-square test was used to test
hypothesis and P < 0.05 was considered statistically
significant.
Technique of plain abdominal radiography
The gowned patient lies on the X-ray table with both
shoulders and hips equidistant from the table for the supine
radiograph, while in erect radiograph, he stands with ventral
abdomen toward the image detector.
Projection is anteroposterior at full inspiration for supine
and posteroanterior for the erect. The centering point is the
midsagittal (equidistant from each anterior superior iliac
spine) at the level of the iliac crest and 5 cm above the level
of iliac crest for supine and erect, respectively. Collimation
includes the lateral abdominal walls, the diaphragm and
lung bases, and inferior to the inferior pubic rami.
Radiographic orientation is portrait, detector size of 35 cm x
34 Journal of Radiation Medicine in the Tropics | Volume 1 | Issue 1 | January-June 2020
43 cm was used, and exposure factors were 70–80 kVp and
30–120 mAs.[13]
Results
Plain abdominal radiographs of 92 adult subjects were
assessed, out of which 55.4% (n = 51) were male and 44.6%
(n = 41) were female. Furthermore, 42.4% (n = 39) of these
radiographs were erect, while 57.6% (n = 53) were supine.
As shown in Table 1 and Figure 1, image performance
analysis based on radiographic technical parameters shows
that only 2% of the images were optimal, while 50% were
suboptimal and 48% were poor. The detail revealed patient
identification to be adequate in only 4.3% (n = 4) and not
adequate in 87.0% (n = 80) of the radiographs, and
collimation shows 40.2% (n = 37) adequate and poor in
33.7% (n = 31). In 92.4% (n = 85) of the radiographs,
anatomical maker was present, whereas it was absent in
7.6% (n = 7). Symmetrical presentation of structures (i.e.,
absent of rotation) was observed in 68.6% (n = 63) of the
radiographs, while 31.4% (n = 29) showed presence of
rotation. Artifacts were absent in 84.8% (n = 78) of the
radiographs, whereas 15.2% (n = 14) were denuded by the
presence of artifact.

Table 1: Results of assessed radiographic technical parameters and European Commission guideline criteria
Radiographic Technical Parameter

Adequate Not Adequate Poor

Patient Identification 4.3% (n=4) 87.0% (n=80) 8.7% (n=8)

Evidence of good collimation 40.2% (n=37) 26.1% (n=24) 33.7% (n=31)
Present Absent

Anatomical Marker 92.4% (n=85) 7.6% (n=7)

Rotation 31.4% (n=29) 68.6% (n=63)
Artefact 15.2% (n=14) 84.8% (n=78)
European Commission Guideline

Adequate Not Adequate Poor

Area Coverage 70.7% (n=65) 19.6% (n=18) 9.7% (n=9)

Present Absent

Kidneys outline 10.9% (n=10) 89.1% (n=82)

Psoas Muscles outline 7.6% (n=22) 92.4% (n=85)
Liver outline 64.1% (n=59) 35.9% (n=33)
Sharp Presentation of Bones 83.7% (n=77) 16.3% (n=15)
Image Centralization 62.9% (n=58) 37.1% (n=34)

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Musa, et al.: Assessment of image quality

based on these latter criteria, therefore rejecting the null

hypothesis and hence favoring the alternate hypothesis.

Figure 1: Image performance based on radiographic technical
parameters
igure 2 illustrates the image performance of the radiographs
based on EC guideline for image quality criteria revealing
only 3% of the radiographs had optimal image quality, the
majority were either suboptimal or poor ( 63% and 34%
respectively). Table 1 also displays further in-depth analysis
of the components, comprising 70.7% (n = 65) adequate
area coverage, 12.6% (n = 18) not adequate, and 9.7% (n =
9) poor. The kidney outlines were present in 10.9%, the
psoas muscles outline in only 7.6% the liver was outlined in
Journal of Radiation Medicine in the Tropics | Volume 1 | Issue 1 | January-June
2020
Discussion
The study revealed that only 2% of the reviewed plain
abdominal radiographs were optimal based on the
radiographic technical parameters, i.e., the plain abdominal
radiographs that met all the five radiographic technical
parameters, 50% were suboptimal, and 48% were poor. This
result though abysmal, its similar to the findings of
Cheema[14] at East Surrey Hospital, who reported
inadequacy of plain abdominal X-ray produced with only
18% adequacy, but in contrast to Shettima et al[11] who
reported 50.6% adequacy. The variation of this study from
the others may be attributed majorly to the grossly
inadequate patient identification as observed, having 87.0%
‘not adequate’. This is majorly because of absence of
patient age in the request form, making most of the
radiographs falling short of the five sets of criteria, which is
a wide contrast to the findings of Egbe et al. [2] who recorded
only 6.7% ‘not adequate’ and 81.3% adequate patient
identification.

Collimation, as one of the technical parameters observed

64.1% of the radiographs. The study also revealed that during the study, showed 40.2% adequate, 26.1% not
83.7% (n = 77) of the radiographs had sharp presentation of
the bones, whereas 16.3% (n = 15) were not sharp; 62.9%
(n = 58) of the radiographs were centralize, whereas Table 2: Patients gender performance in relation to
37.1% (n = 34) were not centralized. and radiographic technical parameter score (A) and
European Commission guideline for image quality
Table 2 shows the relative effect of gender on image quality
criteria (B), respectively
based on radiographic technical parameters (A) and EC
guideline (B). The former (A), revealed that only 1.9% of Gender Optimal Suboptimal Poor Total
No. (%) No. (%) No. No.
the radiographs of the male participants were optimal, 51%
(%) (%)
suboptimal, and 47.1% poor; a similar trend was observed
A 51
in the female with 2.4% optimal, 48% suboptimal, and 48%
Male 1 (1.9%) 26 (51%) 24 (47.1%) (100%)
poor radiographs, respectively. While the latter
parameter(B), show 3.9% of the male participants’ Female 1 (2.4%) 20 (48.8%) 20 (48.8%) 41
(100%)
radiographs to be optimal, 74.5% sub optimal and 21.6%
poor, also the female had 2.4% optimal, 48% sub optimal B 51
and 48% poor radiographs respectively. Male 2 (3.9%) 38 (74.5%) 11 (21.6%) (100%)
Female 1 (2.4%) 20 (48.8%) 20 (48.8%) 41
Table 3 shows the relationship between genders in the two (100%)
image quality assessment guidelines. The radiographic
technical criteria (A) showed no significant statistical
difference between the two genders (Chi-square test, P = Table 3: The correlation between gender and image
0.985). This depicts that gender does not affect image quality base on radiographic technical parameter
quality based on radiographic technical parameters, score (A) and European Commission guideline (B),
therefore affirming the null hypothesis. respectively
Value Df P
Whereas based on the EC guideline(B) significant statistical
difference exist between the two gender (Chi-square test P A 0.9
= 0.023). This depicts that gender affects image quality Pearson Chi-Square 0.029 2 85
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Musa, et al.: Assessment of image quality
No. of Valid Cases 92
B 0.0
Pearson Chi-Square 7.535 2 23
No of Valid Cases 92
adequate, and 33.7% poor. Shettima et al.[11] also found that
beam collimation is the most common factor that affects the
quality of the radiographs with only 18.8% having adequate
collimation, 6.9% not adequate, and 74.2% had poor
collimation due to misalignment of the beam or improper
collimation during procedures under collimation of the
x-ray beam resulting in irradiation of areas of noninterest
and poor beam centring resulting in cut-off of area of
interest are the cause of the “poor collimation” observed in
this study.
Another technical parameter assessed was the presence of
permanent anatomical marker, which shows 92.4%
presence. This is in line with the findings of Shettima et al.
[11]
and Egbe et al.[2] who reported 91.5% presence of
anatomical marker and 86% presence and correctly
positioned anatomical marker on the radiographs,
respectively.
Egbe et al.[2] reported that 40% of the radiographs had
rotation due to poor patient positioning and Shettima et al.
[11]
reported that 52.3% of the radiographs had rotation. This
study shows a similar finding but less proportion of
radiographs, that is, 31.4% with rotation due to poor
positioning. These narrow variations may be attributed to
difference in patients’ clinical condition as this contributes
to their ability to maintain position.
An incidence of 40.8% radiographic artifacts was reported
by Shettima et al.[11] and the artifacts were mainly due to
Figure 2: Image performance based on European Commission guideline
for image quality criteria
improper fixation resulting in thiosulfide deposit on the
radiographs produced. This study reported a very low
incidence of artifact, i.e., 15.2% and were mainly due to
elastic bands, button’s and hooks from patents’
short-knicker. This is contrary to the earlier findings of
Shettima et al.[11] in both values and nature of artifacts.
These differences could be accounted for by the use of
computed radiography in this index study as against
darkroom radiography in the former.
On the basis of EC guideline, this study revealed that 3% of
the reviewed radiograph were optimal, 63% suboptimal, and
34% poor. This is in tandem with the study of Shettima et
al.[11] whose findings also shows 3.8% adequate, but
contradict that of Egbe et al.[2] who reported quite high
adequate value of 80% in teaching hospitals, 62% in
specialist hospitals, and 74.1% in private hospitals. This
variation is attributed to the different scoring methods used;
Egbe et al.[2] considered the score of 3 and above to be
adequate, while this index study only considers the score of
6 to be adequate.
In this study, the visualization of kidney and psoas muscles
outline as components of the EC guideline revealed; 10.9%
and 7.6% respectively. These low values can be attributed
majorly to the patient’s clinical condition at the time of
examination, as most of the cases were acute abdomen with
patient in painful distress and agitated, hence staying
motionless for imaging is a difficult task. The resultant
motion blurring contributes to the poor visualization of the
kidneys and psoas muscles outline. This finding is in
keeping with that of Shettima et al.[11] who reported
visualization of kidneys outline in 9.6% and psoas muscle
outline in 16.9%.
However visualization of liver outline was in 64.1% of the
radiographs which is in contrast to Shettima et al.[11] who
reported a paltry 19.2%. The use of film-screen radiography
mainly by the latter as against computed radiography of the
index study could account for this difference.
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Musa, et al.: Assessment of image quality
Sharp presentation of bones has the highest percentage of
83.7% as observed in this study, which is in agreement with
the finding of Shettima et al.[11] who reported visualization
36 Journal of Radiation Medicine in the Tropics | Volume 1 | Issue 1 | January-June 2020
of bone in 78.1% and also as the parameter of image quality
that has the highest percentage.
Furthermore, the study revealed that 62.9% of the reviewed
radiographs were well centralized. This assertion is in line
with the finding of Egbe et al.[2] and that of Shettima et al.[11]
who reported 69.3% adequate patient positioning and
70.8% image centralization, respectively.
Shettima et al.[11] reported that 64.2% of the reviewed
radiographs were adequate in coverage, 21.2% were fairly
covered, and 14.6% were poorly covered; Cheema [14]
reported that only 18% of the reviewed radiographs
included the four anatomical land marks as described by the
ACR. Findings of this study revealed 70.7% adequate
coverage of the area of interest, 19.6% not adequate, and
9.8% poor, which is a wide disagreement with the result of
Cheemah,[14] but similar to that of Shettima et al.[11]
In this study, gender did not significantly affect image
quality when criteria for the assessment are radiographic
technical parameter; however, a significant gender effect on
the image quality was observed when EC guideline for
image quality was considered. These variations might be
attributed to the fact that all the radiographic technical
parameters have little or nothing to do with the body
physique of the individual than when compared to
individual criteria for the EC guidelines. This study, first of
its kind in this region, has brought to limelight the grossly
inadequate\substandard radiographs produced at this facility
and has revealed both the clinicians (not providing adequate
clinical\biodata on request forms) and the radiographers
(faulty radiographic techniques) to be culpable. The paucity
of literature on this subject matter and lack of adequate
information on subjects chronological age has made
assessment of image quality in terms of age difficult and
hence limited the discussion.
Conclusion
This study has unveiled that images produced at this facility
are of suboptimal quality, which has the potential of causing
missed or misdiagnosis, which could be of deleterious effect
to the patient and frustrating to the clinician. An urgent need
for improvements is desirable, and this can be achieved
using this study as a baseline, through rigorous
implementation of quality control programs, familiarizing
the radiographers with the guidelines for assessing image
quality, and total replacement of obsolete equipment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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