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AXR Interpretation
Mike Cadogan ●
Sep 19, 2023

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Abdominal X-Ray Views

The two most commonly requested films are:

Anteroposterior (AP) supine
Anteroposterior (AP) erect, or horizontal beam view.
Other views include
Lateral decubitus—horizontal beam view with the patient rolled onto one side.
A useful alternative to the erect AP view if patient is unable to sit or stand
Supine lateral—the beam is shot across the patient
KUB (kidneys, ureters, bladder)—follow-up passage of renal tract calculi.

Indications for Abdominal X-ray

Indications for plain AXR differ depending on the availability of CT or USS, which
give considerably more information.
Abdominal X-rays are only useful for certain defined pathology such as abnormal
‘gases, masses, bones and stones’.
May be useful in undifferentiated abdominal pain with a provisional diagnosis of:
Toxic megacolon in acute IBD. Colonic diameter >6 cm
Bowel obstruction (50% sensitive for acute obstruction)
Bowel ischaemia
Perforation of a viscus with abdominal free air (ask for an erect CXR as well).
(USS has higher sensitivity and specificity for perforation)
KUB for renal tract calculi: 80–90% sensitivity if radiopaque stone >3 mm
diameter.
Foreign body—following ingestion (radiodense tablets such as iron; illicit
wrapped drugs i.e. ‘body packers’), penetrating injury. [Plain AXR has 90%
sensitivity for foreign body identification.]
There is no evidence correlating AXR findings with ‘constipation’, so do not use
radiography to make a diagnosis of this.

Radio-opaque medical related abdominal ingestions

Radio-dense Tablets
Iron tablets
Potassium Chloride (KCL Tablets)
Metals
Mercury
Iatrogenic
Barium

Interpretation

A systematic approach to AXR interpretation is essential to avoid missing significant

pathological changes.

Determine the ownership, adequacy and technical quality of the film.

Name and date of birth of the patient and date radiograph was performed.
Projection.
Posture (e.g. supine or erect).
Adequacy of exposure. Look for ‘gases, masses, bones and stones’.
Gases
Look for normal or abnormal intraluminal and extraluminal gas distribution.
(Note: high inter-observer variability in interpretation of gas patterns)
Small bowel
Intraluminal gas is usually minimal, centrally located within numerous tight
loops of small diameter (2.5–3.5 cm), distinguished by valvulae
conniventes (Stack of coins), characteristic mucosal folds that stretch all
the way across the small bowel loops.
Large bowel
Has a mixture of gas and faeces located within loops of larger diameter
(3–5 cm) around the periphery, with haustra, which are mucosal folds that
stretch only part-way across the diameter of the large bowel loops.
Abnormal findings include:
Dilated loops of small or large bowel—obstruction, ileus or inflammation
Air–fluid levels on erect AXR—more than 5 fluid levels, greater than 2.5 cm
in length is abnormal and associated with obstruction, ileus, ischaemia
and gastroenteritis.
Intramural gas—ischaemic colitis
Intraperitoneal gas—perforated viscus or penetrating abdominal
injury. Rigler sign (double-wall sign) occurs when both sides of the bowel
wall can be visualised and is a good indication of free intraperitoneal gas.
However the sensitivity for detecting perforation on AXR is low and is best
confirmed as subdiaphragmatic air on erect CXR or with a CT scan.
Extraperitoneal gas—within the soft tissues, retroperitoneal structures or
chest in infection or trauma.
Masses
Look for the size and position of the solid organ shadows of the liver, spleen,
kidneys and bladder
Identify the retroperitoneal shadow of the psoas muscles. Bulging of the
lateral margin or obliteration of the psoas shadow may indicate
retroperitoneal pathology. Look for the dilated, calcified sac of a ruptured
aortic aneurysm, or adjacent bony trauma (e.g. transverse process fractures).
Bones
Look for abnormalities of the visible bones such as the ribs, spine, sacrum
and pelvis (e.g. fractures, scoliosis, degenerative disease, tumours and
metastatic deposition).
These may be incidental or provide additional information on the cause of the
abdominal pain.
Stones
Look for renal, ureteric and bladder stones/calcification.
Trace the course of the ureter from the pelvis of the kidney, along the tips of
the lumbar spine transverse processes, over the sacroiliac joint, down to the
ischial spine and medially to the bladder; 80–90% of renal tract stones are
radio-opaque, but will require non-contrast CT or USS to confirm their
position in the ureter.
Examine the RUQ and transpyloric plane at the level of L1 for evidence of
gallstones (15% radio-opaque) or pancreatic calcification. Again,
confirmation with USS or CT is indicated.

Examples of Abdominal X-Ray Pathology

Small Bowel Obstruction Small Bowel Obstruction

Erect Abdomen Supine Large bowel obstruction