Textbook of Gastrointestinal Radiology

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 TEXTBOOK OF
GASTROINTESTINAL
RADIOLOGY
 TEXTBOOK OF
GASTROINTESTINAL
RADIOLOGY
FIFTH EDITION

Richard M. Gore, MD
Chief, Gastrointestinal Radiology
Department of Radiology
North Shore University Health System
Evanston, IL, USA;
Professor
Department of Radiology
The University of Chicago Pritzker School of Medicine
Chicago, IL, USA

Marc S. Levine, MD
Professor Emeritus of Radiology
Department of Radiology
Perelman School of Medicine at the University of Pennsylvania
Philadelphia, PA, USA
Elsevier
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For Margaret, George, Elizabeth, Diana, and Aaron
RICHARD M. GORE

To my four fabulous children,

Daniel, Amy, Kevin, and Laura
My three thrilling grandchildren,
Henry, Eloise, and Sonny
My two terrific daughters-in-law,
Barrie and Kelsey
My two tremendous brothers,
Jeffrey and David
And my one and only wondrous wife,
Deborah
I love you all
MARC S. LEVINE
 LIST OF CONTRIBUTORS

Jalil Afnan, MD, MRCS Laura R. Carucci, MD

Assistant Professor of Radiology Professor of Radiology, Director of CT and MRI
Department of Radiology Department of Radiology
Tufts University Medical School Virginia Commonwealth University Health System
Boston, MA, USA; Richmond, VA, USA
Department of Radiology
Lahey Hospital and Medical Center Wei-Chou Chang, MD
Burlington, MA, USA Department of Radiology and Biomedical Science
University of California
Mark E. Baker, MD San Francisco, CA, USA
Professor of Radiology
Cleveland Clinic Lerner College of Medicine Jayakrishna Chintanaboina, MD, MPH, FACP
Case Western Reserve University Associate Clinical Professor of Medicine
Imaging Institute University of California at San Francisco
Cleveland Clinic Division of Gastroenterology, UCSF
Imaging Institute, Digestive Disease Institute, Cancer Institute Fresno, CA, USA
Cleveland Clinic
Cleveland, OH, USA Byung Ihn Choi, MD
Professor of Radiology
Stephen R. Baker, MD, MPHIL Department of Radiology
Professor Emeritus and Chair of Radiology Chung-Ang University Hospital
New Jersey Medical School of Rutgers University Seoul, Republic of Korea
Newark, NJ, USA
Peter L. Cooperberg, MD, OBC, MDCM,
Aparna Balachandran, MD FRCP(C), FACR, FFR(RCSI)hon
Department of Imaging Professor Emeritus of Radiology
University of Texas MD Anderson Cancer Center University of British Columbia
Houston, TX, USA Vancouver, BC, Canada

Emil J. Balthazar, MD Carolyn K. Donaldson, MD, RPVI

Department of Radiology
Professor of Radiology (Emeritus)
North Shore University Health System
New York University,
The University of Chicago Pritzker School of Medicine,
New York, NY, USA
Evanston, IL, USA
Ahmed Ba-Ssalamah, MD Jacob S. Ecanow, MD
Department of Biomedical Imaging and Imaging-Guided Therapy Department of Radiology
Medical University of Vienna North Shore University Health System
Vienna, Austria Clinical Assistant Professor of Radiology
University of Chicago Pritzker School of Medicine
Genevieve L. Bennett, MD Evanston, IL, USA
Assistant Professor of Radiology
Department of Radiology Ronald L. Eisenberg, MD, JD
Division of Abdominal Imaging Professor of Radiology
New York University Langone Medical Center Harvard Medical School
New York University Grossman School of Medicine Radiologist
New York, NY, USA Beth Israel Deaconess Medical Center
Boston, MA, USA
Jonathan W. Berlin, MD, FACR
Clinical Professor of Radiology Sukru Mehmet Erturk, MD
University of Chicago Pritzker School of Medicine Radiology Department
NorthShore University HealthSystem Istanbul University, Istanbul Medical Faculty
Evanston, IL, USA Istanbul, Turkey

David H. Bruining, MD Elliot K. Fishman, MD, FACR

Division of Gastroenterology and Hepatology Professor of Radiology
Mayo Clinic Johns Hopkins University
Rochester, MN, USA Baltimore, MD, USA
vii
viii List of Contributors

Joel G. Fletcher, MD Nancy A. Hammond, MD

Department of Radiology Associate Professor of Radiology
Mayo Clinic Director of the School of Ultrasound
Rochester, MN, USA Northwestern University
Chicago, IL, USA
Ann S. Fulcher, MD
Professor and Chair Karen M. Horton, MD
Department of Radiology Professor and Chairman
Virginia Commonwealth University Medical Center Department of Radiology
Richmond, VA, USA Johns Hopkins University
Baltimore, MD, USA
Helena Gabriel, MD
Professor of Radiology Aleksandar M. Ivanovic, MD
Department of Radiology Associate Professor of Radiology
Northwestern University Center for Radiology and MRI
Chicago, IL, USA Clinical Center of Serbia
University of Belgrade
Gabriela Gayer, MD Faculty of Medicine
Clinical Professor of Radiology Belgrade, Serbia
Stanford University
Stanford, CA, USA Jill E. Jacobs, MD
Professor of Radiology
Matthew D. Genet, MD Department of Radiology
Department of Radiology NYU Langone Medical Center
Northwestern University Feinberg School of Medicine New York, NY, USA
Chicago, IL, USA
David H. Kim, MD
Gary G. Ghahremani, MD Professor of Radiology
Emeritus Professor of Radiology Department of Radiology
Department of Radiology University of Wisconsin School of Medicine and Public Health
University of California, San Diego Madison, WI, USA
San Diego, CA, USA
Michael L. Kochman, MD
Seth N. Glick, MD Wilmott Family Professor of Medicine
Clinical Professor of Radiology Gastroenterology Division, Department of Medicine
Perelman School of Medicine at the University of Perelman School of Medicine at the University of Pennsylvania
Pennsylvania Philadelphia, PA, USA
Philadelphia, PA, USA
Igor Laufer, MD (Deceased)
Margaret D. Gore, MD Professor Emeritus of Radiology
Department of Radiology Perelman School of Medicine at the University of Pennsylvania
North Shore University Health System Philadelphia, PA, USA
University of Chicago Pritzker School of Medicine
Evanston, IL, USA Jeong Min Lee, MD
Professor of Radiology
Richard M. Gore, MD Seoul National University College of Medicine
Chief, Gastrointestinal Radiology Seoul National University Hospital
Department of Radiology Seoul, Republic of Korea
North Shore University Health System
Evanston, IL, USA; Marc S. Levine, MD
Professor Professor Emeritus of Radiology
Department of Radiology Department of Radiology
The University of Chicago Pritzker School of Medicine Perelman School of Medicine at the University of Pennsylvania
Chicago, IL, USA Philadelphia, PA, USA

Robert A. Halvorsen, MD (Deceased) Angela D. Levy, MD

Professor Emeritus of Radiology Professor of Radiology
Medical College of Virginia Hospitals Department of Radiology
Virginia Commonwealth University Medstar Georgetown University Hospital
Richmond, VA, USA Washington, DC, USA
 List of Contributors ix

Hsuan-Hwai Lin, MD Frank H. Miller, MD

Department of Radiology and Biomedical Science, Lee F. Rogers MD Professor of Medical Education
University of California, San Francisco Department of Radiology
San Francisco, CA, USA Northwestern University Feinberg School of Medicine
Chief, Body Imaging Section and Fellowship and GI Radiology
Dean D.T. Maglinte, MD Medical Director, MRI
Distinguished Professor (Emeritus) Chicago, IL, USA
Department of Radiology and Imaging Sciences
Indiana University School of Medicine Tara A. Morgan, MD
Indianapolis, IN, USA Associate Professor of Radiology and Biomedical Imaging
University of California
Abdullah S. Mahmutoglu, MD San Francisco, CA, USA
Attending Radiologist, Department of Radiology
Sisli Etfal Training and Research Hospital Geraldine Mogavero Newmark, MD
Istanbul, Turkey Department of Radiology
North Shore University Health System
University of Chicago Pritzker School of Medicine
Charles S. Marn, MD
Evanston, IL, USA
Professor of Radiology
Medical College of Wisconsin
Milwaukee, WI, USA Paul Nikolaidis, MD
Professor
Department of Radiology
Gabriele Masselli, MD, PhD Northwestern University
Professor Feinberg School of Medicine
Department of Radiology Chicago, IL, USA
Umberto I Hospital Sapienza University
Viale del Policlinico
Rome, Italy David J. Ott, MD
Professor Emeritus
Department of Radiology
Alec J. Megibow, MD, MPH, FACR Wake Forest University Medical Center
Professor of Radiology and Surgery Winston Salem, NC, USA
Department of Radiology
New York University Langone Medical Center Joseph W. Owen, MD
New York, NY, USA Assistant Professor
Department of Radiology
Christine O. Menias, MD University of Kentucky
Professor of Radiology Lexington, KY, USA
Department of Radiology
Mayo Clinic Betsa Parsai Salehi, MD
Scottsdale, AZ, USA; Resident
Adjunct Professor of Radiology Department of Radiology
Department of Radiology Lahey Hospital and Medical Center
Washington University Burlington, MA, USA
St. Louis, MO, USA
Perry J. Pickhardt, MD
James M. Messmer, MEd, MD Professor of Radiology
Professor Emeritus Chief, Gastrointestinal Imaging
Department of Radiology Medical Director, Cancer Imaging
Virginia Commonwealth University University of Wisconsin School of Medicine & Public Health
Richmond, VA, USA Madison, WI, USA

Joseph A. Meranda, MD Aliya Qayyum, MD

Partner Professor of Radiology
Radiology Associates of Northern Kentucky The University of Texas MD Anderson Cancer Center
Cincinnati, OH, USA Houston, TX, USA

Morton A. Meyers, MD, FACR, FACG David N. Rabin, MD

Distinguished Professor Clinical Assistant Professor
Department of Radiology Department of Radiology
Stony Brook School of Medicine North Shore University Health System
Stony Brook, NY, USA University of Chicago Pritzker School of Medicine
Evanston, IL, USA
x List of Contributors

Siva P. Raman, MD Paul M. Silverman, MD

Department of Radiology Professor of Radiology, ret.
Eden Medical Center Gerald D. Dodd Jr. Distinguished Chair
Walnut Creek, CA, USA MD Anderson Cancer Center
Houston, TX, USA
Ahsun Riaz, MD, MBBS
Assistant Professor of Radiology (Vascular and Robert I. Silvers, MD
Interventional Radiology) Department of Radiology
Northwestern University North Shore University Health System
Feinberg School of Medicine University of Chicago Pritzker School of Medicine
Chicago, IL, USA Evanston, IL, USA

Pablo R. Ros, MD, PhD Gail S. Smith, MD

Professor of Radiology and Pathology Department of Radiology
Vice Chair North Shore University Health System
Department of Radiology The University of Chicago Pritzker School of Medicine
Stony Brook University Evanston, IL, USA
Stony Brook, NY, USA
Sat Somers, MB ChB, FRCPC, FFRRCSI(Hon.),
Stephen E. Rubesin, MD FACR, FSAR, FCAR
Professor Emeritus of Radiology Professor Emeritus
Perelman School of Medicine at the University of Pennsylvania Department of Radiology
Philadelphia, PA, USA McMaster University
Hamilton, ON, Canada
Tara Sagebiel, MD
Department of Imaging Allison L. Summers, MD
University of Texas MD Anderson Cancer Center Essentia Health-Duluth Clinic
Houston, TX, USA Duluth, MN, USA

Kumaresan Sandrasegaran, MD Richard A. Szucs, MD

Professor of Radiology Chairman of Radiology
Department of Radiology Bon Secours St. Mary’s Hospital
Mayo Clinic Arizona Richmond, VA, USA
Phoenix, AZ, USA Mark Talamonti, MD
Professor and Chairman
Adeel R. Seyal, MD Department of Surgery
Department of Radiology NorthShore University HealthSystem
Saint Elizabeth’s Medical Center Evanston, IL, USA
Brighton, MA, USA
Kiran H. Thakrar, MD
Christopher D. Scheirey, MD Clinical Associate Professor
Assistant Professor Department of Diagnostic Radiology
Department of Radiology, NorthShore University HealthSystem
Tufts University Medical School; Evanston, IL, USA
Department of Radiology
Lahey Hospital and Medical Center Ruedi F. Thoeni, MD
Burlington, MA, USA Professor of Radiology (Retired)
Department of Radiology
Francis J. Scholz, MD University of California San Francisco
Attending Radiologist San Francisco, CA, USA
Department of Radiology
Lahey Clinic William Moreau Thompson, BA, MD
Burlington, MA, USA; Professor
Professor of Radiology Department of Radiology
Department of Radiology, University of New Mexico
Tufts University School of Medicine Albuquerque, NM, USA
Boston, MA, USA
Temel Tirkes, MD, FACR, FSAR
Joon Soo Shin, MD Associate Professor of Radiology and Imaging Sciences
Resident Adjunct Associate Professor of Urology
Department of Radiology Department of Radiology
University of Florida Indiana University School of Medicine
Gainesville, FL, USA Indianapolis, IN, USA
 List of Contributors xi

Mary Ann Turner, MD, FACR, FSAR Ellen L. Wolf, MD

Professor and Vice Chair of Faculty Professor of Radiology
Department of Radiology Department of Radiology
Virginia Commonwealth University Medical Center Albert Einstein College of Medicine
Richmond, VA, USA Montefiore Medical Center
Bronx, NY, USA
Camila Lopes Vendrami, MD
Department of Radiology Verity H. Wood, MBChB, FRANZCR
Northwestern University Department of Radiology
Feinberg School of Medicine Canterbury District Health Board
Chicago, IL, USA Christchurch Public Hospital
Christchurch, Canterbury, New Zealand
Patrick M. Vos, MD
Clinical Associate Professor Vahid Yaghmai, MD, MS
Professor and Chairman
Department of Radiology
Department of Radiology
University of British Columbia
University of California–Irvine
Vancouver, BC, Canada
Orange, CA, USA
Natasha E. Wehrli, MD Benjamin M. Yeh, MD
Department of Radiology Professor of Radiology
Weill Cornell Medical Center Department of Radiology and Biomedical Imaging
New York, NY, USA University of California, San Francisco
San Francisco, CA, USA
Daniel R. Wenzke, MD
Clinical Assistant Professor of Radiology Jeong Hee Yoon, MD
Department of Radiology Associate Professor of Radiology
NorthShore University Health System Seoul National University College of Medicine
University of Chicago Pritzker School of Medicine Seoul National University Hospital
Evanston, IL, USA Seoul, Republic of Korea

In the nearly 30 years since the publication of the first edition of
Textbook of Gastrointestinal Radiology, significant changes have
occurred in our discipline. Revolutionary technical and soft-
ware improvements have dramatically improved the capabilities
of computed tomography (CT), magnetic resonance imaging
(MRI), ultrasound, fluoroscopy, nuclear medicine, angiography,
and interventional radiology. The remarkable anatomic reso-
lution offered by state-of-the-art imaging techniques has been
complemented by the integration of metabolic, functional, and
molecular imaging, providing unprecedented opportunities for
the diagnosis and staging of malignant tumors. These improve-
ments have also enhanced our ability to monitor the efficacy
of conventional and novel chemotherapeutic agents, molecular-
targeted therapy, and immunotherapy.
As in the previous four editions, our organizing principle is
the integration of rapidly changing information, common sense,
and good judgment to produce a rational and useful guide for
the diagnosis of gastrointestinal disorders.
PREFACE
Unlike the previous four editions, which consisted of two
volumes, the fifth edition instead contains one volume. This
substantial reduction in the length of the text for the fifth edi-
tion challenged our contributors to update their chapters with
state-of-the-art discussions of diagnostic and therapeutic gas-
trointestinal imaging in a compact, lucid, and user-friendly for-
mat. We believe our contributors have met that challenge.
Once again, we have been fortunate to assemble a truly out-
standing group of internationally recognized authors for the
fifth edition. We greatly appreciate the time, effort, and exper-
tise required for their contributions. We trust that the collective
efforts of the authors and editors of the fifth edition will provide
both students and practitioners of gastrointestinal radiology a
valuable educational resource that is clear, comprehensive, and
easy to read.
Richard M. Gore, MD
Marc S. Levine, MD
February 2021
xiii
 CONTENTS

Video Contents xviii 13 Other Malignant Tumors of the

Esophagus 162
MARC S. LEVINE

SECTION I Abdominal Radiography

14 Miscellaneous Abnormalities of the
1 Abdomen: Normal Anatomy and Examination Esophagus 174
Techniques 3 MARC S. LEVINE

WILLIAM MOREAU THOMPSON

15 Abnormalities of the Gastroesophageal
2 Abnormal Bowel Gas Patterns and Extraluminal Junction 194
Gas in Abdomen 13 MARC S. LEVINE

JAMES M. MESSMER | MARC S. LEVINE

16 Postoperative Esophagus 203
3 Abdominal Calcifications 28 STEPHEN E. RUBESIN

STEPHEN R. BAKER | MARC S. LEVINE

SECTION Stomach and Duodenum

IV 
SECTION II Pharynx
17 Peptic Ulcers 215
4 Pharynx: Normal Anatomy and Function and MARC S. LEVINE

Examination Techniques 37
STEPHEN E. RUBESIN 18 Inflammatory Conditions of the Stomach and
Duodenum 236
5 Abnormalities of the Pharynx 49 MARC S. LEVINE

STEPHEN E. RUBESIN
19 Benign Tumors of the Stomach and
Duodenum 256
SECTION III Esophagus MARC S. LEVINE

20 Carcinoma of the Stomach and

6 Barium Studies of the Upper Gastrointestinal Duodenum 273
Tract 73 MARC S. LEVINE | ALEC J. MEGIBOW | JAYAKRISHNA
MARC S. LEVINE | IGOR LAUFER CHINTANABOINA | MICHAEL L. KOCHMAN

7 Motility Disorders of the Esophagus 81 21 Other Malignant Tumors of the Stomach and
DAVID J. OTT | MARC S. LEVINE Duodenum 290
MARC S. LEVINE | ALEC J. MEGIBOW
8 Gastroesophageal Reflux Disease 90
MARC S. LEVINE 22 Miscellaneous Abnormalities of the Stomach
and Duodenum 312
9 Infectious Esophagitis 104 RONALD L. EISENBERG | MARC S. LEVINE
MARC S. LEVINE

23 Postoperative Stomach and Duodenum 331

10 Other Esophagitides 114 LAURA R. CARUCCI
MARC S. LEVINE

11 Benign Tumors of the Esophagus 132 SECTION V Small Bowel

MARC S. LEVINE

12 Carcinoma of the Esophagus 144 24 Barium Studies of the Small Bowel 353
STEPHEN E. RUBESIN
MARC S. LEVINE | ROBERT A. HALVORSEN | RICHARD M. GORE

xv
xvi Contents

25 Computed Tomography Enterography 363 41 Ulcerative and Granulomatous Colitis:

JOEL G. FLETCHER | DAVID H. BRUINING Idiopathic Inflammatory Bowel Disease 560
RICHARD M. GORE | JONATHAN W. BERLIN |
ALEKSANDAR M. IVANOVIC
26 Magnetic Resonance Enterography 373
GABRIELE MASSELLI
42 Other Inflammatory Conditions of the
27 Crohn’s Disease of the Small Bowel 386 Colon 578
MARK E. BAKER | RICHARD M. GORE ALEKSANDAR M. IVANOVIC | RICHARD M. GORE | SETH N. GLICK  

28 Other Inflammatory Conditions of the Small 43 Polyps and Colon Cancer 585
RUEDI F. THOENI
Bowel 407
STEPHEN E. RUBESIN
44 Other Tumors of the Colon 621
STEPHEN E. RUBESIN
29 Malabsorption 418
STEPHEN E. RUBESIN
45 Polyposis Syndromes 631
ANGELA D. LEVY
30 Benign Tumors of the Small Bowel 430
TEMEL TIRKES
46 Miscellaneous Abnormalities of the Colon 640
JACOB S. ECANOW | RICHARD M. GORE |
31 Malignant Tumors of the Small Bowel 435 RICHARD A. SZUCS | ELLEN L. WOLF | FRANCIS J. SCHOLZ |
JOSEPH W. OWEN | CHRISTINE O. MENIAS | KUMARESAN RONALD L. EISENBERG | STEPHEN E. RUBESIN
SANDRASEGARAN

47 Postoperative Colon 656

32 Small Bowel Obstruction 443 CHRISTOPHER D. SCHEIREY | BETSA PARSAI SALEHI |
STEPHEN E. RUBESIN | RICHARD M. GORE JALIL AFNAN | MARC S. LEVINE

33 Vascular Disorders of the Small Intestine 455

SIVA P. RAMAN | KAREN M. HORTON | ELLIOT K. FISHMAN
SECTION Gallbladder and Biliary
VII 
34 Postoperative Small Bowel 472 Tract
TEMEL TIRKES 48 Magnetic Resonance
Cholangiopancreatography 667
35 Miscellaneous Abnormalities of the Small ANN S. FULCHER | MARY ANN TURNER

Bowel 478
STEPHEN E. RUBESIN 49 Cholelithiasis, Cholecystitis,
Choledocholithiasis, and Hyperplastic
Cholecystoses 680
GENEVIEVE L. BENNETT

SECTION VI Colon
50 Neoplasms of the Gallbladder and Biliary
36 Barium Studies of the Colon 487 Tract 707
MARC S. LEVINE | IGOR LAUFER BYUNG IHN CHOI | JEONG MIN LEE | JEONG HEE YOON

37 Functional Imaging of Anorectal and Pelvic 51 Inflammatory Disorders of the Biliary Tract 743
BENJAMIN M. YEH | WEI-CHOU CHANG | HSUAN-HWAI LIN
Floor Dysfunction 494
SAT SOMERS | DEAN D.T. MAGLINTE
52 Postsurgical and Traumatic Lesions of the Biliary
38 Computed Tomography Colonography and Tract 753
SIVA P. RAMAN | ELLIOT K. FISHMAN | GABRIELA GAYER
Evaluation of the Colon 507
DAVID H. KIM | PERRY J. PICKHARDT

39 Diverticular Disease of the Colon 526 SECTION VIII Liver

KIRAN H. THAKRAR | RICHARD M. GORE | VAHID YAGHMAI |
EMIL J. BALTHAZAR
53 Benign Tumors of the Liver 767
PABLO R. ROS | SUKRU MEHMET ERTURK
40 Diseases of the Appendix 541
DANIEL R. WENZKE | JILL E. JACOBS | EMIL J. BALTHAZAR |
NATASHA E. WEHRIL
54 Malignant Tumors of the Liver 788
PABLO R. ROS | SUKRU MEHMET ERTURK
 Contents xvii

55 Focal Hepatic Infections 819

PABLO R. ROS | SUKRU MEHMET ERTURK | SECTION X Spleen
ABDULLAH S. MAHMUTOGLU

62 Benign and Malignant Lesions of the

56 Diffuse Liver Disease 828 Spleen 953
TARA A. MORGAN | ALIYA QAYYUM | RICHARD M. GORE VERITY H. WOOD | PETER L. COOPERBERG | PATRICK M. VOS

57 Vascular Disorders of the Liver and Splanchnic 63 Splenic Trauma and Surgery 990
Circulation 859 VAHID YAGHMAI | ADEEL R. SEYAL
ALEKSANDAR M. IVANOVIC | RICHARD M. GORE |
AHMED BA-SSALAMAH

58 Hepatic Trauma and Surgery 880 SECTION XI Peritoneal Cavity

HELENA GABRIEL | NANCY A. HAMMOND |
MARK TALAMONTI | AHSUN RIAZ | RICHARD M. GORE 64 Pathways of Abdominal and Pelvic Disease
Spread 1001
JACOB S. ECANOW | ALEKSANDAR M. IVANOVIC |
SECTION IX Pancreatitis RICHARD M. GORE | MORTON A. MEYERS | DAVID N. RABIN

59 Pancreatitis 903 65 Ascites and Peritoneal Fluid Collections 1017

JACOB S. ECANOW | RICHARD M. GORE | ROBERT I. SILVERS |
FRANK H. MILLER | JOON SOO SHIN | CAMILA LOPES VENDRAMI GERALDINE MOGAVERO NEWMARK | MARGARET D. GORE

60 Pancreatic Neoplasms 924 66 Mesenteric and Omental Lesions 1026

ALEC J. MEGIBOW APARNA BALACHANDRAN | TARA SAGEBIEL | PAUL M. SILVERMAN

61 Pancreatic Trauma and Surgery 936 67 Hernias and Abdominal Wall Pathology 1037
PAUL NIKOLAIDIS | MATTHEW D. GENET | JOSEPH A. JACOB S. ECANOW | RICHARD M. GORE | GARY G.
MERANDA | FRANK H. MILLER | ALLISON L. SUMMERS | GHAHREMANI | CAROLYN K. DONALDSON | GAIL S. SMITH |
HELENA GABRIEL | MARK TALAMONTI | RICHARD M. GORE CHARLES S. MARN

Index 1053
VIDEO CONTENTS
25 Computed Tomography Enterography
Video 25.1 Enterography Demonstrating Both Jejunal and
Ileal Crohn’s Enteric Inflammation.
xviii
38 Computed Tomography Colonography and
Evaluation of the Colon
Video 38.1 CTC Interpretation.
Video 38.2 2D Detection Pitfall.
Video 38.3 2D Detection Pitfall.
Video 38.4 3D Detection Pitfall.
Video 38.5 Characterization Pitfall.
 I
SECTION

Abdominal Radiography
 1
Abdomen: Normal Anatomy and
Examination Techniques
WILLIAM MOREAU THOMPSON
CHAPTER OUTLINE
Technique
Standard Projections
Supplemental Projections
Normal Anatomy
Peritoneal Cavity
Retroperitoneum and Abdominal Wall
Pelvis
From the 1970s to 1990s, the abdominal radiograph tradition-
ally served as the initial radiologic means of evaluating patients
with suspected abdominal pathology. Since the early 2000s,
however, computed tomography (CT) has become the major
imaging procedure in patients with acute abdominal signs and
symptoms.1–3 As a screening test, abdominal radiographs have a
low diagnostic yield, especially in patients with mild or nonspe-
cific symptoms.4–6 Nevertheless, abdominal radiographs remain
useful for evaluating patients with a strong clinical suspicion of
disease (including bowel obstruction, ischemia, or perforation)
or recent abdominal surgery.2,3,7–9
Technique
STANDARD PROJECTIONS
A supine anteroposterior radiograph is the most common plain
film examination of the abdomen (Fig. 1.1). The patient should
be positioned on his or her back without rotation of the pelvis.
Maximal relaxation of the abdominal musculature is facilitated
by supporting and slightly flexing the patient’s knees to reduce
motion artifact. The film or field of view for digital imaging
should be positioned with its lower edge at the symphysis pubis
and the x-ray beam centered at the iliac crests to incorporate both
the lung bases and symphysis pubis on the radiograph. The expo-
sure is made during expiration and should begin 1 to 2 seconds
after respiration is suspended.10
Delineation of the intra-abdominal soft tissues on abdomi-
nal radiographs depends on the inherent contrast provided
by soft tissues, fat, and intraluminal gas. Radiographic con-
trast results from differential attenuation of the x-ray beam
by patients.11 Most abdominal radiographs are obtained using
routine equipment exposed at a low kilovoltage (60–75 kV),
depending on the size of the patient.10 A short exposure time
is desirable to avoid motion unsharpness. The lowest pos-
sible peak kilovoltage that can penetrate the patient and has
an acceptable exposure time should be used. Conventional
films require a reciprocating (Potter-Bucky) grid and careful
collimation to reduce scatter.10 In males with reproductive
potential, gonadal shielding should be used if the gonads lie
within 5 cm of the primary beam and if such shielding does not
compromise the study’s clinical objectives.
Portable abdominal radiographs may be obtained in
extremely ill, hospitalized patients, but these radiographs are
of lower quality than abdominal radiographs obtained in the
radiology department. Such patients are usually too ill for a
breath-hold, and most portable x-ray units have fixed milliam-
pere settings, often necessitating a higher peak kilovoltage that
decreases contrast. In addition, a stationary grid, rather than a
Potter-Bucky grid, must be used to control scatter, and when
these grids are poorly positioned, the image may be degraded
secondary to grid cutoff.
SUPPLEMENTAL PROJECTIONS
In addition to the anteroposterior supine view, other projections
may be helpful in specific clinical settings and are sometimes
included as part of a routine abdominal series. In patients with
abdominal pain, upright posteroanterior abdominal or chest
radiographs may facilitate detection of free intraperitoneal
air, small bowel obstruction, and unsuspected thoracic disease
causing abdominal symptoms (Fig. 1.2).
Upright abdominal radiographs are particularly important
for showing free intraperitoneal air (pneumoperitoneum) in
patients with an acute abdomen and clinically suspected per-
foration. It has been shown, however, that upright posteroan-
terior chest radiographs are more sensitive for detecting small
amounts of free intraperitoneal air than upright abdominal
radiographs.12 This difference in sensitivity most likely occurs
because the x-ray beam is centered at the iliac crest on abdomi-
nal radiographs, so it penetrates air beneath the diaphragm
obliquely rather than tangentially, making small gas collec-
tions more difficult to detect. Many experts therefore recom-
mend including upright chest radiographs as well as supine and
upright abdominal radiographs to complete the so-called “per-
foration” series.12–14 Even tiny amounts of free air can be detected
with the use of proper technique (see Fig. 1.2D). If patients are
too ill or debilitated to stand, however, free intraperitoneal air
can also be detected between the lateral border of the liver and
right abdominal wall on left lateral decubitus views of the abdo-
men (Fig. 1.3).
In patients with suspected bowel obstruction, upright radio-
graphs are also useful for showing air-fluid levels in the bowel
when supine radiographs show no evidence of dilated bowel or
a gasless abdomen (see Fig. 1.2A and B). Air-fluid levels can also
be shown on lateral decubitus radiographs in patients who are
too ill to stand.
Additional projections such as prone, oblique, lateral, or
coned views may be useful for better defining and localizing
3
4 SECTION I Abdominal Radiography

A B
Fig. 1.1 Normal supine and upright abdominal radiographs. (A) Supine abdominal radiograph shows a normal bowel gas pattern with gas in the
stomach (large white arrow), small bowel (small white arrow), transverse colon (large white arrowheads), and rectum (black arrowhead). The hepatic angle
(curved white arrow) is outlined by extraperitoneal fat, and the posteromedial surface of the right lobe of the liver is outlined by perirenal fat (small white
arrowheads). The left psoas muscle (black arrow) is also seen. (B) Upright abdominal radiograph shows a normal air-fluid level in the stomach (large
white arrow). Note the hepatic angle (small white arrow), posteromedial surface of the right lobe of the liver (arrowheads), left psoas muscle (large black
arrows), and splenic tip (small black arrow).

Fig. 1.2 Value of upright

abdominal radiograph in patients
with small bowel obstruction or
intestinal perforation. (A) Supine
abdominal radiograph shows a
relatively gasless abdomen in
a patient with signs and symp-
toms of intestinal obstruction. (B)
Upright radiograph in the same
patient shows multiple tiny air-fluid
levels (arrows) caused by fluid-
filled loops of dilated small bowel
with trapping of air superiorly in
these loops (producing the string-
of-pearls sign). The patient was
found at surgery to have a closed-
loop small bowel obstruction sec-
ondary to adhesions. (C) Upright
abdominal radiograph in another
patient whose supine radiograph
did not reveal any free air shows
a large amount of free intraperi-
toneal air (arrows) beneath both A B
hemidiaphragms. (D) Upright
abdominal radiograph in a third
patient shows a tiny amount of free
air (arrows) between the liver and
right hemidiaphragm.

D
 1 Abdomen: Normal Anatomy and Examination Techniques 5

mass lesions, calcifications, or hernias. When distal colonic

obstruction is suspected, prone abdominal radiographs are
more helpful than supine radiographs because colonic gas
tends to occupy the more anterior transverse and sigmoid
colon on supine radiographs (Fig. 1.4A), making it more dif-
ficult to distinguish distal colonic obstruction from an ileus.
In contrast, prone (or right lateral decubitus radiographs)
may show gas filling the rectosigmoid colon if no mechanical
obstruction is present (Fig. 1.4B), thereby differentiating ileus
from obstruction.15

Normal Anatomy
Abdominal soft tissue planes and visceral surfaces are visible on
abdominal radiographs because of the natural contrast created
by surrounding fat. Interfaces are best visualized when they are
smoothly marginated and oriented in a sagittal or transverse
plane tangential to the incident x-ray beam. Familiarity with the
location of abdominal organs and commonly visualized tissue
planes is helpful for identifying normal anatomic structures and
recognizing pathologic processes.

Fig. 1.3 Value of left lateral decubitus radiograph of the abdo-
men in a patient with pneumoperitoneum. Coned-down view of the
right upper quadrant from a left lateral decubitus radiograph shows
obvious free intraperitoneal air (arrows) between the liver and right lat-
eral abdominal wall. A supine abdominal radiograph did not show the
free air.
PERITONEAL CAVITY
Liver
In the normal adult, the liver occupies the right upper quad-
rant of the abdomen, measuring 20 to 22 cm in its greatest
transverse dimension and 16 cm in its greatest vertical dimen-
sion near its right lateral border.16 There is considerable varia-
tion in the normal shape of the liver.17 With its most cephalad
portion lying just beneath the right hemidiaphragm, the supe-
rior aspect of the liver is commonly S-shaped or concave. The
inferior edge is usually triangular, with its apex directed cau-
dad toward the right lower quadrant. Between 4% and 14% of

A B
Fig. 1.4 Value of prone abdominal radiograph in patients with suspected colonic obstruction. (A) Supine abdominal radiograph shows dilated
colon to the level of the distal descending colon with a paucity of gas in the sigmoid colon and rectum. These findings are worrisome for distal colonic
obstruction. (Note residual barium in sigmoid diverticula). (B) Prone abdominal radiograph in the same patient shows considerable gas in the sigmoid
colon (small arrows) and rectum (large arrow), indicating that the patient has a colonic ileus rather than distal colonic obstruction.
6 SECTION I Abdominal Radiography
the population have a prominent inferior component of the
right lower lobe, also known as Riedel’s lobe, which usually
extends below the iliac crest and does not by itself indicate
hepatomegaly.
Although intraperitoneal fat is not always present around
the liver, the right inferior edge of the liver (hepatic angle)
is often visible on abdominal radiographs because it indents
extraperitoneal fat in the parietal peritoneum (Fig. 1.5; see Fig.
1.1).17 This fat consists of posterior pararenal fat laterally and
perirenal fat medially. Perirenal fat may outline not only the
medial aspect of the hepatic angle but also the cephalad por-
tion of the posteromedial surface of the right lobe of the liver
(see Fig. 1.1). The hepatic angle may be obscured by blood or
effusions that infiltrate the retroperitoneal fat or by ascites that
displaces the liver edge away from the adjacent fat (Fig. 1.6).18
While the posterior edge of the liver is visible on abdominal
radiographs (see Fig. 1.1), the anterior and left lateral margins
of the liver are not.
Hepatomegaly may be recognized on abdominal radiographs
by visualization of the entire liver extending inferiorly into the
lower abdomen, elevation of the right hemidiaphragm, inferior
displacement of the hepatic flexure of the colon, and lateral dis-
placement of the lesser curvature of the stomach by an enlarged
left lobe of the liver.19
Gallbladder
The gallbladder occupies a shallow fossa on the inferior surface
of the liver between the right and left lobes and is not usually
visualized on abdominal radiographs.16 The gallbladder lies
superior and lateral to the duodenal bulb and gastric antrum
and superior to the proximal transverse colon. The fundus of
the gallbladder may occasionally be seen if it indents the sur-
rounding fat (Fig. 1.7; see Fig. 1.5A). Only about 15% of gall-
stones are sufficiently calcified to be visualized on abdominal
radiographs, so the abdominal series is a poor screening study
for gallbladder disease.
A B
Fig. 1.5 Gallbladder, liver, spleen, and stomach. (A) Supine abdominal radiograph shows the gallbladder (small black arrows), hepatic angle (large
black arrowhead), splenic tip (white arrowhead), and stomach (large black and white arrows). Note the partially visualized right kidney (small black
arrowheads). (B) Coronal computed tomography scan of the abdomen shows the hepatic angle (large arrow), splenic tip (small arrow), psoas muscles
(arrowheads), and kidneys. K, Kidney; L, liver; Sp, spleen; St, stomach.
Spleen
The spleen occupies the left upper quadrant of the peritoneal cav-
ity beneath the left 10th rib and hemidiaphragm posterolateral
to the gastric fundus.20 The normal adult spleen measures 12 cm
in length and 7 cm in width.20 The lower edge of its inferolateral
surface often indents extraperitoneal fat, and the lower medial
aspect is adjacent to the left kidney, so it may be outlined by peri-
renal fat (see Figs. 1.1B and 1.5). An enlarged spleen should be
suspected when abdominal radiographs show elevation of the left
hemidiaphragm, medial displacement of the gastric air bubble, or
the splenic tip extending below the left costal margin.19
Stomach
The stomach usually contains air and fluid and can be recog-
nized by its characteristic location in the left upper quadrant
(see Fig. 1.1). When the patient is supine, gas in the stomach
rises to the anteriorly located antrum, while fluid gravitates into
the more dependent fundus. When the fluid-filled fundus is
visible on abdominal radiographs, it can occasionally be mis-
taken for a soft tissue mass (see Fig. 1.5A). This confusion may
be eliminated on upright radiographs showing gas in the gas-
tric fundus. The stomach is a valuable landmark for identifying
space-occupying lesions in surrounding structures such as the
spleen laterally, the liver medially, and the pancreas and lesser
sac posteriorly.
Small Intestine
The small bowel occupies the central portion of the peritoneal
cavity.16 As a result, gas-filled small bowel loops may be distin-
guished from colon by their more central location as well as
their smaller caliber and thinner, more closely spaced folds, also
known as the valvulae conniventes (see Fig. 1.6A).
Although transit time through the small bowel is sufficiently
rapid to prevent swallowed air from accumulating in the small
St Sp
L
K
K
 1 Abdomen: Normal Anatomy and Examination Techniques 7

A B
Fig. 1.6 Intraperitoneal fluid (hemorrhage) in paracolic gutters. (A) Supine abdominal radiograph in a patient with a traumatic liver laceration
shows a large amount of fluid in both paracolic gutters (arrows) displacing bowel medially from the flank stripes. Note the central location of small
bowel loops with closely spaced valvulae conniventes. Also note the loss of the hepatic angle normally outlined by extraperitoneal fat. The bleed-
ing was controlled by embolization of the liver (note the radiopaque coil overlying the liver). (B) Axial computed tomography scan of the abdomen
confirms the presence of ascitic fluid displacing adjacent bowel (arrows) from the paracolic gutters.

The term nonspecific gas pattern has been used to describe

Fig. 1.7 Paracolic gutters and lateroconal fascia. Coned-down view
from supine abdominal radiograph shows the left and right paracolic
gutters between the transversalis fascia (arrowheads) and lateroconal
fascia (large arrows). Small arrows denote the gallbladder.
bowel, loops that contain small amounts of gas may be visible
on abdominal radiographs as a normal finding (see Fig. 1.1A).
In contrast, large amounts of air and fluid in dilated small bowel
indicate a prolonged transit time caused by mechanical obstruc-
tion or an adynamic ileus. Scattered gas and fluid may be pres-
ent within minimally dilated small bowel loops in a variety of
conditions, including gastroenteritis, pancreatitis, inflamma-
tory bowel disease, and aerophagia.
abdominal radiographs showing more than the average amount
of small bowel gas without clear indication of obstruction. How-
ever, this vague terminology is not helpful to the referring phy-
sician and therefore should not be used in the radiology report.
Instead, radiologists should clearly describe the radiographic
findings and the most reasonable diagnostic considerations.
Colon
The adult colon usually contains gas and fecal material that
frame the abdomen, with the small bowel located more cen-
trally. The more anterior transverse and sigmoid segments
usually contain the greatest amount of gas when the patient is
supine. Unlike valvulae conniventes in the small bowel, colonic
haustral folds are more widely spaced and usually do not cross
the entire lumen (see Fig. 1.1A).16 The caliber of the colon varies
from 3 to 6 cm, with the cecum having the greatest diameter.
Persistent cecal diameters of 9 to 10 cm or more may indi-
cate that the patient is at risk for impending perforation from
mechanical obstruction or ileus.21
The sigmoid colon and transverse colon are intraperitoneal
structures suspended by the sigmoid mesentery and trans-
verse mesocolon, respectively. Conversely, the ascending and
descending colon and rectum are fixed retroperitoneal struc-
tures. In about 20% of the population, the cecum and a variable
portion of the ascending colon have a persistent mesentery.22 In
such cases, the cecum is mobile and its position is more ante-
rior and medial than usual. Although these patients are usu-
ally asymptomatic, this anatomic variation predisposes affected
individuals to cecal volvulus or bascule.23 The sigmoid colon is
an intraperitoneal structure, but sigmoid diverticula are fre-
quently oriented toward the sigmoid mesentery, so rupture of
a diverticulum (with subsequent diverticulitis) usually results
8 SECTION I Abdominal Radiography
in the development of retroperitoneal gas rather than free intra-
peritoneal air.22
On upright abdominal radiographs, air-fluid levels in the
bowel are often interpreted as a sign of obstruction. However,
air-fluid levels may be present in the small bowel and colon in
an adynamic ileus and other nonobstructive conditions. Air-
fluid levels are also seen as a normal finding in the right side of
the colon, particularly after cathartic preparation.24
Potential Intraperitoneal Spaces
A complete description of the intraperitoneal spaces is provided
in the Gray’s Anatomy of the Human Body.16 Only the paracolic
gutters, which are well shown on abdominal radiographs, are
described and illustrated in this chapter. The right paracolic gut-
ter is deeper and wider than the left paracolic gutter. Fluid and
abscesses are often visible in these spaces and can be recognized
indirectly on abdominal radiographs by separation of the ascend-
ing and descending colon from the properitoneal fat (see Fig. 1.6).
RETROPERITONEUM AND ABDOMINAL WALL
The retroperitoneal space is posterior to the parietal peritoneum
and anterior to the transversalis fascia. This space is divided into
three distinct compartments—the perirenal space, posterior
pararenal space, and anterior pararenal space.22
Perirenal Space: Kidneys and Adrenal Glands
The kidneys, adrenal glands, and abundant fat are located within
the left and right perirenal spaces, which are confined by the ante-
rior and posterior layers of renal fascia. The perirenal fat allows
visualization of some or all of the renal outlines on abdominal
radiographs in most patients (see Fig. 1.5A). In contrast, the adre-
nal glands are small and undiscernible unless they are calcified
secondary to previous hemorrhage or granulomatous disease
(Fig. 1.8). The upper half of the psoas muscle and medial aspects
of the hepatic and splenic angles are visualized on abdominal
radiographs because of perirenal fat. Obliteration of the perirenal
fat by inflammation, blood, or urine therefore prevents visualiza-
tion of these structures. The medial perirenal space is continuous
Fig. 1.8 Diaphragmatic crus and calcified adrenal gland. Supine
abdominal radiograph shows the left diaphragmatic crus (white arrow)
and a calcified right adrenal gland (black arrow).
with the aorta and often fills with blood in patients with ruptured
abdominal aortic aneurysms.25 The anterior and posterior layers
of perirenal fascia fuse laterally to form the lateroconal fascia,
which continues laterally and ventrally to fuse with the parietal
peritoneum along the lateral abdominal wall. In patients with
abundant fat, the lateroconal fascia may be visible on abdominal
radiographs as a thin line separating the posterior pararenal and
anterior pararenal fat (Fig. 1.9).26
Posterior Pararenal Space
The posterior pararenal space is located posterior to the posterior
perirenal and lateroconal fascia and anterior to the transversalis
fascia.16 This space contains a variable amount of fat but no organs.
Medially, the posterior pararenal space originates at the lateral
margin of the psoas muscle and is not continuous across the mid-
line. Laterally, the posterior pararenal fat extends around the flank,
joining the properitoneal fat of the lateral abdominal wall to form
the flank stripe (Fig. 1.10). The width of the flank stripe is variable
and depends on body habitus. The posterior pararenal fat is con-
tinuous inferiorly with extraperitoneal fat in the pelvis.
Anterior Pararenal Space: Ascending and
Descending Colon, Duodenum, and Pancreas
The anterior pararenal space, which lies anterior to the perirenal
space and lateroconal fascia, contains the ascending and descend-
ing colon, retroperitoneal duodenum, and pancreas.16 In most
patients, the ascending and descending colon can be identified by
intraluminal fecal material and gas medial to the flank stripes (see
Fig. 1.1). The retroperitoneal duodenum is usually not visible on
abdominal radiographs unless it is filled with gas because of an
ileus, small bowel obstruction, or pancreatitis. Nor is the pancreas
visualized because it has undulating, lobulated borders that are not
outlined by fat. The normal location of the pancreas may be rec-
ognized indirectly on abdominal radiographs, however, if there is
pancreatic calcification because of chronic pancreatitis (Fig. 1.11).
Psoas Muscle
The psoas muscle arises from the T12-L5 vertebrae and extends
inferiorly to join the iliac muscle below the iliac crest. It then con-
tinues as the iliopsoas muscle to the lesser trochanter.16 Perirenal
fat and posterior pararenal fat outline the lateral margin of the
psoas muscle. In about 75% of patients, the psoas muscle is seen
to extend from the diaphragmatic crura to its junction with the
iliac muscle (see Fig. 1.1A).27,28 Fluid in the adjacent retroperito-
neal fat may cause obliteration of this margin. Loss of one or both
shadows of the psoas muscle is a common finding on abdominal
radiographs when blood infiltrates the perirenal and posterior
pararenal spaces because of a ruptured aortic aneurysm.
The psoas muscle is optimally visualized when its lateral mar-
gin is straight and almost parallel to the x-ray beam. As a result,
the psoas margin may not be seen in patients with a structural or
positional lumbar scoliosis if rotation of the spinal column causes
the psoas muscle on the concave side of the spine to assume a
more flattened, horizontal configuration.28 In other patients in
whom the peritoneal cavity extends posteriorly because of lim-
ited retroperitoneal fat, fluid-filled bowel loops may lie directly
adjacent to the psoas muscle, obscuring its margin.
Diaphragmatic Crura
The diaphragmatic crura may be outlined by retroperitoneal fat
that is continuous with the origin of the psoas muscle (see Fig.
1.8). The crura are best seen on abdominal radiographs when
 1 Abdomen: Normal Anatomy and Examination Techniques 9

AC

A B
Fig. 1.9 Lateroconal fascia. (A) Supine abdominal radiograph shows the lateroconal fascia (arrow) along the paracolic gutter as a thin white line extending
from the liver tip to the right lower quadrant. (B) Axial computed tomography scan shows the lateroconal fascia (arrow), which is composed of the anterior
and posterior layers of the perirenal fascia that fuse laterally. The ascending colon (AC) is contained within the anterior pararenal space. K, Kidney.

the x-ray beam is centered near the level of the diaphragm.29
Occasionally, posterior pararenal fat may continue superi-
orly beneath the diaphragm, simulating pneumoperitoneum.
In such cases, a left lateral decubitus view should differentiate
pneumoperitoneum from pararenal fat because the lucency
associated with fat is not affected by changes in patient position.
PELVIS
Delineation of the various muscles and visceral structures in
the pelvis is highly variable and depends on a variety of fac-
tors, including the amount of extraperitoneal pelvic fat, bowel
contents, degree of bladder distention, position of the patient,
and body habitus. As a result, these structures are not always
identified, even in the absence of pelvic disease.
Piriformis Muscle
The piriformis muscle is in the superolateral and posterior
aspect of the pelvis.16 Its inferior margin can be visualized as a
smooth convex interface passing from the sacrum to the greater
sciatic foramen (Fig. 1.12).

Fig. 1.10 Flank stripe. Supine coned-down view of the left side of the
abdomen shows the flank stripe (arrows) outlined by properitoneal fat
just lateral to the descending colon. This fat is contiguous with retroperi-
toneal fat in the posterior pararenal space. When there is no fluid in the
left paracolic gutter, it is only a few millimeters in width.
Fig. 1.11 Pancreatic calcification. Supine abdominal radiograph
shows multiple calcifications outlining the pancreas (arrows) caused by
chronic pancreatitis. The pancreas normally is not visible on abdomi-
nal radiographs.
10 SECTION I Abdominal Radiography

Obturator Internus Muscle

Fig. 1.12 Piriformis muscle. Coned-down view of the pelvis from
a supine abdominal radiograph shows the inferior margins of the
piriformis muscles bilaterally (large arrows). Inferior to the piriformis
muscles is the edge of the sacrospinous ligament and associated coc-
cygeus muscles (small arrows) outlining the roof of the ischiorectal
fossa. The perineum forms the medial boundary of the ischiorectal
fossa (arrowheads).
The obturator internus muscle abuts the lateral pelvic side-
wall and surrounds the greater portion of the obturator
foramen.16 It originates from the pubic ramus, ischium, and
pelvic wall, and its tendon exits the pelvis at the lesser sciatic
foramen just below the sacrospinous ligament. The obturator
internus muscle may be identified on abdominal radiographs
because of subperitoneal fat that surrounds it superiorly and
ischiorectal fat that surrounds it inferiorly (Fig. 1.13). The
obturator canal is located at the superolateral aspect of the
obturator foramen; this canal transmits the obturator vessels
and nerve.30 Hernias may occur at this site, particularly in
older women.
Sacrospinous Ligament and Coccygeus Muscle
The edge of the sacrospinous ligament and associated coccygeus
muscle are outlined by underlying ischiorectal fat.16 These struc-
tures are located just inferior to the piriformis muscle and may
be seen as a smooth band arching from the tip of the sacrum to
the ischial spine (see Fig. 1.12).
Ischiorectal Fossa
The left and right ischiorectal fossae are wedge-shaped, subcu-
taneous fatty masses, with their bases in the perineum and their
apices at the junction of the obturator internus and levator ani
muscles.16 They are often visible on abdominal radiographs (see
Fig. 1.12).

B C
Fig. 1.13 Obturator internus muscles. (A) Coned-down view of the pelvis from a supine abdominal radiograph shows the obturator internus mus-
cles (arrows). (B) Axial computed tomography (CT) scan of the pelvis shows the superior portion of the obturator internus muscles (arrows) outlined
by extraperitoneal fat. (C) Axial CT scan more caudally shows the obturator internus muscles (white arrows) outlined by ischiorectal fat. The left and
right ischiorectal fossae are bounded by the levator ani muscles (black arrows) and obturator internus muscles.
 1 Abdomen: Normal Anatomy and Examination Techniques 11

A B

Fig. 1.14 Ascites demarcated by perivesical fat.

(A) Coned-down view of the pelvis from a supine
abdominal radiograph shows ascites as a hazy
area of increased density above the perivesical
B fat (arrows). Also note how the small bowel is dis-
placed medially by ascitic fluid in the abdomen.
(B) Increased density is again seen in the paravesical
spaces above the bladder on a supine abdominal
U
radiograph in another patient with ascites. Note
how the top of the bladder is outlined by perivesical
fat (arrowheads). (C) Axial computed tomography
of the pelvis in the same patient as in B confirms
the presence of ascites (black arrows) around the
C bladder (B). Also note fluid (arrowheads) behind
the bladder, surrounding the uterus (U).

Gluteus Maximus Muscle
The gluteus maximus muscle forms the posterior border of the
ischiorectal fossa.16 The medial edge of this muscle is outlined by
subcutaneous fat, so it often appears on abdominal radiographs
as a smooth line extending inferiorly and laterally from the tip
of the sacrum.
Pelvic Viscera
The superior and lateral aspects of the urinary bladder are outlined
by perivesical fat (Fig. 1.14). The uterus may also be visible in the
pelvis just above this fat, particularly if the fundus is anteverted,
indenting the adjacent fat. This perivesical fat can be used to help
identify fluid in the pelvis (see Fig. 1.14). Prostatic calculi will iden-
tify the location of the prostate gland, which is caudal to the urinary
bladder and usually not seen on abdominal radiographs. The rec-
tum can usually be recognized posterior to the bladder and uterus
by the presence of intraluminal gas and stool (see Fig. 1.1A).
ACKNOWLEDGMENT
The author would like to acknowledge and thank Susan M. Williams,
MD, for giving permission to use parts of her excellent Chapter 10
from the second edition of this textbook.

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nias. AJR. 1989;153:517–521.
 2
Abnormal Bowel Gas Patterns and
Extraluminal Gas in Abdomen
JAMES M. MESSMER | MARC S. LEVINE

CHAPTER OUTLINE small bowel or remaining colon, particularly the rectum. The
gas-filled ascending and descending colon are usually located
Normal Bowel Gas Patterns in the lateral margins of the peritoneal cavity abutting the flank
Abnormal Bowel Gas Patterns stripes, the sigmoid colon in the lower abdomen, and the rec-
Gastric Outlet Obstruction tum in the lower pelvis extending inferiorly to the pubic sym-
Adynamic Ileus physis. In contrast, gas-filled small bowel loops tend to occupy
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome) the central portion of the abdomen.
Small Bowel Obstruction Apart from location, bowel caliber and intestinal folds are
Colonic Obstruction also important for differentiating colon from the small intestine.
Closed Loop Obstruction In general, the colon has a larger caliber than the small bowel
Volvulus (i.e., colonic diameter is normally up to 5 cm, whereas small
bowel diameter is only up to 3 cm). Haustral folds in the colon
Appendicitis
are normally 2 to 3 mm in width and occur at intervals of 1 cm,
Major Signs of Appendicitis
whereas the circular small bowel folds (also known as plicae cir-
Toxic Megacolon culares) are 1 to 2 mm in width and occur at intervals of only
Pneumoperitoneum 1 mm. Thus, small bowel folds are narrower and more closely
Major Signs of Free Air on Supine Abdominal spaced than colonic haustra.
Radiographs Intestinal gas is a natural contrast agent for the interpreta-
tion of abdominal radiographs. For example, a long, narrowed
Pneumoretroperitoneum
segment of air-filled stomach may indicate an infiltrating pro-
Pneumobilia cess such as linitis plastica. Gastric ulcers and masses are also
Portal Venous Gas occasionally visible (Fig. 2.1A). In the colon, gas may outline
a narrowed lumen from ulcerative or granulomatous colitis,
Intramural Gas thickened haustral folds from ischemia (Fig. 2.1B), or even a
Abscesses polypoid or annular carcinoma (see Fig. 2.4A).
Ascites

Abnormal Bowel Gas Patterns

Even with the widespread availability of cross-sectional imag-
ing studies, abdominal radiography remains a common imag-
ing test in modern radiology practice. Although computed
tomography (CT), magnetic resonance imaging (MRI), and
ultrasound provide more information about acute abdomi-
nal conditions, abdominal radiographs (previously known as
abdominal plain films before the advent of digital radiography)
have the advantages of relatively low cost and ease of acquisi-
tion and can be readily performed on acutely ill or debilitated
patients, so they remain a valuable study.1 This chapter focuses
on abnormalities of gas and soft tissues that can be detected on
abdominal radiographs.
Normal Bowel Gas Patterns
The intestinal tract in adults usually contains less than 200 mL
of gas. Intestinal gas has three sources—swallowed air, bacterial
production, and diffusion from the blood. Supine abdominal
radiographs may show gas accumulating in anteriorly placed
bowel, including the antrum and body of the stomach and
transverse or sigmoid colon. Gas may also be present in the
GASTRIC OUTLET OBSTRUCTION
Gastric outlet obstruction may be manifested on abdominal
radiographs by a dilated stomach containing air, fluid, and/or
debris. A dilated, air-filled stomach is usually recognized with-
out difficulty because of its characteristic shape and location
associated with inferior displacement of the transverse colon.
However, a small amount of air is almost always present in the
stomach, so an upright radiograph of the chest or abdomen
often shows an air-fluid level in the gastric lumen.
The distal gastric antrum and pyloric region are the usual
sites of gastric outlet obstruction, most commonly resulting
from acute edema and spasm associated with a distal ulcer or
chronic antral scarring from a previous ulcer. Other causes of
gastric outlet obstruction include an infiltrating antral carci-
noma and, less commonly, scarring from granulomatous dis-
ease, radiation, or caustic ingestion.
The stomach may also be dilated because of gastroparesis or
gastric atony in the absence of gastric outlet obstruction. The
most common cause is diabetes (i.e., diabetic gastroparesis),2
but other causes include narcotic agents, hypokalemia, uremia,
porphyria, lead poisoning, and previous truncal vagotomy.
Pancreatitis or gastritis may also result in reflex gastric atony,
13
14 SECTION I Abdominal Radiography

A B
Fig. 2.1 Abnormal bowel contours. (A) Gas in the stomach outlines a mass (white arrows) on the lesser curvature, with an irregular central gas
collection (black arrows) representing a large benign ulcer with surrounding edema. (B) Air in the transverse colon outlines thickened haustral folds
(arrows) in a patient with colonic ischemia. (A, Courtesy Timothy J. Cole, MD, Richmond, VA.)

and general anesthesia may occasionally cause marked gastric
distention.
ADYNAMIC ILEUS
The term adynamic ileus (or paralytic ileus) refers to dilated
bowel in the absence of mechanical obstruction. A more spe-
cific term, postoperative ileus, is reserved for patients with recent
abdominal surgery. All these terms refer to a state of decreased
or absent intestinal peristalsis, causing swallowed air and fluid
to accumulate in dilated bowel.3 An adynamic ileus is typically
manifested on abdominal radiographs by dilated small bowel
and colon, with multiple air-fluid levels on upright or horizontal
beam decubitus views, so the presence of dilated colon enables
differentiation from mechanical small bowel obstruction, in
which only the small bowel is affected (see later, “Small Bowel
Obstruction”). Sometimes, however, an adynamic ileus is con-
fined to the small bowel, mimicking the findings of small bowel
obstruction (Fig. 2.2); therefore, the absence of colonic disten-
tion in no way excludes this condition. Other patients may have
an adynamic ileus that is confined to the colon. In such cases,
supine and upright abdominal radiographs typically reveal dif-
fusely dilated colon and rectum with multiple air-fluid levels,
whereas colonic obstruction is usually associated with a paucity
of colonic gas distal to the site of obstruction. An adynamic ileus
may result from many causes, including recent abdominal sur-
gery, electrolyte imbalances, sepsis, generalized peritonitis, blunt
abdominal trauma, and infiltration of the mesentery by tumor.4
Other patients may have a localized ileus (i.e., a sentinel ileus)
involving several loops of the small bowel or colon. This type
of ileus usually results from acute inflammatory conditions
in adjacent regions of the abdomen, including the right lower

A B
Fig. 2.2 Postoperative ileus mimicking small bowel obstruction. (A) Supine abdominal radiograph shows multiple loops of dilated small bowel
with a paucity of colonic gas. (B) Upright radiograph shows multiple air-fluid levels. Although the radiographic findings are suggestive of small bowel
obstruction, this patient had a postoperative ileus involving the small bowel (note the longitudinal row of skin staples from recent abdominal surgery).
 2 Abnormal Bowel Gas Patterns and Extraluminal Gas in Abdomen
quadrant in appendicitis, left lower quadrant in diverticulitis,
and right upper quadrant in cholecystitis.
ACUTE COLONIC PSEUDO-OBSTRUCTION
(OGILVIE’S SYNDROME)
Acute colonic pseudo-obstruction (also known as Ogilvie’s syn-
drome) was first described in 1948 by Ogilvie5 who postulated
that progressive colonic dilation is caused by interruption of
sympathetic innervation with unopposed parasympathetic
innervation of the colon. The most common clinical presen-
tation is acute abdominal distention, usually occurring within
10 days of the onset of the precipitating pathologic process.
Intra-abdominal inflammation, alcoholism, cardiac disease,
burns, retroperitoneal disease, trauma, and pregnancy with
spontaneous delivery or cesarean section have been described
as causes of Ogilvie’s syndrome.6,7
Abdominal radiographs may reveal marked colonic disten-
tion, typically confined to the cecum and the ascending and
transverse colon. Occasionally, however, gas may extend as far
distally as the sigmoid colon. The underlying clinical condi-
tion and rapid onset of colonic distention usually suggest the
diagnosis of colonic pseudo-obstruction, but CT or a limited
single-contrast enema may be required to rule out obstructing
lesions.
Prediction of impending cecal perforation, as judged by
cecal diameter, is unreliable because the risk of cecal perfora-
tion depends not only on the degree of distention but also on
the duration. As a result, the risk is considerably less in patients
with long-standing cecal distention than in those with an acute
increase in cecal caliber. Although some authors have indicated
that a cecal diameter of 9 to 12 cm suggests impending perfora-
tion, cecal diameters of 15 to 20 cm are commonly observed in
patients who recover spontaneously from Ogilvie’s syndrome.6
Intravenous (IV) neostigmine is sometimes used for the ini-
tial treatment of Ogilvie’s syndrome.8 Prolonged cecal distention
should prompt colonoscopic or surgical decompression.9–11 The
A B
Fig. 2.3 Small bowel obstruction. (A) Supine abdominal radiograph shows dilated small bowel loops in the upper abdomen with a paucity of
colonic gas. (B) Upright radiograph demonstrates multiple air-fluid levels. Small amounts of gas trapped between small bowel folds in the left
midabdomen (arrows) produce the string of pearls sign.
15
presence of intramural gas in the region of the dilated cecum
should strongly suggest infarction and impending perforation.
SMALL BOWEL OBSTRUCTION
Small bowel obstruction is often difficult to diagnose on abdom-
inal radiographs, with false-positive and false-negative rates as
high as 20%.12 The diagnostic sensitivity can be increased by
obtaining serial abdominal radiographs to show an evolving
obstructive pattern.
When the small bowel is completely obstructed, accumula-
tion of swallowed air and intestinal secretions causes proximal
dilation of the bowel, while intestinal peristalsis progressively
eliminates bowel contents distal to the obstruction. As a result,
this condition is typically characterized on supine abdominal
radiographs by dilated, gas-filled small bowel loops larger than
3 cm in diameter, with little or no gas in the small bowel or
colon distal to the obstruction (Fig. 2.3A). Upright or decubitus
abdominal radiographs typically reveal multiple air-fluid levels
in the dilated small bowel because of accumulation of gas and
fluid in these loops (Fig. 2.3B).
As small bowel obstruction progresses, gas-filled small bowel
loops above the obstruction become more dilated and tend to
have a horizontal orientation in the central abdomen, produc-
ing a classic stepladder appearance. However, the amount of gas-
eous distention depends not only on the degree of obstruction
but also on its duration, the amount of air swallowing or emesis,
and the use of nasogastric suction for decompression. In some
patients who swallow little air, supine abdominal radiographs
may be unrevealing, whereas upright or decubitus radiographs
will show multiple air-fluid levels in small bowel loops above
the obstruction. In other patients, small amounts of gas trapped
between small bowel folds on upright or decubitus radiographs
may appear as tiny bubbles of gas lined up along the nonde-
pendent bowel surface, also known as the string of pearls sign
(see Fig. 2.3B). Finally, when patients swallow little or no air,
abdominal radiographs may reveal multiple tubular soft tissue
16 SECTION I Abdominal Radiography
densities representing fluid-filled loops of small bowel, and a
paucity of bowel gas distal to the obstruction, producing a so-
called gasless abdomen.
Most small bowel obstructions are caused by postoperative
adhesions, which may occur as early as 1 week after surgery, but
usually develop months to years later. In the absence of a sur-
gical history, an obstructing hernia should be suspected; 95%
are external hernias (inguinal, femoral, umbilical, or incisional).
The presence of air-filled bowel loops below either pubic ramus
should suggest an obstructing inguinal hernia. Other, less com-
mon causes of small bowel obstruction include small bowel
tumors, ectopic gallstones, acute appendicitis, and, occasionally,
intestinal parasites or bezoars.13–15
If small bowel obstruction is suspected on abdominal
radiographs, further evaluation with CT is usually indicated.16
Barium studies of the small bowel may also be helpful when
abdominal radiographs suggest low-grade or partial small
bowel obstruction.
COLONIC OBSTRUCTION
More than 50% of colonic obstructions are caused by annular
carcinomas of the colon.17 The most common site is the sigmoid
A B
C the presence of a mass (arrows) in the
colon, where the bowel has a narrower caliber. Conversely, car-
cinomas of the cecum and ascending colon are less likely to
cause obstruction because of the wider caliber of the right side
of the colon.
Colonic obstruction is typically manifested on abdominal
radiographs by dilated, gas-filled loops of colon proximal to the
obstruction, with a paucity gas in the distal colon and rectum
(Fig. 2.4A). The absence of rectal gas is a particularly impor-
tant feature for differentiating colonic obstruction from colonic
ileus. If prone, decubitus, or left lateral-vertical beam views of
the pelvis show free passage of gas into the rectum, distal colonic
obstruction is very unlikely. Air-fluid levels in the dilated colon
are often seen on upright or decubitus views (Fig. 2.4B).
Abdominal CT or a single-contrast enema may be performed
to confirm the presence of obstruction and determine its under-
lying cause (Fig. 2.4C). In patients with a competent ileocecal
valve, there may be marked colonic (especially cecal) dilation,
with little or no gas in the small bowel. As the cecal diameter
increases, the risk of perforation also increases. In various series,
colonic perforation has been reported in as many as 7% of all
colonic obstructions and 2% of obstructing carcinomas.18,19 Such
perforations usually result from progressive ischemia of the
dilated colon or cecum proximal to the obstruction.20
Fig. 2.4 Colonic obstruction caused
by colonic carcinoma. (A) Supine
abdominal radiograph shows dilated
colon with a soft tissue mass (arrows) in
the sigmoid colon and a paucity of gas
in the rectum. (B) Upright radiograph
shows air-fluid levels in the colon
proximal to the site of obstruction.
(C) Computed tomography confirms
sigmoid colon.
 2 Abnormal Bowel Gas Patterns and Extraluminal Gas in Abdomen 17

In some patients with colonic obstruction, an incompetent

ileocecal valve allows colonic gas to reflux into the small bowel,
decompressing the colon, so the radiographic findings can mimic
those of small bowel obstruction. Nevertheless, this distinction
has important implications, as orally administered barium can
inspissate above an unsuspected colonic obstruction. Abdominal
CT or a single-contrast enema should therefore be considered in
patients with apparent obstruction of the distal small bowel on
abdominal radiographs (especially an older patient with no prior
abdominal surgery) to rule out an underlying colonic carcinoma
as the cause.

CLOSED LOOP OBSTRUCTION

A closed loop obstruction refers to a segment of bowel that
is obstructed at two points. Closed loop obstructions usually
involve the small bowel and are caused by adhesions, internal
hernias, or volvulus. The findings on abdominal radiographs are
often nonspecific. Occasionally, there may be a disproportion-
ately dilated, gas-filled loop of small bowel that has the appear-
ance of a coffee bean. Vascular compromise may lead to edema
of the affected loop with thickened or effaced folds in this loop.
If the obstructed segment fills with fluid, a rounded soft tissue
density produces a pseudotumor appearance. CT may be help-
ful for further evaluation of these patients.

VOLVULUS
Any segment of intestine with a mesenteric attachment has
the potential to undergo a volvulus. Some patients may have
intermittent intestinal twists with recurrent episodes of pain or
emesis. If the twist is greater than 360 degrees, however, it is
unlikely to resolve spontaneously. The risk of vascular compro-
mise in the twisted segment is even more life-threatening than
the obstructive effect of the volvulus. Severe vascular compro-
mise may result in necrosis and perforation of the bowel, caus-
ing sepsis and death.
Sigmoid Volvulus
The term sigmoid volvulus refers to twisting of an elongated
sigmoid colon on its mesentery. Sigmoid volvulus constitutes
60% to 75% of all cases of colonic volvulus and 1% to 2% of
all intestinal obstructions in the United States.21,22 The inci-
dence of sigmoid volvulus is extremely high in some parts of
South America and Africa, presumably because of a high-fiber
diet and the resultant large, bulky stools, producing a chroni-
cally dilated, elongated sigmoid colon that predisposes patients
to this type of volvulus. In the United States, sigmoid volvulus
tends to occur in older men and in residents of nursing homes
and mental hospitals, in whom chronic constipation causes gas-
eous and fecal distention of the sigmoid colon and subsequent
stretching of the sigmoid mesocolon.
Patients with sigmoid volvulus typically present with abdom-
inal pain and distention from colonic obstruction. Obstipation
and vomiting are less common. The symptoms are usually acute
but sometimes have a gradual onset.
Findings on abdominal radiographs are diagnostic of sig-
moid volvulus in about 75% of patients. The classic appearance
consists of a massively dilated sigmoid loop that has an inverted
U configuration and extends superiorly into the left upper quad-
rant beneath the left diaphragm, with air-fluid levels in both its
ascending and descending limbs. However, the dilated sigmoid
Fig. 2.5 Sigmoid volvulus. Supine abdominal radiograph in a patient
with sigmoid volvulus shows a massively dilated loop of the sigmoid
colon extending superiorly into the right upper quadrant and elevating
the right hemidiaphragm, with no gas seen in the rectum.
loop can be in the midline or even extend into the right upper
quadrant (Fig. 2.5). Although the more proximal colon may
also be dilated, disproportionate sigmoid dilation and exten-
sion of the dilated loop superiorly above the transverse colon
are important features for differentiating sigmoid volvulus from
simple colonic obstruction.23
The diagnosis of sigmoid volvulus may be confirmed by
abdominal CT or a single-contrast enema showing high-grade
obstruction with smooth, tapered, beaklike narrowing at the
site of the twist or volvulus.
Some patients with sigmoid volvulus can be successfully
treated by placement of a rectal tube for decompression of the
dilated sigmoid loop. Patients who have clinical or radiographic
signs of ischemia, persistent sigmoid dilation despite rectal
tube placement, or recurrent episodes of sigmoid volvulus may
require surgical resection of the sigmoid colon for definitive
treatment.
Cecal Volvulus
The term cecal volvulus refers to a condition caused by a rota-
tional twist of the right colon on its long axis, so the cecum flips
into the midabdomen or left upper quadrant. Cecal volvulus can
occur only when the right colon is incompletely fused to the
posterior parietal peritoneum, an embryologic variant present in
10% to 37% of adults.24–26 Such individuals have a persistent mes-
entery on the ascending colon, which is therefore mobile and
can twist on its mesentery, producing a volvulus. Nevertheless,
the vast majority of patients with this embryologic variant never
18 SECTION I Abdominal Radiography

A B
Fig. 2.6 Cecal volvulus. (A) Supine abdominal radiograph shows a markedly dilated viscus in the left upper quadrant, representing the obstructed
cecum. Also note multiple loops of dilated small bowel. (B) Upright radiograph shows the caput of the cecum superiorly (small thick arrows) and ileo-
cecal valve (long thin arrow), with a single air-fluid level in the dilated cecum. These findings are characteristic of cecal volvulus.

develop cecal volvulus. Furthermore, the term “cecal volvulus” is
a misnomer because the twist occurs distal to the ileocecal valve.
Cecal volvulus is less common than sigmoid volvulus, account-
ing for about one-third of all cases of colonic volvulus.
The characteristic findings of cecal volvulus, which are pres-
ent on abdominal radiographs in about 75% of patients, con-
sist of a markedly dilated, gas-filled cecum containing a single
air-fluid level in an ectopic location (Fig. 2.6), usually with the
cecal apex in the left upper quadrant. The medially placed ileo-
cecal valve may produce a soft tissue indentation, so the gas-
filled cecum has the appearance of a coffee bean or kidney bean.
In most patients, little gas is seen more distally in the colon.
The diagnosis may be confirmed by abdominal CT or a single-
contrast enema showing a beaklike configuration at the point of
the volvulus in the proximal ascending colon.27
In 1938, Weinstein described a condition known as cecal bas-
cule, which involved folding of the right colon without twisting,
so the cecum occupied a position in the midabdomen.28 This
entity also requires a persistent mesentery on the ascending
colon.29 Others have challenged the concept of cecal bascule,
arguing that these patients have a focal adynamic ileus of the
cecum.16 Regardless of the pathophysiology, these patients are
also at risk for cecal perforation. A dilated, ectopically located
cecum may therefore be a source of abdominal symptoms and
potential cecal perforation.
Cecal volvulus should be differentiated from a prolonged
colonic ileus in bedridden patients with a persistent mesentery
on the ascending colon because the anteriorly located cecum in
these patients may become disproportionately dilated, mimick-
ing the appearance of a cecal volvulus. This has been described
as cecal pseudovolvulus. Unlike patients with true cecal volvu-
lus, however, this condition is associated with diffuse colonic
distention, so it is usually possible to differentiate these condi-
tions on abdominal radiographs.
Transverse Colon Volvulus
Volvulus of the transverse colon is an uncommon condition,
accounting for only about 4% of all cases of colonic volvulus
in the United States.22 In such patients, elongation of the trans-
verse mesocolon and close approximation of the hepatic and
splenic flexures may allow the transverse colon to twist on its
mesenteric attachment. Failure of normal fixation of the mes-
entery may lead to increased mobility of the ascending colon
and hepatic flexure, predisposing these patients to volvulus of
the transverse colon.30 Mortality rates as high as 33% have been
reported in these individuals.31
Abdominal radiographs are usually not helpful for patients
with volvulus of the transverse colon and may erroneously sug-
gest sigmoid volvulus. A single-contrast enema may confirm
the diagnosis if it shows typical beaking and obstruction at the
level of the transverse colon. Two separate air-fluid levels some-
times can be seen in the dilated transverse colon, a finding that
helps differentiate volvulus of the transverse colon from cecal
volvulus.
Splenic Flexure Volvulus
Splenic flexure volvulus is the least common type of colonic
volvulus. Postoperative adhesions, chronic constipation, and
congenital or surgical absence of the normal peritoneal attach-
ments of the splenic flexure predispose patients to this uncom-
mon condition.32,33 Abdominal radiographs may reveal a dilated,
featureless, air-filled loop of bowel in the left upper quadrant
separate from the stomach, with air-fluid levels in the transverse
colon and cecum. When a splenic flexure volvulus is suspected,
 2 Abnormal Bowel Gas Patterns and Extraluminal Gas in Abdomen 19

a single-contrast enema may be performed for a more definitive

diagnosis.

Appendicitis
The development of acute appendicitis requires obliteration
of the appendiceal lumen, usually by a concretion that may
be visible on abdominal radiographs, also known as a feca-
lith or coprolith, but the preferred term is appendicolith. The
concretion often consists of inspissated feces and calcium salts
adhering to a central nidus, so it eventually reaches a size large
enough to occlude the appendiceal lumen. Accumulation of
mucus proximal to the obstruction may distend the appendix
with subsequent appendiceal inflammation, ischemia, and
perforation.
Abdominal radiographs are often of little value in diagnosing
appendicitis.34,35 Occasionally, however, they may be obtained
as the first imaging study in patients with right lower quadrant
pain, and the findings may be helpful in some patients. Nev-
ertheless, CT, MRI, and ultrasound are much more sensitive
and specific imaging tests for diagnosing this condition (see
Chapter 40).

MAJOR SIGNS OF APPENDICITIS

Appendicolith. The presence of an appendicolith is the single
most helpful sign of appendicitis on abdominal radiographs.
Appendicoliths are found in about 10% of patients with acute
appendicitis, typically appearing as round or ovoid calcified
densities that are frequently laminated (Fig. 2.7). Most appendi-
coliths range from 1 to 2 cm in size.36–38 They are usually located
in the right lower quadrant but can also be in the pelvis or
even in the right or left upper quadrant if the patient has a long
appendix or a mobile cecum. The presence of an appendicolith
is an important finding because it indicates a greater likelihood
of superimposed perforation and abscess formation.36–38
Abnormal Bowel Gas Pattern. About 25% of patients with
appendicitis have an abnormal bowel gas pattern, usually a
localized adynamic (sentinel) ileus occurring as a response to
focal inflammation in the right lower quadrant. Less frequently,
affected individuals may develop a diffuse ileus. Occasionally,
these individuals may even present with small bowel obstruc-
tion if the terminal ileum is compressed by the inflamed appen-
dix or a periappendiceal abscess (see Fig. 2.7).37
Abnormal Cecum and Ascending Colon. Localized inflam-
mation and edema may cause thickening of the cecal wall and
widening of haustral folds in this region. An air-fluid level may
also be present in the cecum on upright or decubitus abdominal
radiographs.
Extraluminal Soft Tissue Mass. A soft tissue mass can be
found in up to one-third of patients with perforation. This mass
may be caused by edema, fluid, or abscess formation in the right
lower quadrant. A mottled or loculated extraluminal gas collec-
tion in this region should strongly suggest an abscess.
Gas in the Appendix. Gas in the appendix has been described
as a sign of acute appendicitis on abdominal radiographs, even
though the pathophysiology of the disease is more likely to
Fig. 2.7 Acute appendicitis with partial small bowel obstruction.
Supine abdominal radiograph shows a laminated appendicolith (arrows)
in the right lower quadrant in a patient with appendicitis. Also note a
paucity of bowel gas in the colon and dilated small bowel more proxi-
mally because of associated small bowel obstruction.
result in an absence of appendiceal gas.39 At the same time, an
air-filled appendix may be seen as a normal finding in some
patients, reflecting a nondependent location of the appendix in
relation to the cecum. Because of the effect of gravity, an ascend-
ing retrocecal appendix is more likely to contain gas.40
Free Intraperitoneal Air. A ruptured appendix rarely may lead
to the development of a small amount of free intraperitoneal air,
but the obstructed appendiceal lumen usually prevents larger
collections of gas from escaping into the peritoneal cavity, so
free air is rarely found.41,42
Obliteration of Normal Fat Planes. Inflammation and edema
may alter the water content of surrounding fat and obscure the
normal fat planes of the psoas muscle, obturator muscle, or pro-
peritoneal flank stripe. This finding is nonspecific and is usu-
ally associated with other signs of appendicitis on abdominal
radiographs.
Scoliosis of the Lumbar Spine. Some patients with appendici-
tis may develop a lumbar scoliosis as a result of splinting. This
finding is nonspecific, however, and can be related to patient
positioning.
Toxic Megacolon
Toxic megacolon, or toxic dilation of the colon, may be diag-
nosed on the basis of a dilated colon on abdominal radiographs
in patients with fever, tachycardia, and hypotension. Toxic
20 SECTION I Abdominal Radiography
megacolon is classically associated with ulcerative colitis but
can also occur in patients with granulomatous colitis, amebiasis,
cholera, pseudomembranous colitis, cytomegalovirus colitis,
and ischemic colitis. Toxic megacolon develops in 5% to 10% of
patients with ulcerative colitis, but in only 2% to 4% of patients
with granulomatous colitis.43–45
When toxic megacolon is suspected on clinical grounds, it
is important to assess not only the degree of colonic dilation on
abdominal radiographs but also the appearance of the colonic
mucosa outlined by intraluminal air and the presence or absence
of free intraperitoneal air. In general, the transverse colon tends
to become disproportionately dilated, but this finding is more
likely a reflection of its anterior location in the abdomen than
of a greater predisposition to disease.46 The normal upper limit
for the diameter of the transverse colon is about 6 cm, whereas
this diameter typically ranges 6 to 15 cm in patients with toxic
megacolon (Fig. 2.8).47 A nodular mucosa may be visible in the
dilated transverse colon as a result of inflammatory pseudopol-
yps in this region (see Fig. 2.8).48
Colonic perforation occurs in 30% to 50% of patients with
toxic megacolon and is associated with high mortality rates.43,49
As a result, a delayed diagnosis on abdominal radiographs may
have disastrous consequences. The diagnosis of toxic megacolon
is usually made based on a combination of the clinical and plain
film findings, so a contrast enema is not required and, in fact, is
contraindicated because of the risk of perforation.50 When toxic
megacolon is suspected, CT may be performed to better depict
the underlying colitis and detect life-threatening complications
such as colonic perforation.51
Fig. 2.8 Toxic megacolon. There is marked colonic distention in a
patient with ulcerative colitis and toxic megacolon. Note the nodular
mucosal contour (arrows) in the transverse colon.
Pneumoperitoneum
The presence of free intraperitoneal air (i.e., pneumoperito-
neum) is an important radiographic observation that usually
indicates bowel perforation in patients with an acute abdo-
men. A classic study by Miller and Nelson showed that as
little as 1 mL of free air can be detected below the right hemi-
diaphragm on upright chest radiographs.52 Upright chest
radiographs are highly sensitive in detecting free air because
the x-ray beam strikes the diaphragms tangentially at their
highest point.
In contrast, upright abdominal radiographs are less sensitive
than upright chest radiographs in detecting free air because they
result in an oblique view of the diaphragms that may prevent
visualization of small amounts of free air. Left lateral decubitus
views of the abdomen are better for detecting small amounts of
free air interposed between the free edge of the liver and right
lateral wall of the peritoneal cavity. Not surprisingly, CT is more
sensitive in detecting free air than upright or decubitus abdomi-
nal radiographs.53
Because upright or left lateral decubitus abdominal radio-
graphs cannot be obtained in patients who are too sick or debili-
tated to stand or lay on their side, it is important to recognize
indirect signs of free intraperitoneal air that can be detected on
supine abdominal radiographs in nearly 60% of patients.54
MAJOR SIGNS OF FREE AIR ON SUPINE
ABDOMINAL RADIOGRAPHS
Rigler’s Sign. Gas normally outlines only the luminal surface
of the bowel. When gas is present on both sides of the bowel,
however, the bowel wall may be outlined as a thin, linear stripe
(Fig. 2.9). Since its original description by Rigler in 1941,55
Fig. 2.9 Pneumoperitoneum with Rigler’s sign. Close-up view of
the right upper quadrant in a patient with massive pneumoperitoneum
shows gas outlining both sides of the bowel wall (i.e., Rigler’s sign) (black
arrows). Also note gas outlining the inferior edge of the liver (white
arrows).
 2 Abnormal Bowel Gas Patterns and Extraluminal Gas in Abdomen
this sign (also known as Rigler’s sign) has been recognized as
an important finding of pneumoperitoneum, but a moderate
amount of free air must be present in the abdomen.
A false-positive Rigler’s sign may result from overlapping
loops of small bowel in the central abdomen or from Mach
bands, a phenomenon in which there is the perception of a line
at the interface between two areas of differing density (i.e., gas
and soft tissue). However, the perceived line has almost no dis-
cernable thickness, whereas the bowel wall has a measurable
thickness of 1 mm or more in patients with a true Rigler’s sign.54
Still other patients may have a pseudo-Rigler’s sign caused
by faint residual oral contrast material (usually from recent
abdominal CT) coating the luminal surface of the bowel, so the
increased density of the wall creates the erroneous impression
that gas is present on both sides of the wall.
Increased Lucency in the Right Upper Quadrant. Air accu-
mulating superiorly between the anterior aspect of the liver and
the abdominal wall may cause increased lucency in the right
upper quadrant (Fig. 2.10A). Small collections of air may also
be seen as subtle rounded lucencies overlying the liver.56 Finally,
linear collections of gas may be visualized in the subhepatic
space.54 The latter finding must be differentiated from subhe-
patic fat.54
A B
C form ligament as a thin, vertically oriented density
21
Visualization of the Undersurface of the Diaphragm. Air
may be trapped anteriorly in the cupola of the diaphragm, per-
mitting visualization of the undersurface of the central portion
of the diaphragm or diaphragmatic muscle slips laterally.57,58
Air in Morison’s Pouch (Posterior Hepatorenal Space). Mori-
son’s pouch is an intraperitoneal recess bounded anteriorly by
the liver and posteriorly by the right kidney. Air escaping from
a perforated viscus may be trapped in this space because of sur-
rounding inflammation. Air in Morison’s pouch is characterized
on abdominal radiographs by a linear or triangular collection of
gas in the medial aspect of the right upper quadrant outside the
expected location of the bowel (Fig. 2.10B).59–61
Outline of Normal Peritoneal Ligaments. Larger amounts
of free air occasionally may outline the falciform ligament
(Fig. 2.10C) or extrahepatic segment of the ligamentum teres
in the right upper quadrant, the lateral umbilical ligaments
(inverted V sign) in the lower abdomen, and the urachus.62–65
Football Sign. Originally described in infants, the football sign
is caused by a large amount of free air filling the oval-shaped
peritoneal cavity, resembling an American football.66 Occasion-
ally, this sign may be seen in adults.
Fig. 2.10 Other signs of pneumoperitoneum
on supine abdominal radiographs. (A) Increased
radiolucency (arrows) is seen in the right upper
quadrant. This finding is caused by air interposed
between the anterior abdominal wall and the liver.
(B) Air in Morison’s pouch is seen as a triangular
collection of gas in the medial aspect of the right
upper quadrant (arrows). (C) Air outlines the falci-
in the right upper quadrant (arrows).
22 SECTION I Abdominal Radiography

TABLE
Causes of Pneumoperitoneum
retroperitoneal structures such as the duodenum, ascending
2.1 and descending colon, and rectum most commonly accounts
BOWEL for this finding.68
Perforation of benign ulcer Gas escaping from a perforated duodenum tends to be con-
Perforation of neoplasm fined to the right anterior pararenal space, but occasionally it
Perforation of appendix may enter the perirenal space and outline the right kidney. Duo-
Jejunal diverticulitis denal ulcers, iatrogenic duodenal injuries, and blunt abdominal
Diverticulitis of sigmoid colon trauma are all possible causes of perforation of the extraperito-
Pneumatosis cystoides intestinalis neal portion of the duodenum.69
Pneumatosis coli Gas from a rectal perforation may be confined to the peri-
Foreign body perforation rectal space or may extend into the anterior and posterior ret-
TRAUMA roperitoneal spaces and even superiorly into the mediastinum.70
Abdominal surgery Iatrogenic trauma is one of the most common causes of rectal
Anastomotic leak perforation, so radiologists should be aware of the potential risk
Peritoneal tap of this serious complication when insufflating a balloon during
Endoscopy or biopsy barium enemas.71
Penetrating injury
Percutaneous endoscopic gastrostomy
FEMALE GENITAL TRACT Pneumobilia
Rubin test Gas in the bile ducts, or pneumobilia, is characterized radio-
Sexual intercourse or cunnilingus graphically by thin, branching, linear radiolucencies overly-
Pelvic examination
ing the central portion of the liver (Fig. 2.12). The central
Athletic activities such as water skiing
location of this gas is explained by the direction of the flow of
bile from the periphery of the liver toward the porta hepatis.
Pneumobilia almost always results from some type of com-
munication between the bile ducts and intestine. One of the
Air in the Lesser Sac of the Peritoneal Cavity. Intraperitoneal most common causes is a surgically created biliary enteric fis-
air that traverses the foramen of Winslow may become trapped tula such as a choledochojejunostomy or cholecystojejunos-
in the lesser sac. Such gas may be manifested by an ill-defined tomy (see Fig. 2.12). The most common nonsurgical cause of a
lucency above the lesser curvature of the stomach.67 choledochoduodenal fistula is a penetrating duodenal ulcer,72
The presence of pneumoperitoneum does not always indi- and the most common nonsurgical cause of a cholecystodu-
cate an acute abdominal condition and occasionally may be odenal fistula is a gallstone eroding into the duodenum. In
detected in asymptomatic individuals. Various causes of free air some patients with a cholecystoduodenal fistula, a patent cys-
are listed in Table 2.1. tic duct may allow air to enter the intrahepatic bile ducts.73,74
If an ectopic gallstone that has eroded into the intestine is
2.5 cm or larger in diameter, it may obstruct the small bowel,
Pneumoretroperitoneum usually at or near the ileocecal valve, producing a so-called
Gas in the retroperitoneal spaces (i.e., pneumoretroperito- gallstone ileus; the term is actually a misnomer because these
neum) usually can be distinguished from intraperitoneal patients have mechanical small bowel obstruction caused
gas. Because retroperitoneal gas is bound by fascial planes, by a gallstone impacted in the distal ileum. The classic triad
it tends to collect in a linear fashion along the lateral mar- (also known as Rigler’s triad) of air in the biliary tree, small
gins of the kidneys and psoas muscles and along the medial bowel obstruction, and an ectopic, calcified gallstone is virtu-
undersurface of the diaphragms (Fig. 2.11). Perforation of ally diagnostic of gallstone ileus on abdominal radiographs.75

A B
Fig. 2.11 Retroperitoneal air in a patient with retroperitoneal perforation after endoscopy. (A) Retroperitoneal air is manifested by linear gas
collections (arrows) dissecting along the right margin of the psoas muscle in the upper retroperitoneum superiorly to the undersurface of the medial
aspect of the right hemidiaphragm. (B) Computed tomography confirms the retroperitoneal location of this extraluminal air (arrows). (Courtesy Laura
R. Carucci, MD, Richmond, VA.)
 2 Abnormal Bowel Gas Patterns and Extraluminal Gas in Abdomen
Fig. 2.12 Pneumobilia. Air is seen collecting centrally in the biliary
tree (arrows) in a patient with a choledochojejunostomy.
An incompetent sphincter of Oddi, recent sphincterotomy or
sphincteroplasty, and recent passage of a common duct stone
are other causes of pneumobilia.76
Portal Venous Gas
Since its original description in 1960, portal venous gas has
77
been recognized as an ominous radiographic finding charac-
terized by thin, branching, tubular radiolucencies that occupy
the periphery of the liver (Fig. 2.13). The peripheral location
of the gas reflects the hepatopetal flow of blood in the portal
venous system away from the porta hepatis. In advanced cases,
air can be seen outlining the more centrally located main portal
vein, but this finding is less common. A left lateral decubitus
radiograph of the abdomen may facilitate visualization of portal
venous gas. Unless the gas has been introduced iatrogenically
by vascular catheterization, endoscopic manipulation, or other
iatrogenic causes, the source of the gas is almost invariably
the intestine. Intraluminal intestinal air can breach a damaged
mucosa, enter the bloodstream, and eventually reach the portal
venous system of the liver.
The most important cause of portal venous gas is intestinal
ischemia or infarction. In adults with ischemic bowel disease,
death often occurs shortly after portal venous gas has been
observed.78,79 The finding of portal venous gas should therefore
lead to a careful search for gas in the wall of the bowel caused by
intestinal infarction (see later, “Intramural Gas”).
Portal venous gas occasionally may have benign causes. Dila-
tion of the stomach and small bowel may allow air to enter the
intestinal mucosa, eventually reaching the liver.80 Nonfatal cases
of portal venous gas have also been described in patients with
diverticulitis and inflammatory bowel disease and in patients
who have undergone double-contrast barium enemas or colo-
noscopy for inflammatory bowel disease.81–84 Traumatic injury
to the common bile duct as a complication of endoscopic ret-
rograde cholangiopancreatography (ERCP) and endoscopic
sphincterotomy has also been reported as a benign cause of
portal venous gas.85
23
Fig. 2.13 Portal venous gas. Tiny, branching gas collections are seen
extending toward the periphery of the liver in a patient with infarcted
bowel and portal venous gas.
Intramural Gas
Gastric emphysema is a relatively benign form of intramural
gas (i.e., pneumatosis), usually resulting from iatrogenic injury
to the mucosa at endoscopy or increased intraluminal pressure
in the stomach associated with gastric outlet obstruction.86,87
This condition is characterized by linear collections of gas in
the gastric wall. In contrast, emphysematous gastritis is a rare,
fulminant form of phlegmonous gastritis; hemolytic Streptococ-
cus is the most frequently implicated organism.88,89 Underlying
causes of this life-threatening condition include ingestion of
caustic agents and gastroduodenal surgery that compromises
the vascular supply of the stomach.88,89 Emphysematous gastritis
is characterized by cystic, bubbly collections of gas in the gastric
wall that have a very different appearance than the linear intra-
mural collections seen in gastric emphysema.
Gas in the wall of the small bowel (also known as pneumato-
sis intestinalis) is characterized by two radiographic patterns—a
bubbly appearance or thin, linear streaks of gas.90 The bubbly
appearance of intramural gas is easily mimicked by fecal mate-
rial in the colon, but close inspection may reveal small bubbles
of gas outside the bowel lumen, leading to the correct diagnosis.
In contrast, linear gas collections tend to be more readily appar-
ent and should always be considered an important finding on
abdominal radiographs, regardless of their location (Fig. 2.14).
In combination with portal venous gas (see earlier, “Portal
Venous Gas”), linear gas collections in the intestinal wall are
usually a sign of severe bowel ischemia or infarction in adults.91
24 SECTION I Abdominal Radiography
Fig. 2.14 Infarcted bowel with intramural gas. Linear gas collections
are seen in the wall of the cecum and proximal ascending colon second-
ary to bowel infarction.
Other findings of bowel ischemia or infarction include dila-
tion of bowel and nodular thickening or thumbprinting of the
bowel wall. CT is more sensitive than abdominal radiographs
for detection of bowel ischemia or infarction.92,93 Pneumatosis is
particularly well shown by CT, but does not necessarily indicate
irreversible infarction of the bowel unless the pneumatosis is
associated with portomesenteric venous gas.94 The linear pattern
of pneumatosis identified on CT is more likely to be associated
with transmural bowel infarction than the bubbly pattern.95
Pneumatosis cystoides intestinalis and pneumatosis coli are
rare benign conditions characterized by multiple gas-filled
cysts or blebs in the wall of the small bowel and colon, respec-
tively.90,96 The cysts appear radiographically as grapelike clusters
of gas, usually segmental in distribution (Fig. 2.15). These cystic
collections may protrude into the intestinal lumen giving the
bowel a scalloped appearance on barium studies. In the large
intestine, the left colon tends to be involved more frequently
than the right colon. Despite the dramatic radiographic find-
ings, affected individuals often have mild abdominal pain or are
asymptomatic.
Abscesses
Although CT is the most definitive imaging test for diagnos-
ing abscesses, abdominal radiographs are helpful in some
patients.88,97,98 An abdominal abscess may be manifested by a
soft tissue mass that displaces adjacent bowel or by mottled or
bubbly extraluminal gas collections in the abscess (Fig. 2.16A).
Other patients may have a single rounded or ovoid collection
Fig. 2.15 Pneumatosis coli. Multiple rounded, grapelike collections of
gas (arrows) are seen in the wall of the sigmoid colon in a patient with
benign pneumatosis coli.
of gas with an air-fluid level on horizontal beam views. Fecal
material sometimes can mimic the appearance of a mottled gas
collection but is usually distinguished by its location within the
colon. When an abscess is suspected on abdominal radiographs,
abdominal CT should be obtained to determine the extent of
disease and the cause of the underlying pathology (Fig. 2.16B).99
ASCITES
Because of the widespread use of abdominal CT and ultra-
sound, less emphasis is now placed on the findings of ascites
on abdominal radiographs. Nevertheless, it is important to
recognize these signs because abdominal radiographs may be
obtained as the first imaging study in patients with abdominal
distention. In general, only large amounts of ascites are identi-
fied on abdominal radiographs. Major signs of ascites include
obliteration of the inferior edge of the liver (Fig. 2.17A); wid-
ening of the distance between the flank stripe and ascending
colon (normally only 2 to 3 mm) secondary to fluid in the right
paracolic gutter; medial displacement of the lateral edge of
the liver (Hellmer’s sign); accumulation of fluid in the pouch
of Douglas indented by the bladder, causing symmetric bulges
that have been described as dog ears; and in patients with large-
volume ascites, a ground-glass appearance of the abdomen,
centrally located bowel loops, separation of bowel loops, and
bulging flanks (see Fig. 2.17A). When ascites is suspected on
abdominal radiographs, CT can be performed to confirm this
finding (Fig. 2.17B).
 2 Abnormal Bowel Gas Patterns and Extraluminal Gas in Abdomen 25

A B
Fig. 2.16 Lesser sac abscess secondary to pancreatitis. (A) A mottled collection of gas (arrows) is present in the left upper abdomen. (B) Com-
puted tomography shows gas and fluid (arrows) in the abscess cavity in a patient with pancreatitis.

A B
Fig. 2.17 Ascites. (A) The inferior liver edge is obscured by ascitic fluid on a supine abdominal radiograph. Also note the central location of bowel
loops, which are separated by fluid in the abdomen. (B) Computed tomography confirms the presence of ascites, particularly in the perihepatic
region.

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R587714.
Universal international newsreel. Vol. 20, no. 76. By Universal
Pictures Company, Inc. 1 reel. © 25Sep47; M2433. Universal
Pictures (PWH); 15Oct74; R587714.

R587715.
Universal international newsreel. Vol. 20, no. 77. By Universal
Pictures Company, Inc. 1 reel. © 25Sep47; M2469. Universal
Pictures (PWH); 15Oct74; R587715.

R587716.
Universal international newsreel. Vol. 20, no. 78. By Universal
Pictures Company, Inc. 1 reel. © 30Sep47; M2470. Universal
Pictures (PWH); 15Oct74; R587716.
R587974.
Shoe-shine. By Alfa Cinematograsica. 12 reels. Add. ti.: Sciuscia. ©
15Dec46; L1735. Lardos Anstalt (PWH); 17Oct74; R587974.

R587990.
Paramount news, number 13. By Paramount Pictures, Inc. 1 reel.
© 11Oct47; M2439. Major News Library (PWH); 21Oct74; R587990.

R587991.
Paramount news, number 14. By Paramount Pictures. Inc. 1 reel.
© 15Oct47; M2440. Major News Library (PWH); 21Oct74; R587991.

R588088.
This time for keeps. By Loew’s, Inc. 7 reels. © 3Oct47; L1271.
Metro-Goldwyn-Mayer, Inc. (PWH); 21Oct74; R588088.

R588089.
Have you ever wondered? By Loew’s, Inc. 1 reel. © 16Oct47;
M2526. Metro-Goldwyn-Mayer, Inc. (PWH); 21Oct74; R588089.

R588090.
Surfboard rhythm. By Loew’s, Inc. 752 feet. © 8Oct47; M2418.
Metro-Goldwyn-Mayer, Inc. (PWH); 17Oct74; R588090.

R588303.
Paramount news, number 15. By Paramount Pictures, Inc. 1 reel.
© 18Oct47; M2443. Major News Library (PWH); 23Oct74; R588303.

R588304.
Paramount news, number 16. By Paramount Pictures, Inc. 1 reel.
© 22Oct47; M2444. Major News Library (PWH); 23Oct74;
R588304.

R588392.
Killer McCoy. By Loew’s, Inc. 103 min. © 23Oct47; L1284. Metro-
Goldwyn-Mayer, Inc. (PWH); 29Oct74; R588392.

R588501.
Trailing danger. By Monogram Pictures Corporation. 6 reels. ©
29Mar47; L908. Allied Artists Pictures Corporation, formerly known
as Monogram Pictures Corporation (PWH); 23Oct74; R588501.

R588502.
Fall guy. By Monogram Pictures Corporation. 7 reels. © 15Mar47;
L943. Allied Artists Pictures Corporation, formerly known as
Monogram Pictures Corporation (PWH); 23Oct74; R588502.

R588503.
It happened on Fifth Avenue. 12 reels. © 25Mar47; L949. Allied
Artists Productions, Inc. (PWH); 23Oct74; R588503.

R588504.
Land of the lawless. By Monogram Pictures Corporation. 6 reels.
© 27Mar47; L981. Allied Artists Pictures Corporation, formerly
known as Monogram Pictures Corporation (PWH); 23Oct74;
R588504.

R588505.
High conquest. By Monogram Pictures Corporation. 9 reels. ©
2Mar47; L1154. Allied Artists Pictures Corporation, formerly known
as Monogram Pictures Corporation (PWH); 23Oct74; R5885O5.

R588538.
 Trail to San Antone. By Republic Productions, Inc. 8 reels. ©
22Jan47; L841. Gene Autry (PWH); 25Oct74; R588538.

R588539.
Twilight on the Rio Grande. By Republic Productions, Inc. 8 reels.
© 17Mar47; L975. Gene Autry (PWH); 25Oct74; R588539.

R589192.
Pluto’s blue note. By Walt Disney Productions. 1 reel. © 4Sep47;
L1376. Walt Disney Productions (PWH); 7Oct74; R589192.

R589193.
The Trial of Donald Duck. By Walt Disney Productions. 1 reel. ©
11Sep47; L1971. Walt Disney Productions (PWH); 7Oct74; R589193.

R589194.
Inferior decorator. By Walt Disney Productions. 1 reel. © 24Sep47;
L1975. Walt Disney Productions (PWH); 7Oct74; R589194.

R589329.
News of the day. Vol. 19, issue no. 208. By Hearst Metrotone
News, Inc. 1 reel. © 2Oct47; M2456. Hearst Metrotone News, a
division of the Hearst Corporation (PWH); 4Nov74; R589329.

R589330.
News of the day. Vol. 19, issue no. 207. By Hearst Metrotone News,
Inc. 1 reel. © 1Oct47; M2457. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589330.

R589331.
 News of the day. Vol. 19, issue no. 213. By Hearst Metrotone News,
Inc. 1 reel. © 22Oct47; M2604. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589331.

R589332.
News of the day. Vol. 19, issue no. 214. By Hearst Metrotone News,
Inc. 1 reel. © 24Oct47; M26O5. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589332.

R589333.
News of the day. Vol. 19, issue no. 215. By Hearst Metrotone News,
Inc. 1 reel. © 29Oct47; M2606. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589333.

R589334.
News of the day. Vol. 19, issue no. 216. By Hearst Metrotone News,
Inc. 1 reel. © 31Oct47; M2607. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589334.

R589335.
News of the day. Vol. 19, issue no. 211. By Hearst Metrotone News,
Inc. 1 reel. © 15Oct47; M2718. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589335.

R589336.
News of the day. Vol. 19, issue no. 212. By Hearst Metrotone News,
Inc. 1 reel. © 17Oct47; M2719. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589336.

R589337.
News of the day. Vol. 19, issue no. 209. By Hearst Metrotone
News, Inc. 1 reel. © 6Oct47; M2720. Hearst Metrotone News, a
division of the Hearst Corporation (PWH); 4Nov74; R589337.
R589338.
News of the day. Vol. 19, issue no. 210. By Hearst Metrotone News,
Inc. 1 reel. © 8Oct47; M2721. Hearst Metrotone News, a division of
the Hearst Corporation (PWH); 4Nov74; R589338.

R589339.
The Last round-up. By Gene Autry Productions. 8 reels. ©
28Oct47; L1258. Gene Autry (PWH); 4Nov74; R589339.

R589461.
The Tender years. By Alson Productions, Inc. 9 reels. © 24Oct47;
L2306. Alan Enterprises, Inc. (PWH); 1Nov74; R589461.

R589462.
Paramount news, number 18. By Paramount Pictures, Inc. 1 reel.
© 29Oct47; M2452. Major News Library (PWH); 1Nov74; R589462.

R589463.
Paramount news, number 17. By Paramount Pictures, Inc. 1 reel.
© 25Oct47; M2451. Major News Library (PWH); 1Nov74; R589463.

R589513.
Soup’s on. By Walt Disney Productions. 1 reel. © 29Oct47; L1972.
Walt Disney Productions (PWH); 4Nov74; R589513.

R589514.
Cat nap Pluto. By Walt Disney Productions. 1 reel. © 13Oct47;
L1974. Walt Disney Productions (PWH); 4Nov74; R589514.

R589600.
 Visiting Virginia. By Loew’s, Inc. 1 reel. © 29Oct47; M2450.
Metro-Goldwyn-Mayer, Inc. (PWH); 4Nov74; R589600.

R589668.
Children of Paradise. 16 reels. Add. ti.: Les Enfants du Paradis. ©
15Nov46; L701. Societe Nouvelle Pathe Cinema (PWH); 5Nov74;
R589668.

R590126.
Green for danger. By Individual Pictures, Ltd. 10 reels. © 4Oct47;
L1281. Rank Film Distributors, Ltd. (PWH); 8Nov74; R590126.

R590127.
Fame is the spur. By Two Cities Films, Ltd. 13 reels. © 3Nov47;
LF154. Rank Film Distributors, Ltd. (PWH); 8Nov74; R590127.

R590128.
October man. By Two Cities Films, Ltd. 10 reels. © 6Oct47; LF158.
Rank Film Distributors, Ltd. (PWH); 8Nov74; R590128.

R590468.
Paramount news, number 24. By Paramount Pictures, Inc. 1 reel ©
19Nov47; M2533. Major News Library (PWH); 21Nov74; R590468.

R590680.
Paramount news, number 19. By Paramount Pictures, Inc. 1 reel.
© 1Nov47; M2481. Major News Library (PWH); 15Nov74; R590680.

R590681.
Paramount news, number 20. By Paramount Pictures, Inc. 1 reel.
© 5Nov47; M2482. Major News Library (PWH); 13Nov74; R590681.
R590682.
Paramount news, number 21. By Paramount Pictures, Inc. 1 reel ©
8Nov47; M2484. Major News Library (PWH); 13Nov74; R590682.

R590683.
Paramount news, number 22. By Paramount Pictures, Inc. 1 reel.
© 12Nov47; M2485. Major News Library (PWH); 13Nov74;
R590683.

R590795.
Wotta knight. By Paramount Pictures, Inc. 1 reel. © 24Oct47;
L1260. United Artists Television, Inc. (PWH); 13Nov74; R590795.

R590796.
The Unsuspected. By Michael Curtiz Productions, Inc. 11 reels. ©
11Oct47; L1270. United Artists Television, Inc. (PWH); 13Nov74;
R590796.

R590797.
The Voice of the turtle. By Warner Brothers Pictures, Inc. 10 reels.
© 6Oct47; L1477. United Artists Television, Inc. (PWH); 13Nov74;
R590797.

R590798.
House hunting mice. By Vitaphone Corporation. 1 reel. © 7Oct47;
M2374. United Artists Television, Inc. (PWH); 13Nov74; R590798.

R590799.
Little orphan airedale. By Vitaphone Corporation. 1 reel. ©
6Oct47; M2417. United Artists Television, Inc. (PWH); 13Nov74;
R590799.
R590800.
Fishing the Florida Keys. By Vitaphone Corporation. 1 reel. ©
20Oct47; M2424. United Artists Television, Inc. (PWH); 13Nov74;
R590800.

R590801.
Tennis town. By Vitaphone Corporation. 1 reel. © 13Oct47;
M2425. United Artists Television, Inc. (PWH); 13Nov74; R590801.

R590802.
Big time revue. By Vitaphone Corporation. 1 reel. © 15Oct47;
M2426. United Artists Television, Inc. (PWH); 13Nov74; R590802.

R590803.
Rubber River. By Vitaphone Corporation. 1 reel. © 9Oct47;
M2427. United Artists Television, Inc. (PWH); 13Nov74; R590803.

R590887.
Stork bites man. By Comet Productions, Inc. 8 reels. © 1Aug47;
L1208. Repix, Inc. (PWH); 18Nov74; R590887.

R590888.
The Black widow. Chap. no. 6–13. By Republic Productions, Inc. 16
reels. © 2Sep47; L1217. Repix, Inc. (PWH); 18Nov74; R590888.

R590889.
Driftwood. By Republic Productions, Inc. 10 reels. © 17Sep47;
L1218. Repix, Inc. (PWH); 18Nov74; R590889.

R590890.
 Along the Oregon Trail. By Republic Productions, Inc. 7 reels. ©
2Sep47; L1219. Repix, Inc. (PWH); 18Nov74; R590890.

R590891.
Exposed. By Republic Productions, Inc. 7 reels. © 17Sep47; L1252.
Repix, Inc. (PWH); 18Nov74; R590891.

R590892.
It’s a grand old nag. By Republic Productions, Inc. 1 reel. ©
13Nov47; L1293. Repix, Inc. (PWH); 18Nov74; R590892.

R590893.
The Fabulous Texan. By Republic Productions, Inc. 10 reels. ©
12Nov47; L1294. Repix, Inc. (PWH); 18Nov74; R590893.

R590894.
G-Men never forget. No. 1–6. By Republic Productions, Inc. ©
13Nov47; L1295. Repix, Inc. (PWH); 18Nov74; R590894.

R590895.
The Flame. By Republic Productions, Inc. 10 reels. © 13Nov47;
L1326. Repix, Inc. (PWH); 18Nov74; R590895.

R590896.
The Wild frontier. By Republic Productions, Inc. © 13Nov47;
L1327. Repix, Inc. (PWH); 18Nov74; R590896.

R590897.
Under Colorado skies. By Republic Productions, Inc. 7 reels. ©
14Nov47; L1385. Repix, Inc. (PWH); 18Nov74; R590897.
R590967.
Green Dolphin Street. By Loew’s, Inc. 8 reels. © 22Oct47; L1283.
Metro-Goldwyn-Mayer, Inc. (PWH); 18Nov74; R590967.

R590970.
Ride the pink horse. By Universal Pictures Company, Inc. 11 reels.
© 31Oct47; L1338. Universal Pictures (PWH); 18Nov74; R590970.

R590971.
Wistful widow of Wagon Gap. By Universal Pictures Company, Inc.
& CS Company. 8 reels. © 31Oct47; L1919. Universal Pictures
(PWH); 18Nov74; R590971.

R590972.
Universal international newsreel. Vol. 20, no. 79. By Universal
Pictures Company, Inc. 1 reel. © 3Oct47; M2471. Universal Pictures
(PWH); 18Nov74; R590972.

R590973.
Universal international newsreel. Vol. 20, no. 80. By Universal
Pictures Company, Inc. 1 reel. © 7Oct47; M2472. Universal Pictures
(PWH); 18Nov74; R590973.

R590974.
Universal international newsreel. Vol. 20, no. 81. By Universal
Pictures Company, Inc. 1 reel. © 9Oct47; M2473. Universal Pictures
(PWH); 18Nov74; R590974.

R590975.
Universal international newsreel. Vol. 20, no. 82. By Universal
Pictures Company, Inc. 1 reel. © 14Oct47; M2474. Universal Pictures
(PWH); 18Nov74; R590975.
R590976.
Universal international newsreel. Vol. 20, no. 83. By Universal
Pictures Company, Inc. 1 reel. © 16Oct47; M2475. Universal Pictures
(PWH); 18Nov74; R590976.

R590977.
Universal international newsreel. Vol. 20, no. 84. By Universal
Pictures Company, Inc. 1 reel. © 21Oct47; M2476. Universal Pictures
(PWH); 18Nov74; R590977.

R590978.
Universal international newsreel. Vol. 20, no. 85. By Universal
Pictures Company, Inc. 1 reel. © 24Oct47; M2477. Universal Pictures
(PWH); 18Nov74; R590978.

R590979.
Universal international newsreel. Vol. 20, no. 86. By Universal
Pictures Company, Inc. 1 reel. © 28Oct47; M2478. Universal
Pictures (PWH); 18Nov74; R590979.

R590980.
Universal international newsreel. Vol. 20, no. 87. By Universal
Pictures Company, Inc. 1 reel. © 30Oct47; M2479. Universal
Pictures (PWH); 18Nov74; R590980.

R591171.
Paramount news, number 23. By Paramount Pictures, Inc. 1 reel.
© 15Nov47; M2532. Major News Library (PWH); 19Nov74; R591171.

R591328.
Violence. By Monogram Pictures Corporation. 7 reels. © 1Apr47;
L940. Allied Artists Pictures Corporation, formerly known as
Monogram Pictures Corporation (PWH); 22Nov74; R591328.

R591417.
When a girl’s beautiful. By Columbia Pictures Corporation. 7 reels.
© 23Sep47; L1199. Columbia Pictures Industries, Inc. (PWH);
25Nov74; R591417.

R591418.
Swiss tease. By Screen Gems, Inc. 1 reel. © 11Sep47; L1201.
Columbia Pictures Industries, Inc. (PWH); 25Nov74; 5591418.

R591419.
Bulldog Drummond strikes back. By Columbia Pictures
Corporation. 7 reels. © 4Sep47; L1202. Columbia Pictures
Industries, Inc. (PWH); 25Nov74; R591419.

R591420.
Her husband’s affairs. By Columbia Pictures Corporation. 9 reels.
© 29Sep47; L1213. Columbia Pictures Industries, Inc. (PWH);
25Nov74; R591420.

R591421.
Key witness. By Columbia Pictures Corporation. 67 min. ©
9Oct47; L1239. Columbia Pictures Industries, Inc. (PWH); 25Nov74;
R591421.

R591422.
Captain Silver sails again. By Columbia Pictures Corporation. (The
Sea Hound, chap. 1) 3 reels. © 4Sep47; L1241. Columbia Pictures
Industries, Inc. (PWH); 25Nov74; R591422.

R591423.