1

PLAIN ABDOMINAL FILMS

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

The supine abdomen film

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

The erect chest film

The erect chest film can assess :
Small pneumoperitoneum.
Chest conditions may mimic an acute
abdomen.
Acute abdominal conditions may be
complicated by chest pathology,
e.g. pleural effusion frequently complicate
acute pancreatitis, etc.
4

The erect chest film

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

The horizontal-ray abdominal film

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

ACUTE ABDOMEN

Perforation
Intestinal obstruction
Paralytic ileus
Acute colitis
Intraperitoneal fluid
Inflammatory conditions
Intramural gas
Calcification associated with acute abdominal
conditions
7

PERFORATION
PNEUMOPERITONEUM
Require emergency surgery!

Small pneumoperitoneum (I ml of free gas)

erect chest/LLD abdominal films.

Small pneumoperitoneum

PNEUMOPERITONEUM

Radiological appearances:
Plain abdominal film:
- Oval/linear collection of gas:
Subhepatic space
Morisons pouch
Beneath the diaphragm (the cupola sign)
In the centre of the abdomen over a fluid
collection (the football sign)
Fissure for ligamentum teres
10

- Small triangular collections of gas between

loops of bowel.
- Visualisation of the outer as well as the
inner wall of a loop of bowel (Riglers sign).
CT:
Free gas over the liver, anteriorly in the mid
abdomen, & in the peritoneal recesses.

11

Pneumoperitoneum

12

Pneumoperitoneum

Fissure for ligamentum teres

Riglers sign

13

Pneumoperitoneum

14

SUSPECTED PERFORATION
Severe upper abdominal pain.
No free gas is seen on plain films.
Contrast media:
100 ml air is injected down the tube
(NGT)LLD film is taken after 10 min.
50 ml of non-ionic contrast medium
(orally) placed on the right side
film is taken after 5 min.
15

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

Gastric Dilatation:
Etiology:
- Mechanical gastric outlet obstruction
- Paralytic ileus
- Gastric volvulus
- Air swallowing
16

Gastric Dilatation

17

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

18

 Radiological appearances:

Plain film changes appear after 3-5 h

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

19

Small-Bowel Obstruction
due to adhesion

20

Small-Bowel Obstruction
due to gallstone ileus

21

Small-Bowel Obstruction
due to Intussusception

A crescent of air at the apex of an intussusception

22

 Erect film:
- Multiple fluid levels (Stepladder pattern).
- String of beads sign
= small bubbles of gas may be trapped
in rows between the valvulae conniventes.
Oral dose of 100 ml of non-ionic contrast medium :
The contrast hasnt reached the caecum at 4 h
surgery is required!

23

Stepladder pattern in mechanical

obstruction of the small bowel

24

Small-Bowel Obstruction:
String of beads sign

25

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

26

 CT:

* CT should be performed whenever

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

27

Small-Bowel Obstruction

Fluid-filled loops

Bowel calibre change

28

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

29

Type IA : The ileocaecal valve is competent

Distended large bowel, particularly ascending colon
& caecum. No distention of small- bowel.
Type IB:
Caecal distension & small-bowel distension.
Type II:The ileocaecal valve is incompetent
No distension of caecum & ascending colon but
distension of small-bowel.

30

LARGE-BOWEL OBSTRUCTION

31

LARGE-BOWEL OBSTRUCTION
due to Sigmoid Volvulus

32

LARGE-BOWEL OBSTRUCTION
due to Caecal Volvulus

33

PARALYTIC ILEUS
Generalised paralytic ileus:
Etiology:
- Peritonitis
- Post-operative
- Hypokalaemia
- General debility or infection
- Drugs: morphine
- Congestive cardiac failure, renal colic, etc.
Radiological appearances:
- Both small & large-bowel dilatation
- Horizontal-ray films: multiple fluid levels
34

PARALYTIC ILEUS

35

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

36

ACUTE COLITIS
Acute inflammatory colitis
Toxic megacolon
Pseudomembranous colitis
Ischaemic colitis

37

Acute inflammatory colitis

Plain film can assess :
the extent of the colitis
the state of mucosa:
It can be assessed from :
- the faecal residue:
In left-sided disease, the proximal limit of
faecal residue will indicate the extent of
active mucosal lesion.
- the width of the bowel lumen
- the mucosal edge
- the haustral pattern
38

* The mucosal edge is smooth & the haustral

clefts are sharp no mucosal change.
* Fuzzy mucosal edges, widened clefts/absent
haustrations active disease.
* Coarse irregularity of the mucosal edge &
absent haustrations marked ulceration.
* Extensive mucosal destruction mucosal islands
or pseudopolyps toxic dilatation
indication for surgery!

39

 The depth of the ulceration

The presence/absence of megacolon and/or
perforation.
Severe disease process:
- The presence of large amounts of faeces
in the caecum & ascending colon
- A gasless colon
Urgent surgery:
- Ulceration penetrate the muscle layer
- Dilated bowel 5.5 cm

40

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

41

Toxic megacolon

42

Pseudomembranous colitis
Etiology: Clostridium difficile
Involve the whole of the colon
Radiological appearances:
Plain films:
- Thumb-printing
- Thickened haustra in left half
- Abnormal mucosa
- Dilated bowel in the right half
- Ascites
43

Ischaemic colitis
Etiology:
Vascular insufficiency & bleeding into the wall
of the colon.
Sudden onset of severe abd.pain in the early
hours of the morning, followed by bloody
diarrhoea.
In middle-aged & elderly patients.
The wall of splenic flexure & descending colon is
greatly thickened thumb printing (plain films).
The right side of colon is frequently distended.
44

Ischaemic colitis

thumb printing

45

INTRAPERITONEAL FLUID
Fluid within the peritoneal cavity is commonly
present in acute abdominal conditions.
Ro findings:
- The earliest signs:
Fluid density within the pelvis, visualised superiorly
& laterally to the bladder/rectal gas shadows.
- Displace colon medially from the flank fat stripes.

46

- Huge amounts of fluid:

A generalised haze over the abdomen &
poor visualisation of normal structures, e.g.
psoas & renal outlines.
Separation of bowel loops.
Thinning of the flank stripes laterally.

47

INFLAMMATORY CONDITIONS

Intraabdominal abscesses
Appendicitis
Acute cholecystitis
Emphysematous cholecystitis
Acute pancreatitis

48

Intra-abdominal abscesses

Displacement of adjacent structures.

Loss of visualisation of normal fat lines.
One/several tiny bubble-like lucencies.
Long air-fluid levels on horizontal-ray films
Pelvis is the most common site of residual
abscess
formation following generalised peritonitis.

49

Subphrenic abscess

Appear in the post-operative period, perforated

peptic ulcer, appendicitis, diverticulitis, perforations
of the GIT, or penetrating abdominal injuries.

Ro.findings:
- A raised hemidiaphragm
- Basal consolidation
- Pleural effusion (unilateral)
- Decreased diaphragmatic movement
- Generalised/localised paralytic ileus
- Scoliosis toward the lesion
- Decreased organ morbility
50

Subphrenic abscess

51

Intra-abdominal sepsis
Plain films:
- Small gas bubbles, unchanged in position
on consecutive films.
- Displacement of organs & bowel.
- Effacement of fat lines
CT:
- A mass with an attenuation value of
15-35HU.
- Ring enhancement after i.v. contrast
medium.
52

Appendicitis
Signs of acute appendicitis:

- Appendix calculus (0.5-6cm)

- Localised paralytic ileus in RLQ
- Sentinel loop-dilated atonic ileum containing
a fluid level
- Widening of the preperitoneal fat line
- Blurring of the preperitoneal fat line
- Blurring of the right psoas outline-unreliable
cont
53

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

54

Small bowel obstruction due to

Appendix abscess

55

 Ultrasound signs of acute appendicitis :

- Blind-ending tubular structure at the point
of tenderness:
Non-compressible
Diameter 7 mm
No peristalsis
- Appendicolith casting acoustic shadow
- High echogenicity non-compressible
surrounding fat
- Surrounding fluid/abscess
- Oedema of caecal pole
56

Acute appendicitis

57

Acute appendicitis

Acute appendicitis with appendicolith.

Abscess formation & appendicolith.

58

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

59

 Ultrasound imaging:
- A circumferential halo of low echogenicity
with thickening of the gallbladder wall
(8-10mm) in fasting state.
- Indistinct contour to the gallbladder wall
- Fluid around the fundus of the gallbladder
- Gallstones casting acoustic shadow
- A distended gallbladder (a stone obstructing
the cystic duct)
- Echogenic sediment in the lumen
- Positive sonographic Murphy sign
60

Acute cholecystitis

61

Emphysematous cholecystitis

Etiology: Clostridium welchii

30% of cases are diabetic
More common in men
Gas in the wall/lumen of the gallbladder (right
hypochondrium).
Gas in the bileducts in 20%
Obstructed cystic duct enlarged gallbladder
Small-bowel fluid levels

62

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

63

CHRONIC CHOLECYSTITIS

64

Cholangitis
Ultrasound imaging:
- The common bile duct (CBD) is thickened
& dilated, especially in the ampulla of vater
- Cholangitis abscess

65

Acute pancreatitis
Plain chest film:
- A left side pleural effusion
- Basal parenchymal shadowing
- Elevated left hemidiaphragm-unreliable
Plain abdominal film:
- Normal plain films in two-thirds of cases
- Duodenal ileus
Gas in a dilated duodenal loop in the LLD
- A gasless abdomen due to vomiting
cont
66

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

67

 Ultrasound signs of acute pancreatitis:

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

68

ACUTE PANCREATITIS

69

- Complication:
Necrotising pancreatitis
liquid/semiliquid tissue is spreading beyond
organ boundaries to the retroperitoneal,
pararenal space & the lesser sac of
the peritoneum)
Pancreatic pseudocyst
A transonic mass

70

 CT signs of acute pancreatitis:

- Necrosis, haemorrhage, & solid parenchyma that

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

71

CHRONIC PANCREATITIS
Plain abdominal film:
- Calcification

Ultrasound imaging:

- Atrophic/subnormal size
- Contours irregular
- Increased in echogenicity
- The pancreatic duct is irregularly dilated
(zipperlike pattern) & contains calculi
- Complication:
pseudocyst or thrombosis of the splenic
vein, portal vein, or both.
72

CHRONIC PANCREATITIS

73

INTRAMURAL GAS
Cystic pneumatosis
= pneumatosis cystoides intestinalis
- Cyst-like collections of gas ( 0.5-3 cm)
in the walls of hollow viscera.
- It is most frequently seen in the GIT (=pneumatosis
cystoides intestinalis) in the left half of colon.
- Cysts rupture pneumoperitoneum without evidence
of peritonitis unnecessary laparotomy!
74

Pneumatosis cystoides
intestinalis

75

 Interstitial emphysema
- Rare condition
- Etiology:
Gastroscopy, pyloric stenosis, & toxic megacolon
- In toxic megacolon it is a sign of impending
perforation.
- Linear gas, in single/double streaks in the bowel
wall, & isnt associated with infection.

76

 Gas-forming infections (gastritis, enterocolitis, cystitis)

Etiology:
E.coli, Clostridium welchii & Klebsiella aerogenes.
Emphysematous gastritis:
- A contracted stomach, with a frothy/mottled
radiolucency visible in the left upper abdomen
due to gas within the stomach wall.
- High mortality.

77

Emphysematous enterocolitis:
- Premature babies/adults
- In an adult, has a grave prognosis
Emphysematous cystitis:
- More common in diabetics.
- Linear gas streaks & gas cysts within
the wall of the urinary bladder.
- Associated with gas within the lumen of
the bladder itself.

78

CALCIFICATION ASSOCIATED WITH

ACUTE ABDOMINAL CONDITIONS

79

80

BLUNT HEPATIC TRAUMA

The third most common organ injured in the
abdomen.
The need for surgery is determined by the size
of the laceration, the amount of hemoperitoneum,
& the patients clinical status.
Ultrasound findings:
- Laceration (3%) (right lobe > left lobe)
81

- Intrahepatic hematoma:
* Hyperechoic in the first 24 hours
* Hypoechoic & sonolucent thereafter
- Subcapsular hematoma:
* Unilateral, along the area of laceration
* Anechoic, hypoechoic, septated lenticular,
or curvelinear (DD/ascitic fluid)
- Capsular disruption
- Intraperitoneal fluid
82

Ultrasound findings

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

83

BLUNT HEPATIC TRAUMA

84

BLUNT HEPATIC TRAUMA

85

BLUNT HEPATIC TRAUMA

86

SUBACUTE SUBCAPSULAR
HAEMATOMA OF THE LIVER

87

BLUNT HEPATIC TRAUMA

88

HEPATIC CONTUSION WITH

HAEMATOMA

89

GALLBLADDER INJURY

90

SPLENIC INJURY
Most commonly injured
Ultrasound findings:
- Splenomegaly, with progressive enlargement
- Irregular splenic border
- Intrasplenic hematoma
take longer
- Contusion (splenic inhomogeneity)
- Subcapsular and pericapsular fluid collections
- Free intraperitoneal blood (disappear 2-4 weeks)
- Left pleural effusion
- When the spleen returns to normal small irregular
foci /normal parenchyma
91

SPLENIC INJURY

92

SPLENIC INJURY

93

HAEMOPERITONEUM
(FRAGMENTED SPLEEN)

94

BLUNT PANCREATIC INJURY

95

BLUNT PANCREATIC INJURY

96

97

Stomach and duodenum disorders:

- Hypertrophic pyloric stenosis
- Gastritis
- Peptic ulceration
- Miscellaneous conditions (gastric volvulus,
gastric diverticulum, duodenal diverticulum)
- Benign tumours and malignant tumours
- Duodenal atresia
- Duodenitis
- Duodenal ulcer

98

Maagduodenography

99

Hypertrophic pyloric stenosis

Congenital abnormality of the pyloric musculature.
Radiological findings:
- Contrast studies:
* Tit sign
* Shoulder sign
* String sign
* Railroad track
* Umbrella sign

100

Hypertrophic pyloric stenosis

1.Tit sign, 2. shoulder sign, 3. string

sign, 4. railroad track, 5. umbrella sign

101

Hypertrophic pyloric stenosis

102

Hypertrophic pyloric stenosis

- Ultrasound imaging:
* A hypertrophied muscle layer (width of > 2 mm) is
hypoechoic to the adjacent liver, with a double line
of hyperechoic mucosa seen centrally.
* No transit of gastric contents into the duodenum
was observed

103

Hypertrophic pyloric stenosis

Pyloric stenosis

Normal pylorus
104

Gastritis
Classified into:
1. Superficial gastritis
2. Atrophic gastritis
3. Hypertrophic gastritis
Radiographic appearances:
1. Superficial gastritis (involve mucosa):
- No detectable alteration
- Severe irregularity of the gastric folds

105

2. Atrophic gastritis:
- The stomach is usually rather long & tubular
- Fundus of the stomach appears like a small dome.
- Mucosal folds in the fundus/body of the stomach
are very thin (tissue paper folds)
- A very thin gastric wall
- The greater curvature of the stomach is remarkably
smooth

106

3. Hypertrophic gastritis :
- Marked enlargement of the mucosal fold
(up to 1 cm in width)
- Irregularity of the greater curvature
- Marked thickening of the gastric wall
- Peculiar reticular pattern of barium which
mixes poorly with large amounts of mucus
- Gastric emptying is delayed

107

Atrophic gastritis

108

Gastric ulceration
Discontinuity in the mucous membrane of
the stomach with inflammatoory base.
Roentgen signs of a benign ulcer:
1. Location: lesser curvature & adjacent part of the
posterior wall
2. Multiple
3. 4% of benign ulcers greater in diameter than 4 cm
4. Ulcer niche/fleck/spot

109

5. Cartwheel configuration
= folds radiate from the ulcer like the spokes
on a wheel
6. An incicura on the greater curvature opposite
a gastric ulcer.
7. The ulcer protrudes beyond the line of the lumen.

110

111

112

8. Edematous ridge leads to the ulcer & surrounds

it at its base:
- Hamptons line
- Ulcer collar
- Ulcer mound
9. The association of a gastric ulcer with a duodenal ulcer
10. 80% heal within 4 weeks (rapid healing)

113

Roentgen signs of a malignant ulcer:

1. Location: upper part of the greater curvature
2. Ulcer edges irregular
3. Doesnt protrude beyond the line of the lumen
4. Ulcer within a polypoid mass
5. Shallow ulcer surrounded by thick rigid fold

114

6. The Carman-Kirklin meniscus sign:

Large ulcer niche ( 3 to 8 cm) with an elevated
rolled margin:
- In antrum: crater is crescentic toward lumen of
stomach
- In body: crater is crescentic & curves away
from lumen of stomach

115

Gastric ulceration

Benign ulcer

Malignant ulcer

116

Gastric diverticulum
Protrusions of the mucosa & submucosa through
a congenitally weakened muscular coat.
Location:
- posterior wall of fundus of the stomach (common)
- prepyloric (rare)
Radiographic appearances (barium study):
- Size: few mm 8 cm
- Single or multiple
117

- Pocketlike structure attached to the inner

wall with a smooth outline
- The lining mucosa may show an area
gastricae pattern
Complications:
- Inflammation
- Ulceration
- Perforation
- Malignant degeneration

118

Gastric diverticulum

119

Tumours of the stomach

Benign tumours of the stomach:
- Adenoma
- Leiomyoma
- Lipoma
- Abberant pancreas
- Inflammatory polyps, etc
Location:
- pyloric portion (75%)
- body (20%)
- fundus & cardia (5%)
120

Radiographic appearances:
- A sharply circumscribed filling defect
projecting within the lumen
Malignant tumours of the stomach:
Gross morphologic types:
- Ulcerative (28%)
- Fungating/polypod (22%)
- Spreading/infiltrating (13%)
- Remainder unclassifiable

121

Usual histologic pattern: well-differentiated adenoca

Location: pyloric & prepyloric regions
Radiographic appearances:
1. Irregular filling defect.
2. Malignant ulcer within the filling defect.
3. A leather bottle type stomach suggesting scirrhous ca.

122

Duodenal atresia
Radiographic appearances:
* Plain film: double bubble sign with an absence
of distal air
* Barium study: complete obstruction

123

Duodenal atresia

124

Duodenitis
Radiographic appearances:
- A coarsening of the duodenal folds
- Erosions (en face): Dots of barium with/without
a radiolucent halo
- A cobblestone appearance to the duodenal cap

125

Duodenitis

126

Duodenal ulcer

70% of peptic ulcers are in duodenum

62% in the duodenal bulb
Occurs in 4% of gastrointestinal disturbances.
75% in males
Radiographic appearances:
- Single (80%)/multiple (20%)
- Niche/fleck
- Edematous mucosa
- Fragmentation of bulb on compression
- Bulbar deformity & irritability
- Eccentric pylorus with widened rugae
- Cartwheel rugae
127

Duodenal ulcer

128

Duodenal diverticulum
Mucosal herniations through the muscle coat of the
duodenum
Location: Periampullary, the third & fourth parts of the
duodenum.
Radiographic appearance:
- Pocketlike structure attached to the inner
wall with a smooth outline
- Often multiple
Complications: haemorrhage, diverticulitis & perforation.
129

Duodenal diverticulum

130

Tumours of the duodenum

Benign tumours of the duodenum:
- Very rare
- Adenoma, papilloma, lipoma, fibroma, etc.
- Radiographic appearance:
Single smooth filling defect within duodenum
Malignant tumours of the duodenum:
- Rare
- Carcinoma, malignant carcinoid, leiomyosarcoma

131

Ulcerating leiomyoma

132

Chronic duodenal obstruction of the proximal portion of

the fourth part of the duodenum due to
a carcinoma of the duodenum

133

134