Abdominal X-ray

Radiological Signs

Suzanne OHagan
Lightbulb moment
a moment of sudden inspiration, revelation, or recognition
 Approach to AXR
Bowel gas pattern

Extraluminal air

Soft tissue masses

Calcifications
Normal AXR
Liver Gas in
stomach Splenic flexure
11th rib T12

Psoas margin
Left kidney

Hepatic flexure
Transverse colon

Iliac crest
Gas in sigmoid
Sacrum

Gas in caecum
SI joint

Bladder
Femoral head
 Gas pattern
What is normal?
Stomach
Almost always air in stomach
Small bowel
Usually small amount of air in
2 or 3 loops
Large bowel
Almost always air in rectum
and sigmoid
Varying amount of gas in rest of large bowel
 Normal fluid levels
Stomach
Always (upright, decub)

Small bowel
Two or three levels
acceptable (upright, decub)

Large bowel
None normally
(functions to remove fluid)
 Large vs small bowel
Large bowel
Peripheral (except RUQ occupied by liver)
Haustral markings dont extend from wall
to wall

Small bowel
Central
Valvulae conniventes extend across lumen
and are spaced closer together
 Radiographic principles

Series of films for acute abdomen

Obstruction series/ Acute abdominal
series/ Complete abdominal series

Supine (almost always)

Upright or left decubitus (almost always)
Prone or lateral rectum (variable)
Chest, upright or supine (variable)
 Acute abdominal series
What to look for
VIEW LOOK FOR

SUPINE ABDOMEN Bowel gas pattern

Calcifications
Masses

PRONE ABDOMEN Gas in rectosigmoid

Gas in ascending and
descending colon
UPRIGHT ABDOMEN Free air, air-fluid levels

UPRIGHT CHEST Free air, lung pathology

secondary to
intraabdominal process

Substitutes: Prone Lateral rectum

Upright Left lateral decub
Upright chest Supine chest
 Obtaining views
Supine
Patient on back, x ray beam directed
vertically downward, casette
posterior, x-ray tube anterior (AP)

Prone
Patient on abdomen, x-ray beam
directed vertically downward,
cassette anterior, x-ray tube
posterior (PA)

Upright
Patient stands or sits, x-ray beam
directed horizontally, cassette
posterior, x-ray tube anterior (AP)

Upright chest
Patient stands or sits, horizontal x-
ray beam, cassette anterior, x-ray
tube posterior (PA)

1900s X-Ray-based fluoroscopy machine

in which radiation is shot directly through
the patient and into the doctors face.
 Abnormal Gas Patterns
Functional ileus
One or more bowel loops become aperistaltic
usually due to local irritation or inflammation
Localised sentinel loops (one or two loops)
Generalised (all loops of large and small bowel)

Mechanical obstruction
Intraluminal or extraluminal
Small bowel obstruction
Large bowel obstruction
 3, 6, 9 RULE

Maximum Normal Diameter of

bowel
Small bowel 3cm
Large bowel 6cm
Caecum 9cm
 Localised ileus
Key features
One or two persistently
dilated loops of small or
large bowel (multiple views)
Often air-fluid levels in
sentinel loops
Local irritation, ileus in
same anatomical region as
pathology
Gas in rectum or sigmoid
May resemble early SBO
Causes of Localised Ileus
by location

SITE OF DILATED CAUSE

LOOPS
Right upper Cholecystitis
quadrant
Left upper quadrant Pancreatitis
Right lower quadrant Appendicitis
Left lower quadrant Diverticulitis
Mid-abdomen Ulcer or kidney/ureteric
calculi
 Colon cut off sign
Abrupt cutoff of colonic gas column at the splenic flexure (arrow). The colon is
usually decompressed beyond this point.

Explanation:

Inflammatory exudate in acute

pancreatitis extends into the
phrenicocolic ligament via lateral
attachment of the transverse
mesocolon

Infiltration of the phrenicocolic

ligament results in functional
spasm and/or mechanical
narrowing of the splenic flexure at
the level where the colon returns
to the retroperitoneum.
 Generalised ileus
Key features
Entire bowel aperistaltic/hypoperistaltic
Dilated small bowel and large bowel to
rectum (with LBO no gas in rectum/sigmoid)
Long air-fluid levels

CAUSE REMARK

*Postoperative Usually abdominal surgery

Electrolyte imbalance Diabetic ketoacidosis

* almost always
 Generalised adynamic ileus

The large and

small bowel are
extensively airfilled
but not dilated.

The large and

small bowel "look
the same".
 Mechanical SBO
Dilated small bowel

Fighting loops (visible loops, lying

transversely, with air-fluid levels at
different levels)

Little gas in colon, especially rectum

SBO Erect SBO Supine

Air fluid levels

Causes of Mechanical SBO
Adhesions
Hernia*
Malignancy
Gallstone ileus*
Intussesception
Inflammatory bowel
disease

* May be visible on AXR

Step ladder appearance

Loops
arrange
themselves
from left
upper to
right lower
quadrant in
distal SBO
Coil spring sign
 String of pearls sign

Considered diagnostic of obstruction (as opposed to ileus)

and is caused by small bubbles of air trapped in the
valvulae of the small bowel.
Stretch/slit sign

Slit of air caught in a

valvulae, characteristic
of SBO
 Closed loop obstruction
Two points of same loop of bowel
obstructed at a single location
Forms a C or a U shape
Term applies to small bowel, usually
caused by adhesions
Large bowel, called a volvulus
Crescent Sign

Caused by:

LUQ Soft tissue mass

OR

Head of intussusception
in distal transverse colon
 Double Bubble Sign
Duodenal Atresia
 Mechanical LBO
Colon dilates from
point of obstruction
backwards

Little/no air fluid

levels (colon
reabsorbs water)

Little or no air in
rectum/sigmoid
Large bowel obstruction
Bowel loops tend not to
overlap therefore
possible to identify site
of obstruction

Little or no gas in small

bowel if ileocaecal valve
remains competent*

* If incompetent, large bowel

decompresses into small bowel, may
look like SBO
Causes of Mechanical LBO

TUMOUR
VOLVULUS
HERNIA
DIVERTICULITIS
INTUSSUSCEPTION
 Note on volvulus
Sigmoid colon has its own mesentry
therefore prone to twisting

Caecum usually retroperitoneal and

not prone to twisting; 20% people
have defect in peritoneum that
covers the caecum resulting in a
mobile caecum
 Volvulus
A volvulus always extends away from the area of twist.
Sigmoid volvulus can only move upwards and usually
goes to the right upper quadrant. Caecal volvulus
can go almost anywhere.
 Coffee Bean Sign
Sigmoid volvulus

Massively
dilated
sigmoid loop
 Hernia

Lateral decubitus of value

The advantage is that there may be a greater chance of air entering the
herniated bowel because it is the least dependent part of the bowel in the
supine position.
 Apple core sign
Radiologic manifestation of
a focal stricture of the bowel
usually at contrast material
enema examination. The
stricture demonstrates
shouldered margins and
resembles the core of an
apple that has been
partially eaten. The most
common cause is an
annular carcinoma of the
colon.
Thumbprinting

The distance between

loops of bowel is increased
due to thickening of the
bowel wall.

The haustral folds are very

thick, leading to a sign
known as 'thumbprinting.'
Lead pipe
colon
Shortening
of colon
secondary to
fibrosis
Loss of
haustration
Ulcerative
colitis
 Extraluminal air
TYPES
Pneumoperitoneum/free air/intraperitoneal air

Retroperintoneal air

Air in the bowel wall (pneumatosis

intestinalis)

Air in the biliary system (pneumobilia)

 Upright film best
The patient should be positioned sitting
upright for 10-20 minutes prior to
acquiring the erect chest X-ray image.

This allows any free intra-abdominal gas

to rise up, forming a crescent beneath
the diaphragm. It is said that as little as
1ml of gas can be detected in this way.
 Free Air
Causes
Rupture of a hollow viscus
Perforated peptic ulcer
Trauma
Perforated diverticulitis (usually seals off)
Perforated carcinoma

Post-op 5-7 days normal, should get less with

successive studies *NOT ruptured appendix (seals
off)
 Signs of free air
Crescent sign
Chilaiditis sign
Riglers (and False Riglers)
Football sign
Falciform ligament sign
Triangle sign
Cupola sign
Lesser sac sign
Crescent Sign II
Free air under the diaphragm

Best demonstrated on
upright chest x rays or
left lat decub

Easier to see under

right diaphragm
 Chilaiditis sign
May mimic air under
the diaphragm
Look for haustral folds
Get left lat decub to
confirm

In patients who have cirrhosis

or flattened diaphragms due to
lung hyperinflation, a void is
created within the upper
abdomen above the liver. This
space may be filled by bowel. If
this bowel is air filled then it
may mimic free gas.
 Riglers Sign
Bowel wall visualised on both sides due to intra and extraluminal air
Usually large amounts of free air
May be confused with overlapping loops of bowel, confirm with upright view
 False Riglers Sign
The Rigler sign can sometimes be
simulated by contiguous loops of bowel,
whereby intraluminal air in one loop of
bowel may appear to outline the wall of
an adjacent loop, which results in a
misdiagnosis of free air.

Measure distance of interface if unsure

 Football SIgn
Seen with massive
pneumoperitoneum

Most often in children

with necrotising
enterocolitis

In supine position air

collects anterior to
abdominal viscera

Paediatric
Adult
Falciform ligament sign

Normally
invisible.

Supine film, free

air rises over
anterior surface
of liver
Other patterns of air around
liver

Doges Cap Sign

 Inverted V sign
On the supine radiograph, an inverted
"V" may be seen over the pelvis in a
patient with pneumoperitoneum.

While in infants this is produced by

the umbilical arteries, in adults it
appears to be created by the inferior
epigastric vessels
 Continuous diaphragm sign

Sufficient
free air, left
and right
hemi-
diaphragms
appear
continous
 Lesser sac Sign
Cupola Sign
Lesser Cupola
sac sign
sign (white
(black arrows)
arrows)
The lesser sac is
positioned Air superior to
posterior to the left lobe of
stomach and is liver
usually a potential
space. There is
free connection
between the lesser
sac and the
greater sac
through the
foramen of
Winslow Double Bubble Sign
 Cupola Sign
Air beneath the central tendon of the diaphragm

The term cupola comes from a dome such as

this famous dome of the Duomo in Florence.
 Triangle Sign
The triangle
sign refers to
small triangles
of free gas that
can typically be
positioned
between the
large bowel and
the flank
 Retroperitoneal Air
Recognised by:
Streaky, linear appearance outlining
retroperitoneal structures
Mottled, blotchy appearance
Relatively fixed position
May outline:
Psoas muscles
Kidneys, ureters, bladder
Aorta or IVC
Subphrenic spaces
Causes of retroperitoneal air
Bowel perforation (appendix, ileum,
colon)
Trauma (blunt or penetrating)
Iatrogenic
Foreign body
Gas producing infection
 Pneumoretroperitoneum
This patient has free air in
the retroperitoneal space.
The air is seen
surrounding the lateral
border of the right kidney
(white arrow). There is
other evidence of free gas
including Rigler's sign.

If you are not confident

that the appearance is
pneumoretroperitoneum,
you can try an erect and
decubitus view to see if
the gas moves. If the gas
is seen to move, it's not in
the retroperitoneum.
Air in the bowel wall
Signs

Best seen in profile producing a linear

lucency that parallels the bowel

Air en face has a mottled appearance

resembling gas mixed with faeculent
material
 Causes of air in bowel wall
Primary Pneumatosis cystoides intestinalis (rare)
usually affects left colon
Produces cyst-like collections of air in the submucosa or
serosa

Secondary
Diseases with bowel wall necrosis
Obstructing lesions of the bowel that raise intraluminal
pressure

Complications
Rupture into peritoneal cavity
Dissection of air into portal venous system
 Pneumatosis intestinalis
Intramural
air, best
appreciated
in profile
 Air in the biliary tree
One or two tube-like branching
lucencies in the RUQ, conform to
location of major bile ducts
 Causes
Normal if Sphincter of Oddi incompetence
Previous surgery including sphincterotomy
or transplantation of CBD

Pathology (uncommon)
Gallstone ileus: gallstone erodes through wall of
GB into the duodenum producing a fistula
between the bowel and the biliary system.
Stone impacts in small bowel = mechanical
SBO. ileus misnomer
Biliary vs Portal Venous Air
Portal venous air
usually
associated with
bowel necrosis

Air is peripheral
rather than
central

Numerous
branching
structures
 Soft tissue masses
Organomegaly
Know normal landmarks

2 ways to identify soft tissue

masses/organs:

Direct visualisation of edges of structure

Indirect by displacement of bowel
CT, US and MRI have essentially replaced conventional
radiography in the assessment of organomegaly and soft
tissue masses
 Abdominal
Calcifications
Location Pattern
First exclude artefact

Kim Kardashians butt real or artefact?

 Location
Vascular
Liver
Gallbladder
Spleen
Pancreas
Lymph nodes
Adrenals
Kidneys
Ureters
Bladder
Prostate
 Rim-like
Calcification that has occurred in the wall
of a hollow viscus

Cysts
renal, splenic, hepatic
Aneurysms
aortic, splenic, renal artery
Saccular organs
Gallbladder
Urinary bladder

Calcified hydatid cysts

 Linear/Track
Calcification in walls of tubular
structures Aortoiliac calcification

Arteries
Fallopian tubes
Vas deferens
Ureter
Chinese Dragon Sign

Calcified splenic artery

Calcified vas deferens
 Floccular, Amorphous,
Popcorn
Formed in solid organ or tumour
Pancreas (chronic pancreatitis)
Leiomyomas of uterus
Ovarian cystadenomas
Lymph nodes
Adenocarcinomas of stomach, ovary, colon
Metastases
Soft tissue (previous trauma, crystal
deposition)
 Calcified Calcified
enteric fibroids
lymph nodes

Calcified
pancreas

Floccular
 Lamellar or laminar
Formed around a nidus inside hollow
lumen

Concentric layers due to prolonged

movement of stone inside hollow viscus
Renal stones
Gallstones
Bladder stones
 Bladder calculi

Lamellar
Renal calculi
Pelvicalyceal calcifications
 Staghorn Calcification

Renal stones are often small, but if large

can fill the renal pelvis or a calyx, taking on
Tubular its shape which is likened to a staghorn.
Renal calculi
Parenchymal calcification

Nephrocalcinosis
Uncommonly the renal
parenchyma can become
calcified.

This is known as
nephrocalcinosis, a condition
found in disease entities such
as medullary sponge kidney
or hyperparathyroidism.

Flocculent
 Putty Kidney
"Putty kidney"
sacs of casseous,
necrotic material
(TB)
Autonephrectom
y small,
shrunken kidney
with dystrophic
calcification

Flocculent
 Calcified gallstones

Lamellar
 Conclusion
Approach to AXR should include gas
pattern, extraluminal air, soft tissue
and calcifications

Named radiological signs are a useful

way of remembering, identifying and
reporting on films
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radiography
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