The ACUTE ABDOMEN

The role of the Plain Film Abdominal

Series
MI Zucker, MD
A dr Z Lecture
 The Abdominal Series
• For all acute abdominal complaints where
plain film imaging is indicated, get a
COMPLETE abdominal series
• Exceptions: Suspected renal calculus or
foreign body, where a single view is OK
• CT and ultrasound are often performed
after plain films
 Abdominal Series
Indications:
Highest yield: Presentations suggestive of
free air or obstruction
• Not very good for masses, ascites,
organomegaly, biliary tract disease, GI
bleeding and vague abdominal complaints
• Yield is higher in the elderly
 The Abdominal Series
• Erect chest, AP supine and erect abdomen
• Or, if patient unable to sit/stand:
supine chest, supine and left lateral
decubitus abdomen
• For calculus or foreign body: AP supine
abdomen
 The Erect Chest
• Best for free air

• To evaluate for intrathoracic abnormalities

presenting with abdominal complaints,
especially pneumonia (more common in
kids)
 Supine Abdomen
• Best for abdominal detail: Organs, bones
and joints, calcifications, fat and gas pattern
 Erect Abdomen
• For air-fluid levels and little else
Left Lateral Decubitus Abdomen
• Substitute for erect chest (free air) and erect
abdomen (air-fluid levels) in a patient
unable to sit or stand
 Indications for a single erect
abdomen film ONLY
• NONE

• None

• None

• None
 The Check List
• Bones and joints
• Calcifications
• Organs
• Fat
• Gas: In bowel and outside of bowel
 A memory aid
• “First organs, bones, and stones,
• Then masses, fat, and gas.
• Don’t forget the corner zones,
• And you’ll always cover your…subject”
 The Normal Abdominal Series
• Chest
• Supine abdomen
• Erect abdomen
• Left lateral decubitus abdomen
Chest
Supine Abdomen
Erect Abdomen
Left Lateral Decubitus Abdomen
Don’t forget to look for
pneumonia
 GAS

In the gut, and elsewhere

PNEUMOPERITONEUM

FREE AIR: Perforated Gut

 Free Air
• Best views: Erect chest and left lateral
decubitus abdomen
• Erect abdomen is less sensitive
• Supine abdomen is insensitive
 How Sensitive?
• Plain films are 85% sensitive for free air

• Theoretical threshold is 2 cc

• CT is much more sensitive and is the “Gold

Standard”
 Free Air: Erect Chest
• Air under the diaphragm
• Usually on the right
• Occasionally only seen on the left
Free Air: Erect Chest
Free Air: Erect Chest
Free Air: Erect Chest
Free Air: Left Lateral Decubitus
• Right side up, left side down
• Patient who can’t sit or stand
• Air under right abdominal wall
Free Air: Left Lateral Decubitus
 Free Air: Supine Abdomen
• Double bowel wall sign
• Falciform ligament sign
Double Wall sign
Falciform Ligament sign
 Pneumoretroperitoneum
• From perforation of posterior
extraperitoneal portions of duodenum or
colon
• Extension from or through the mediastinum
Pneumoretroperitoneum
Air in Biliary System

Bile ducts
Gall bladder
 Air in Biliary System
• Usually secondary to surgery on bile ducts
• Can be due to biliary-bowel fistula from
infection or neoplasm
• Rarely, can be due to infection
Air in Bile Ducts
Air in Gall Bladder
 Portal Venous Air

A sign of dead or dying bowel

Portal Venous Air
 The GUT

Gas and Fluid

Too Much and Too Little
 The Gas Pattern
• Can be specific for obstruction
• Often, nonspecific: General ileus, focal
ileus, ischemia, or obstruction
• A paucity of gas may be due to vomiting or
fluid-filled bowel
OBSTRUCTION

Small bowel
Colon
 OBSTRUCTION

Small bowel obstruction much more

common than colon: 70:30
 Small Bowel Obstruction:
Causes
• Adhesions 80%
• Hernia 15%
• Tumors, intussusception, midgut volvulus,
etc.
 Small Bowel Obstruction:
Findings
• Step-ladder dilated bowel loops on supine
view
• Step-ladder air-fluid levels on
erect/decubitus views
• Stretch sign on supine view
• String-of-pearls sign on erect/decubitus
views
 How Big is Big?

• In an adult, any visible small bowel is

abnormal, but small amounts often not
significant. Kids normally have small
amounts.
• Jejunum over 3 cm and ileum over 2 cm
diameter is very abnormal, but not specific
for obstruction
 Air, Fluid or Both?
• Small bowel can be distended by either air
or fluid or both
• Fluid-filled bowel may be more significant
than air-filled bowel, but often the
significance is the same
Air Filled Small Bowel
Fluid Filled Small Bowel
 Air-Fluid Levels
• Always abnormal in small bowel, but not
specific; often normal in colon
• The height of the fluid levels, same or
different, is NOT helpful in distinguishing
ileus from obstruction
Small Bowel Air-Fluid Levels
 What is Dilated?
• If small bowel and colon dilated equally,
probably not small bowel obstruction:
nonspecific ILEUS
• If small bowel significantly more dilated
than colon, suggests SBO
• Some gas in colon does NOT exclude SBO
Ileus
Classic Small Bowel Obstruction,
Supine
Classic Small Bowel Obstruction,
Erect
Stretch Sign: Supine
String-of-Pearls Sign: Erect
SBO: Hernia
 COLON Obstruction
Causes
• Carcinoma of the colon 80%
• Volvulus 5%
• Diverticulitis 5%
• Fecal impaction 5%
• Everything else 5%
Colon Obstruction: Carcinoma
 Colon Obstruction: Volvulus
• 5% of total
• 80% sigmoid
• 20% cecum
Volulus: Sigmoid
Volvulus: Cecum
 Colon Obstruction:
Measurements
• The cecum is the most distensible part of
the colon
• A cecum of 9 cm diameter is cause for
concern
• A cecum of 11 cm is impending perforation
Distended Cecum
 Other Emergency Conditions of
the Gut
• Toxic megacolon: Crohn, UC; 5cm
transverse colon is impending perforation
• Enterocolitis: C. diff. and other microbes
• Ischemia
Toxic Megacolon
 A word on Thumbprinting
• It means thickened bowel wall
• It can occur acutely in C. diff. or ischemia
or hemorrhage
• Chronically, it can be seen in inflammatory
bowel disease and neoplasm and a few
other less common diseases
C. diff. Enterocolitis
 Ischemic Bowel Disease
• Arterial emboli: A. fib., MI
• Arterial thrombi: ASCVD
• Venous thrombi: Hypercoag., neoplasm
• Non-occulsive mesenteric ischemia: Low
flow states
 Ischemia: Findings
• Normal gas pattern
• Non-specific ileus
• Thumbprinting
• Gas in bowel wall
• Gas in portal vein system
• Free air
Ischemia: Thumbprinting
Ischemia: CT
ACUTE APPENDICITIS
 Acute Appendicitis: Findings
• Normal
• Focal ileus
• Appendicolith
• Mass
• Free air is very rare
Focal Ileus
Appendicolith
Acute Appendicitis: CT
Acute Appendicitis: CT
Gall Bladder Disease
Cholelithiasis
Cholelithiasis: Ultrasound
PANCREATITIS

Acute
 PANCREATITIS: Findings
• Normal
• General nonspecific ileus
• Focal ileus: Sentinel loop, colon cut-off
sign
• Pancreatic calculi are found in CHRONIC
pancreatitis, not acute
Focal Ileus
Chronic Pancreatitis
Abdominal Aortic Aneurysm
 AAA
• Plain films are not sensitive, but can be
diagnostic
• Calcified walls of aorta can allow
measurement of lumen
• AAA if over 3 cm AP diameter
• Ultrasound and CT are much more sensitive
AAA
AAA: CT
 A few more…

The odd and the interesting

Echinococcus cyst
Ascariasis
Ascariasis
Foreign Body: Battery
Foreign Body: Battery
Tongue Ornament Misadventure
Body Packer or Mule
Customer of Body Packer
???
GOODBYE

• Copyright 2004
MI Zucker, MD