RADIOGRAPHY OF ABDOMEN

• Presented by
• Shweta Sharma
• B.Sc.M.T.X-ray
• Final Year.
• PGIMER.

• MODERATOR:
• MR. RAM SINGH
• Lecturer
• Department of Radiodiagnosis and
Imaging
• PGIMER, Chandigarh.
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 INTRODUCTION
• Abdomen is the lower part of the trunk and lies
below the diaphragm.
• Its upper and lower parts are continuous with the
planes of the pelvic inlet.
• Abdomen is a cavity containing abdominal viscera
and other organs and is enclosed in the abdominal
wall.
• Except for some skeleton abdominal wall consists
of mainly the anterolateral and posterior groups of
abdominal muscles.
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• The tone of the abdominal muscles varies
form individual to individual.
• It is readily distended by the organs it
encloses and it moves with respiration.

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 Planes Of Abdomen
Topographically, the
abdomen can be
divided into right and
left upper and right
and left lower
quadrants by vertical
and horizontal lines
through the umbilicus.
 

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The abdomen may also be
divided into nine regions
by two longitudinal lines
(right and left
midclavicular lines) and
two transverse planes
(subcostal and interspinous
planes). The regions are:
right and left
hypochondriac, right and
left lumbar, right and left
inguinal (or iliac),
epigastric, umbilical and
hypogastric.
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 The skeletal appearances
• The parts of the abdomen usually seen on
the AP view of abdomen are:
• 1)The last 2- sometimes 3- pairs of ribs;
• 2)The last 2- sometimes 3- thoracic
vertebrae;
• 3)All 5 lumbar vertebrae
• 4)Sacrum;
• 5)The hip bones.
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 THE APPEARANCES DUE TO
FAT

• Fat is more radiolucent than other soft

tissues and usually provides sufficient
radiographic contrast for the visualization
of certain abdominal organs.

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 Appearances due to Gastric and
intestinal gases
• In gas, there is no absorption of the beam.
• This medium is radioparent.
• Whenever it is present among structures exposed
to an X-ray beam, it produces areas of deeper
blackening on the film and provides contrast.
• In the alimentary tract, variable quantities of gases
are found as a normal physiologic feature and we
may notice its presence at any or all of numerous
sites on the plain AP radiograph of the abdomen.

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 THE APPEARANCES DUE TO
ABDOMINAL ORGANS
• THE ORGANS TO BE CONSIDERED
ARE:
• 1)Liver;
• 2)Kidneys & Bladder;
• 3)Spleen;
• 4)Pancreas.

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 LIVER
1) Largest gland;
2) Wedge shaped;
3) Dimensions :-
W:L:AP :: 8.5:6.5:4.5 (inches)
4) Quadrants:
-extends across the epigastrium
-left hypochondrium
-right lumbar

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• Anatomically, liver has:
• 2 lobes-RIGHT LOBE
-LEFT LOBE
• 2 minor lobes
-CAUDATE LOBE
-QUADRATE LOBE
• HILUM – b/w 2 minor
lobes.

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 KIDNEYS
• Both lie posteriorly.
• Retroperitoneal.
• Left kidney (relative to rt.)- larger,
narrower, more oblique nearer to the
median plane.
• Right kidney-lower.
• Upper poles- pointed (rel. to lower poles)

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 SPLEEN
• Largest ductless gland;
• Quadrants: mainly lt.hypochondrium, extends to the
epigastium;
• Situated b/w diaphargm & stomach
• Pulpy ,vascular organ;
• 4 impressions-GASTRIC
-RENAL
-PANCREATIC
-COLIC

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 PANCREAS
• Flattened, elongated gland;
• Posterior aspect;
• Quadrants: epigastrium & lt.
hypochondrium;
• Endocrine as well as exocrine;
• ISLETS OF LANGERHANS- Endocrine.

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 APPEARENCES DUE TO
CALCIFICATION
• Calcium- high At. No. element;
• Therefore its presence anywhere in the
body results in radiographic opacities which
are detectable.

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APPEARANCES DUE TO
FOREIGN BODIES

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 INDICATIONS
SAIO (sub acute intestinal obstruction)
It is not a disease in itself but is caused due to:
-constriction of the intestine by strangulated hernia,
volvulus or intussusception.
-stenosis and thickening of the intestinal wall e.g. in
diverticulosis.
-pressure on the intestine from outside e.g. a large
tumor in any pelvic or abdominal organ.
-obstruction by tumor growing in the lumen of the
intestine.
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 Contd……..
Abdominal pain
Abdominal mass
Chronic pancreatitis
Acute pancreatitis
Calcifications
Renal or urinary tract calculi
Pre-operative or post operative evaluation
Blunt trauma
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 EQUIPMENT
Because of the wide range in the thickness
of the abdomen and the delicate differences
in the physical density between the viscera
a high mA machine is used.
• High KVp is not used.
• In our department:
UNIT is SIEMENS optitop.
It’s a ceiling suspension unit.

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• Min KVp is 40
• Max KVp is 125
• Min mAs is 0.5
• Max mAs is 800
• Vertical bucky (vertix) is also there.
• Couch (from multix) with vertical
(motorised movements) and floating
movements is there.

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Control panel Vertical bucky 31
 PATIENT PREPARATION

• For plain x-ray of abdomen there should not be any

faecal matter and gases.
• To get rid of faecal matter patient is given
laxatives( dulcolax 2 tab or castor oil ) one night prior
to the day of examination.
• To stop formation of gases patient is kept ambulent.
• To get rid of already formed gases charcoal tablet is
given.
• On the day of examination patient is asked to empty the
bladder.

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 RADIOGRAPHIC
PROJECTIONS
• AP-SUPINE
-ERECT
• PA
• LATERAL DECUBITUS
• LATERAL
• DORSAL DECUBITUS
• LPO
• AP(ERECT, SUPINE) and CXR in case of acute abdomen.

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 AP for KUB
• Patient is made to lie on the x-ray table in
supine position.
• Sagittal plane of the body is centered to the
table.
• Both antero superior iliac spine should be
equidistant from the table.
• The lower border of the cassette is kept at
the level of the symphysis pubis.

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 Contd…….
• CR: is directed at the mid point at the level
of the iliac crest.
• Patient is asked to hold breathe at the end of
the expiration phase.

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 EVALUATION CRITERIA
1.Both the renal area and the urinary bladder
should be included.
2.Patient should be alligned properly.
3. There should be no rotation.

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 AP SUPINE
• Patient is made to lie on the x-ray table in supine position.
• Sagittal plane of the body is centered to the table.
• Both antero superior iliac spine should be equidistant from
the table.
• Center the cassette at the level of the iliac crests.
• C.R. is directed at the mid point at the level of the iliac
crest.
• Patient is asked to hold breath at the end of expiration
phase.

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Structures seen:-
Size and shape of liver, spleen, kidney.
Any intra abdominal calcifications/tumor
masses.

EVALUATION CRITERIA:-
1.Symphysis pubis to the upper abdomen should
be included.
2.Patient should be aligned properly.
3.There should be no rotation.

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 AP ERECT
• Patient is in erect position with the body facing towards
the x-ray tube.
• Centre the mid-sagittal plane of the body to the midline
of the vertical bucky.
• Centre the cassette 2-3 inch above the level of iliac
crests high enough to include the diaphragm.
• C.R.-PERPENDICULAR TO THE FILM, 2” ABOVE THE
LEVEL OF ILIAC CRESTS TO INCLUDE THE
DIAPHRAGM.
• Patient is asked to hold breath at the end of expiration
phase.

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 PA PROJECTION
• Patient is in upright position.
• Anterior abdominal surface is in contact with vertical grid
device.
• Center the midline to the middle of the vertical grid device.
• Center the film 2 inc. above the iliac crest as in the AP supine.
• C.R. – perpendicular to the film at the level of iliac crests.
• Patient is asked to hold breathe at the end of the expiration
phase.
• This projection greatly reduces dose to the gonads.

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 LEFT LATERAL DECUBITUS
• The patient is made to lie on the left side of the body.
• The arms should be placed above the level of the
diaphragm, so as not to be projected over any abdominal
contents.
• Knees are flexed for stabilization.
• Adjust the height of the VGD so the long axis of the film is
centered to the mid sagittal plane.
• Cassette is centered at the level of the iliac crests.
• CR: is directed horizontal and perpendicular to the
midpoint of the cassette.
• Respiration is suspended at the end of expiration phase.

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STRUCTURES SHOWN:
• Size and shape of liver, kidneys and spleen.
• This projection is most valuable for
demonstrating air-fluid levels when an upright
abdomen projection cannot be obtained.

NOTE: A right lateral decubitus position is often

requested or it may be required when the patient
cannot lie on the left side.

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 EVALUATION CRITERIA
1. Diaphragm should be included.
2. weight bearing side should be elevated and
demonstrated when fluid is suspected.
3. The side that is up should be demonstrated
when free air is suspected.
4. No rotation of the patient.

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 LATERAL VIEW
Indications:-

This view is done to

1. See the aortic calcification in relation to the spine.

2. If any opacity is seen in the AP view on the right side then to

confirm whether the opacity is in kidney or in the gall bladder.
if the opacity is in the posterior region then the opacity is in the
kidney and if the opacity lies in he anterior region then the
opacity is in he gall bladder.

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 POSITIONING
• The patient is turned to Rt./Lt. side.
• Knees flexed to a comfortable position.
• Adjust the body so that a plane approx.5cm
anterior to the midaxillary plane is centered to the
midline of the table.
• Flex the elbows and place the hands under the
patient’s head.
• Center the film at the level of iliac crest or high
enough to include diaphragm.

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 Contd….
• CR:- is perpendicular to the film and enters the
midcoronal plane at the level of iliac crests or 2”
above the iliac crests if the diaphragm is included.
• Respiration is suspended at the end of expiration
phase.

STRUCTURES SHOWN :-
• Prevertebral space occupied by the abdominal aorta.
• Intra-abdominal calcifications or tumor masses.

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 EVALUATION CRITERIA
1. Abdominal contents should be seen with
soft tissue grey tones.
2. There should be no rotation.
3. when diaphragm is included, as much of
the remaining abdomen as possible should
be included.

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 DORSAL DECUBITUS
This view is done when the patient cannot stand or
lie down in lateral position.
• The patient is in supine position with side in
contact with Vertical grid device.
• Arms placed on the head.
• Height of the vertical grid is adjusted so that the
long axis of the cassette is centered to the
midcoronal plane.
• Patient is positioned so that a pt. approx. 5cm above
the level of iliac crests is centered to the cassette.

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 CR :- directed horizontally perpendicular
to the center of the cassette, entering the
midcoronal plane 2” above the level of the
iliac crests.

STRUCTURES SHOWN:
• 1. air-fluid levels.
• 2. prevertebral space.

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 LEFT POSTERIOR OBLIQUE
• This view is done for spleen.
• Patient is in supine position.
• Now, elevate the right side by 40- 45 deg.
• Center the left side to the mid line of the table.
• Center the bucky tray just below the level of the
xiphoid process.
• CR: is directed perpendicularly approx. 5cm left
of the mid line at the level of the xiphoid process.
• Respiration suspended at the end of exp.
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 EVALUATION CRITERIA
1. diaphragm should be included.
2. splenic region should be centered on the
radiograph.
3. Lateral abdomen should not have excessive
density.

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 ACUTE ABDOMEN
Acute abdomen is severe pain in the abdomen.
Its indications can be:-
• Acute appendicitis.
• Acute cholecystitis.
• Perforated peptic ulcers.
• Acute pancreatitis.
• Pleurisy or pneumonia.
• Coronary occlusion.
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In acute abdomen the views done are:
• CXR PA
• AP ERECT
• AP SUPINE
In case of acute abdomen CXR is
done because any disease in lower
lung area or diaphragm transmits
the pain to the abdomen.
e.g. in pleurisy and sub diaphragmatic abscess pain
descends to the abdominal area.
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ABDOMINAL SEQUENCING

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 BLUNT ABDOMINAL TRAUMA
By increasing the mechanized transportation, adults
& children face an increased risk of blunt trauma
that can lead to intra abdominal injuries.
The abdominal organs are more
vulnerable to injury than those in the near by
thorax because they lack the musculoskeletal
protection afforded by the sternum & ribs.
Because of their size, development & location
within immature musculoskeletal system,
children's intra-abdominal organs are at particular
risk for BAT injuries.
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 CAUSES OF BAT:

While MVCs account for the majority of

BAT, other causes such as motor cycle
and all-terrain vehicles collisions, falls,
industrial injuries, assaults and vehicles
striking pedestrians are seen in
emergency departments.

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 GENERAL EVALUATION OF
PATIENTS WITH BAT:
Diagnosing and caring for trauma
patients requires a different
approach for medical
professionals. Life saving
treatment may take precedence
over an initial diagnostic work up.

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 EMERGENCY PATIENT
MANAGEMENT:
The primary survey of the patient consist of
assessing airway, breathing, circulation,
disability and environment (ABCDEs).
Emergency personnel continually assess the
patient and the secondary survey includes a
head-to-toe physical examination and history.
Diagnostic tests usually are ordered during the
secondary survey at the emergency
department.

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 ROLE OF IMAGING IN
EVALUATING BAT
A range of imaging specialties support
the evaluation of BAT. While CT and
ultrasound have emerged as the
specialties of choice,radiographs, radio
nuclide scans, angiography and
magnetic resonance scans also
facilitate diagnose.
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 ROLE OF RADIOGRAPHY
Radiography plays a key role in the secondary
survey of BAT patients. Chest and
abdominal radiographs also may reveal an
elevated diaphragm,indicating trauma to the
abdomen; obliteration of fat planes or the
psoas shadow, indicating retroperitoneal
hematomas or abscesses and visible
hemoperitoneum.
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 ROLE OF ULTRASOUND
Ultrasound is the primary method used to screen BAT.

• FAST TECHNIQUE

(Focused Assessment of Sonography or Trauma)

FAST is rapid bedside ultrasound examination
performed by surgeon and emergency physician to
screen for significant hemoperitoneum or peri-cardial
temponade after trauma. Its role is critical because
rapid identification of hemopritoneum in unstable
BAT patients can lead to early intervention and more
effective injury management. 74
 Advantages of FAST
• Less invasive than
diagnostic peritoneal
lavage.
• Less costly than CT but
achieve similar accuracy.
• Portability.
• Ease of use.
• High speed.
• Non ionizing nature.

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 ROLE OF CT
In 1980’s. CT became an effective tool in
evaluating BAT injuries. Its role has steadily
increased, largely due to the availability of
quality equipment, excellent contrast resolution
and CT image depiction of complex anatomy.
Its greatest value in BAT evaluation is
identification of solid organ injuries. High
resolution CT has effectively changed the
management of Bat because CT scanning allows
for noninvasive trauma identification.
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 ROLE OF MRI
MR generally is not suitable for initial evaluation of
abdominal injuries. MR scans present
complications for any patient who requires life-
support equipment. When undergoing MR scans,
the patient should be able to remain immobile, be
transported to the MR suite and cooperate with
the MR technologist. After a patient is stabilized,
MR scanning can provide better visualization of
specific anatomical detail than CT.
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 EVALUATION OF SPECIFIC
INJURIES

SPLEEN
BAT to the spleen is the most common of all
intra-abdominal injuries. The spleen is also the
most injured intra-abdominal organ in children.
Major or minor trauma can damage the spleen.
The spleen is highly vascular and when injured,
patients can bleed to death.

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MANAGEMENT OF SPLEEN
• If a patient remains stable, physicians rely
heavily on CT findings and physical
examination to ensure that the spleen is
intact.

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LIVER
The liver is the most frequently injured intra-
abdominal organ, it is second to the spleen in
BAT. MVC’s account for the majority of liver and
biliary tract injuries. The liver is highly vascular.
MANAGEMENT
High-resolution CT plays an important role in liver
injury management. Careful clinical and CT
evaluation can prevent unnecessary laparotomies,
particularly in appx. 85% of patients who are
hemodynamically stable.
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OTHER ABDOMINAL INJURIES
Other abdominal injuries rarely occur. The
literature reports cases of abdominal wall
hernias resulting from low- and high-
energy blunt trauma. These injuries are
most often caused by bicycle handlebars.
MVCs or vehicle-related pedestrian
accidents. Seat belt syndrome is another
mechanism of abdominal wall hernias. CT
is generally used to evaluate abdominal
wall hernia resulting from blunt trauma.
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A number of different injuries to the abdominal
organs and structures can occur as a result of
blunt trauma. However, rare and multiple
injuries occur- often with serious morbidity and
mortality if not diagnosed rapidly. Beginning in
the 19th century, development of imaging
techniques revolutionized trauma diagnosis and
treatment by enhancing the accuracy of
diagnosis, imaging techniques have equalized
operative and non operative treatment of trauma
injuries.
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 PRECAUTIONS
• Immobilization devices should be used to
prevent the patient from moving during
exposure.
• Ask the patient to relax to prevent muscle
contraction caused due to tenseness.
• Breathing procedures should be explained
properly to the patient.
• Proper lead markers for side determination.

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 RADIATION PROTECTION
It is the responsibility of the radiographer to observe the
following guidelines concerning radiation protection:
• Gonadal sheilding should be used.
• Restrict the radiation to the area of interest by close
collimation.
• Work carefully and proper exposure factors should be set
so that there is no necessity to repeat the investigation.
• In case of female patients perform radiography of
abdomen and pelvis only if there is no chance of patient
pregnancy.

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 QUALITY OF THE FILM
A SHARPLY DEFINED OUTLINE OF:-
• PSOAS MAJOR
• LOWER BORDER OF THE LIVER
• KIDNEYS
• RIBS
• SPINOUS PROCESS OF THE LUMBAR
VERTEBRAE
Are best criteria to judge the quality of the film.

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 CONCLUSION
RADIATION PROTECTION MUST BE
CONSIDERED.
AVOID UNNECESSARY EXPOSURES.
PATIENT MUST BE POSITIONED
CAREFULLY.

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