ABDOMINAL CAVITY

(PLAIN & ACUTE)

 MEMBER’S NAME
1. SHELLY ANGGRAINI WIDYASTUTI P1337430121022
2. RAHMAD WAHYU P1337430121023
3. FILDZA NABILA HISMARA P1337430121013
4. ANGGERDHA DIFA PRAMANDANI P1337430121025
5.GIA PUTRI SYAKIRA P1337430121015
6. MEILY USWATUN HASANAH P1337430121030
7. NOVI RAHMALITA P1337430121006
8. FESYLIA CAHYARIN AWALINA PUTRI P1337430121037
9. ELITA WIJAYANI P1337430121017
10. ADHITYA KHAIRANI P1337430121018

11. FAIZ WAHDANI P1337430121044

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 BIBLIOGRAPHY
Mosby’s medical dictionary, ed 9, St. Louis, 2013, Elsevier, p 352.
Eisenberg RL, Johnson NM: Comprehensive Radiographic Pathology, ed 5, St. Louis, 2012,
Elsevier Mosby, p 199.
Mosby’s medical dictionary, ed 9, St. Louis, 2013, Elsevier, p 1842.
Mosby’s medical dictionary, ed 9, St. Louis, 2013, Elsevier, p 1843.
Eisenberg RL, Johnson NM: Comprehensive radiographic pathology, ed 5, St. Louis, 2012,
Elsevier Mosby

REFERENSI
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%80%99s%20(1).pdf
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 ABDOMINAL ANATOMY

The abdomen is a cavity-shaped body part located between the thorax and the
pelvis. This cavity contains viscera and is covered by an abdominal wall formed
from the abdominal muscles, the vertebral column, and the ilium bone. To help
determine a location on the abdomen, the most commonly used is the division of
the abdomen by two horizontal and two vertical planes. The shadow plane divides
the anterior abdominal wall into nine regions (regions). Two of these planes run
horizontally through the level of the cartilage of the ninth rib, the lower one is at
the level of the top of the iliac crest and the other two planes are vertical on the left
and right of the body, namely from the cartilage of the eighth rib to the middle of
the inguinal ligament.

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 1. hypocondriaca dextra,
2. epigastrica,
3. hypocondriaca sinistra,
4. lumbalis dextra,
5. umbilical,
6. lumbalis sinistra,
7. inguinalis dextra,
8. pubica/hipogastrica,
9. inguinalis sinistra.

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 ABDOMINAL ANATOMY
 Hypocondriaca dextra includes organs: right lobe of liver, gallbladder, part of duodenum,
hepatic flexure of colon, part of right kidney and right suprarenal gland.
 Epigastrica includes organs: gastric pylorus, duodenum, pancreas and part of the liver.
 Hypocondriaca sinistra includes organs: stomach, spleen, caudal part of pancreas, splenic
flexure of colon, proximal part of left kidney and left suprarenal gland.
 Lumbar dextra includes organs: ascending colon, distal part of the right kidney, part of the
duodenum and jejunum.
 Umbilical organs include: Omentum, mesentery, lower part of duodenum, jejunum and
ileum.
 The left lumbar includes organs: ascending colon, distal part of the left kidney, part of the
jejunum and ileum.
 Inguinalis dextra includes organs: cecum, appendix, distal ileum and right ureter.
 Pubica/Hypogastric includes organs: ileum, urinary bladder and uterus (in pregnancy).
 Left inguinal includes organs: sigmoid colon, left ureter and left ovary.

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For clinical purposes, the abdominal cavity is divided into three regions: the peritoneal cavity,
the retroperitoneum and the pelvic cavity. The pelvic cavity actually consists of part of the
intraperitoneal and partly intraperitonealretroperitoneal. The peritoneal cavity is divided into
two, namely upper and lower. The upper peritoneal cavity, which is covered by the bones of the
thorax, includes the diaphragm, liver, spleen, stomach and transverse colon. This area is also
known as the thoraco-abdominal component of the abdomen. While the lower peritoneal cavity
contains the small intestine, part of the ascending and descending colon, the sigmoid colon,
caecum, and female reproductive organs.

The retroperitoneal cavity is present in the posterior abdomen, containing the abdominal aorta,
inferior vena cava, most of the duodenum, pancreas, kidneys, and ureters, the posterior
surfaces of the ascending and descending colon and the retroperitoneal component of the
pelvic cavity. While the pelvic cavity is surrounded by the pelvic bones which are basically the
bottom of the peritoneal and retroperitoneal cavities. Contains the rectum, bladder, iliac
vessels, and the female internal reproductive organs.

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 DETECTION OF FREE AIR AND PERFORATED VISCUS

Advocates of conventional radiography state that plain abdominal radiography should be the first
diagnostic modality used in suspicion of a perforated viscus. It is possible, using careful radiographic
1.
technique, to demonstrate as little Detection of
as 1 mL of free free
gas on air and
an erect chest or left lateral decubitus
abdominal film. The high percentage of missed cases is due to technical imperfections rather than
perforated
limitations of the test (poor quality of plain viscus excluding the uppermost portion of
abdominal radiography,
the peritoneal cavity of the image). In that study, the radiographs demonstrated pneumoperitoneum in
only 51% of patients with documented visceral perforation. Diagnostic accuracy differed between the
types of radiograph used to demonstrate pneumoperitoneum. Left lateral decubitus radiographs
demonstrated pneumoperitoneum in 96% of patients, chest radiographs in 85%, and upright and supine
abdominal radiographs in 60% and 56%, respectively. Another study described pneumoperitoneum in
only 83% of all patients with documented visceral perforation.
Notes: A 48-year-old male presented at the emergency department with pain
in the entire abdomen, but concentrating in the right lower quadrant.
Palpation of the entire abdomen was extremely painful and laboratory values
showed elevated inflammatory parameters (leucocyte count 17.9 and C-
reactive protein 43). Upright abdominal radiography showed no abnormalities.
Computed tomography of the abdomen showed free intraperitoneal air and
signs of appendicitis acuta. Patient underwent an emergency laparotomy,
which confirmed the diagnosis of perforated appendicitis acuta.
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 DETECTION OF URINARY TRACT STONES

Most ureteral stones can be identified as a calcification causing a filling defect or ureteral obstruction
on plain abdominal radiography. A plain film of the abdomen, including kidney, ureter, and bladder, has
1. Detection
shown sensitivity ranging from 44% up to 77%of andfree air and
specificity in detection of stones from 80% to 87%.
In one study, the diagnosis of patients suspected of ureteral stones before and after plain abdominal
perforated
radiography compared with the final viscusa correct change in diagnosis in six of 11
diagnosis revealed
patients (55%).The level of confidence in the diagnosis remained the same as well as having a positive
predicting value, which reached 57% after clinical evaluation and 58% after radiographs.
 Notes: A 36-year-old female
presented at the emergency
department with left-sided abdominal
pain over the course of 6 hours.
Laboratory values showed elevated
inflammatory parameters (leucocyte
count 15.3 and C-reactive protein 44).
Based on clinical examination, the
patient was suspected of having
bowel obstruction or kidney stones,
and an abdominal radiograph was
ordered. Abdominal radiography
demonstrated no abnormalities other
than multiple clips related to previous
bowel surgery. Computed tomography
of the abdomen demonstrated
hydronephrosis and signs of
pyelonephritis of the left kidney due
to an obstructing ureteral stone.
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 DETECTION OF BOWEL OBSTRUCTION

In patients with a complete obstruction, CT demonstrated a sensitivity of 100%

1. Detection
compared with 46% after of free
plain abdominal air andFor partial obstruction,
radiography.
CT had a sensitivity of 100% compared with 30% for plain abdominal
perforated
radiography. Of the 61 patients viscus surgery, 52 patients were
who underwent
confirmed to be correctly diagnosed preoperatively (85%) based on CT findings.
The exact location of the obstruction was correctly diagnosed in 50 of 53
patients (94%) on CT.
Notes: A 59-year-old female presented at the
emergency department with complaints of
nausea, vomiting, and abdominal pain for one
day. Physical examination demonstrated
abdominal tenderness in all quadrants.
Laboratory values were within normal limits,
with the exception of slightly raised
inflammatory parameters (C-reactive protein 17,
leucocyte count 8) The attending physician
suspected a bowel obstruction and ordered an
abdominal radiograph. Abdominal radiography
showed no abnormalities in addition to minimal
dilation of the small bowel. Computed
tomography demonstrated dilated small bowel
loops, collapsed large bowel loops, and a change
in diameter due to a herniation of small bowel
into the right musculus rectus abdominus.
Images were suggestive of an incarcerated
herniation. After reduction of herniation at the
emergency department, her complaints resolved
and she made an uneventful recovery
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 DETECTION OF INGESTED FOREIGN BODY

Plain radiography has been suggested as a standard method for localization of foreign bodies.
Plain abdominal radiography demonstrates a sensitivity of 90%, specificity of 100%, and
accuracy of 100% for ingested foreign bodies, but the foreign body has to be radio-opaque to be
seen on plain abdominal radiography. The advantage of CT is the ability to provide information
about the location of the foreign body, which is a prerequisite when surgical treatment is
planned. Plain abdominal radiography is used to establish the diagnosis of drug packing and is
considered the gold standard. If plain abdominal radiography is negative or inconclusive but a
high suspicion of body packing remains, a CT scan should be done. The sensitivity of plain
abdominal radiography is 85%–100%, but CT has a higher sensitivity and additionally provides
more accurate information about the number and location of packages. The use of plain
abdominal radiography gives rise to a high number of false negative results, which could be due
to overprojection of feces or a specific packaging method.

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 Notes: A 35-year-old male presented at the emergency department with acute abdominal pain, tachycardia,
and a diffusely rigid abdomen. The patient admitted having ingested eight packets of drugs three days earlier.
An abdominal radiograph was done to confirm ingestion of the packets and to clarify the location and exact
number of packets in need of surgical removal. At least four packets were identified on abdominal radiographs
and the patient underwent a laparotomy due to signs of intoxication; eight packets of drugs were identified and
surgically removed from the small bowel. Postoperatively, the patient remained tachycardic and in pain; a
computed tomography scan was done 24 hours after the initial laparotomy, showing an additional five packets
of drugs in the stomach and ileum
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 TOOLS AND MATERIALS

X-ray Plane

Examination Table Apron

Cassette Film Marker Shield

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 A. ANTEROPOSTERIOR PROJECTION ABDOMINAL RADIOGRAPHY
TECHNIQUE
1. Patient Preparation : The patient changes clothes and removes objects around the abdomen that can cause
radiopague.
2. Patient Positioning : The patient is supine on the examination table with the Mid Sagittal Plane (MSP) of the
body in the center line of the examination table. Both arms straight at the sides of the body and both hands
straight down. Objects are arranged by specifying the upper limit of the xypoideus process and the lower limit
is the symphysis pubis. The aiming point is in the middle of the two iliac crests with a vertical beam
perpendicular to the cassette. Exposure is performed when the patient is fully exhaling and holding his breath.
3. Criteria for Abdominal Radiographa) Visible from the top of the abdomen to the symphysis pubisb) Columna
vertebtrae is in the middlec) Between the two bones, the hip joint and the pelvis are the sameD. No marked
rotation with spinous processes located in the middle of the vertebral column, both iliac bones in hip
symmetrical. e. Soft tissue is obvious and shows the following cons. lateral abdominal wall and properitoneal
fat layer (flank stripe). muscle spoas, lower portions of the liver and kidneys, inferior ribs, transverse
processes and lumbar vertebrae.

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 Evaluation Criteria

Anatomy Demonstrated:
• Outline o liver, spleen, kidneys, psoas muscles, and air- lled stomach and bowel segments and the arch o the symphysis pubis or the
urinary bladder region

Position:
• No. rotatio ; iliac wings, obturator oramina (i visible), and ischial spines appear symmetric in appearance, and outer lower rib margins
are the same distance rom spine (elongation o iliac wing indicates rotation in that direction). Bilateral structure should also be on the
same plane (i not the patient is tilted on the table)
• Collimation to area o interest.
• See Notes about possible two images per projection.

Exposure:
• No. motio ; ribs and all gas bubble margins appear sharp.
• Suffcient exposure actors (kVp and mAs) to visualize psoas muscle outlines, lumbar transverse processes, and ribs.
• Margins o liver and kidneys should be visible on smaller to average-sized patients

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19
 B. POSTERIOR ANTERIOR ABDOMINAL PROJECTION
Factor:
• Minimum SID—40 inches (102 cm)
• IR size—35 × 43 cm (14 × 17 inches), portrait
• Box• Analog system – 70 to 80 kVp . Range
• Digital systems—80 ± 5 kVp . rangeShielding Protects sensitive radio networks outside the area of ​interest

Patient Position
• Prone with the midsagittal plane of the body centered to the midline of the tableor IR
• Legs extended with support under ankle
• Arms beside head; clean pillow provided

Part Position
• no hip or shoulder and chest rotation
• IR center to iliac crest

CR
• CR perpendicular and directed to point IR (to leveliliac crest)recommended collimation 35 × 43 cm (14 × 17 in), planeview or
collimate on four sides for desired anatomy Respiration Perform exposure at the end of expiration

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Note: Tall, asthenic patients may require two images to be placed in a portrait;Extensive, hypersthenic, and obese
patients may require two images to be placedlandscape.

Evaluation criteriaAnatomy Show:

• Outline the liver, spleen, kidney, psoas muscle, and air-filled segments of the stomach and intestines and the symphysis
pubis or urinary bladder region

Position:
• no rotation; the iliac wings appear symmetrical, and the sacroiliac joint and the outer edge of the lower ribs (I see)
should be the same distance from the spine.
• Collimation to the ominat area.
• View notes on possible two images.

Exposure:
• no motive; ribs and all gas bubble margins appear sharp.
• Exposure (mAs) and long-scale contrast (kVp) are sufficient to visualize psoas muscle lines, lumbar transverse
processes, and ribs.• Liver and kidney margins should be visible in small to medium sized patients.

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22
 LATERAL DECUBITUS POSITION (AP P ROJECTION): ABDOMEN
Patient Position
• Lateral recumbent on radiolucent pad, firmly against table or vertical grid device (with wheels on cart locked so as not to move away rom
table)
• Patient on rm sur ace, such as a cardiac or back board, positioned under the sheet to prevent sagging and anatomy cutoff
• Knees partially fexed, one on top o the other, to stabilize patient
• Arms up near head; clean pillow provided

Part Position
• Adjust patient and cart/ table so that center o IR and CR are
approximately 2 inches (5 cm) a over level of iliac crests (to
include diaphragm). Upper margin o IR is approximately at level
o axilla
• Ensure no rotation of pelvis or shoulders
• Adjust height o IR to center midsagittal plane o patient to center of IR, but ensure that upside of a dome is clearly included on the IR

CR
• CR horizontal, directed to center of IR, at about 2 inches (5 cm) above level o iliac crest; use o a horizontal beam to demonstrate air-fuid
levels and free intraperitoneal air

Recommended Collimation
• 35 × 43 cm (14 × 17 inches), eld o view or collimate on our
sides to anatomy o interest
• Must include elevated side o the abdomen

Respiration Make exposure at end o expiration

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 AP P ROJECTION—ERECT POSITION: ABDOMEN
Patient Position
• Upright, legs slightly spread apart, back against table or grid device (see Note regarding weak
or unsteady patients)
• Arms at sides away rom body
• Midsagittal plane o body centered to midline o table or erect bucky

Part Position
• Do not rotate pelvis or shoulders
• Adjust height o IR so that the center is approximately 2 inches (5 cm) above iliac crest (to
include diaphragm), which or the average patient places the top of the IR approximately at the
level of the axilla (Fig. 3.39)

CR
• CR perpendicular, to center o IR

Recommended Collimation
• 35 × 43 cm (14 × 17 inches), field of view or collimate on our sides to anatomy of interest
• Must include upper abdomen

Respiration Exposure should be made at end of expiration

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 AP P ROJECTION—ERECT POSITION: ABDOMEN
Patient Position
• Supine on radiolucent pad, side against table or vertical grid device; secure cart so that it does not move away
rom table or grid device
• Ensure the patient or the cart are not tilted in relation to the IR
• Pillow under head, arms up beside head; support under partially fexed knees may be more com ortable or the
patient

Part Position
• Adjust patient and cart so that center o IR and CR is at level o iliac crest (above iliac crest to include diaphragm)
• Ensure that o rotatio o pelvis or shoulders exists (both ASIS should be the same distance rom tabletop)
• Adjust height o IR to align midcoronal plane with centerline of IR

CR
• CR horizo tal to ce ter of IR above iliac crest and to midcoronal
plane

Recommended Collimation: Collimate to upper and lower abdomen so t tissue borders.

Close collimation is important because of increased scatter produced by exposure o tissue outside the area of
interest

Respiration Exposure is made at end o expiratio

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 LATERAL POSITION: ABDOMEN

Patient Position
• Patient in lateral recumbent position on right or le t side, pillow or head
• Elbows f exed, arms up, knees and hips partially f exed, pillow between knees to
maintain a lateral position
• Ensure patient is not tilted

Part Position
• Align midcoronal plane with CR and midline o table
• Ensure that pelvis and thorax are not rotated but are in a true
lateral position

CR
• CR perpendicular to table, centered at level o the iliac crest to midcoronal plane
• IR centered to CR

Recommended Collimation: Collimate closely to upper and lower IR borders and to

anterior and posterior skin borders to minimize scatter

Respiration Suspend breathing on expiratio

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 ACUTE ABDOMINAL SERIES: ACUTE ABDOMEN
(1) AP SUPINE, (2) ERECT (OR LATERAL DECUBITUS) ABDOMEN, (3) PA CHEST

Positional Guidelines
Review positional guidelines as described on preceding pages or AP supine, AP erect, and PA chest

Patient and Part Positioning

Most department routines or the erect abdomen include centering high to demonstrate possible free intraperitoneal air under
the diaphragm, even i a PA chest is included in the series

Breathing Instructions
Chest projections exposed on full inspiration; abdomen is exposed on expiration

CR
CR to level o iliac crest on supine and approximately 5 cm (2 inches) above level o crest to include diaphragm on erect or
decubitus radiographs

notes: Le t lateral decubitus replaces erect position i the patient is too ill to stand.
Horizontal beam is necessary or visualization o air-fuid levels.

Erect PA chest or AP erect abdomen best visualizes free air under diaphragm.
For le t lateral decubitus, patient should be the right side or a minimum of 5 minutes be ore exposure (10 to 20 minutes pre
erred) to demonstrate potential small amounts o intraperitoneal air

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 ACUTE ABDOMINAL SERIES: ACUTE ABDOMEN
(1) AP SUPINE, (2) ERECT (OR LATERAL DECUBITUS) ABDOMEN, (3) PA
CHEST

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THANKYOU

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