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ABDOMINAL X -RAYS Anya Olsen and Olivia Owen Going to go over abdominal exam In the middle some cases: LFT/abdominal history and examination Abdominal x ray 1 ABDOMINAL X -RAY 1.Check details of the X -ray 2.Structured approach to interpretation:BBC a) Bowel and organs b) Bones c) Calcification and artefact Take a structured approach so you don’t forget what to do if given an abdominal XR in an exam 1 – always check the details (more on next slide) BBC is easy to remember 2 – look at the bowel and other organs (specific signs and pathologies in the bowel, also screen for pathology of other organs which is a bit harder) 3 – look at the bones screening for fractures, osteoporosis, bony mets 4 – Look for any calcification or artefact (external/internal objects) Will briefly explain these in more detail, go through a normal XR then do as many cases as possible All of the images from radiology masterclass so recommend this website as it has lots more on there too Radiology masterclass has tutorials on CXR and AXR which I would recommend Radiopedia 2 ABDOMINAL X -RAY:DETAILS • Correct patient:check name and DOB/hospital number • Date and time of film taken • Is previous imaging available for comparison? • AP supine vs PA erect image? • On anAP supine image,you cannot see fluid levels.On an erect image you can. • Is the whole abdomen visible from the diaphragm to the pelvis • Exposure:is the image under/over/well exposed Remember the things you need to check so you can do them quickly If I am in a f2f osce I will just speak through doing this so the examiner can hear Under = too white Over = too black 3 B:BOWELAND ORGANS • Bowel:pathologies to look for • Small bowel obstruction • Large bowel obstruction • Volvulus • Pneumoperitoneum • Signs of IBD • Other organs:lungs,liver,gallbladder,stomach,kidney,spleen,bladder,psoas muscles Other organs - Lungs - Liver - Gallbladder - Stomach - Kidney - Spleen - Bladder - Psoas muscles Usually better visualized on CT – good practice to screen for pathologies anyway – more difficult to see but sometimes it is possible (will give some examples) 4 B:BOWEL – SMALLVS LARGE SMALL BOWEL LARGE BOWEL • Central • Peripheries • Valvulae conniventes extend full • Haustra only extend part of the way width of the bowel through the width of the bowel • Contains faeces (mottled appearance) 3/6/9 rule : diameter of SI should be no more than 3cm, LI should be no more than 6cm, caecum should be no more than 9cm Dilated large bowel can sometimes have haustra that traverse full width of bowel wall For 3/6/9 rule you will see different rules everywhere you look – this is commonly used, alternatively go with what it says in lecture to be safe 5NORMAL (normal abdominal x ray) Will keep coming back to normal in -between cases https://www.radiologymasterclass.co.uk /quizzes/abdominal_x -ray-quiz_1 First: check the details Name, DOB, date, time, supine or erect film We can see that the image is correctly oriented and well exposed, and we can see from the diaphragm to the pelvis Second: bowel and organs Small bowel: can see it centrally, diameter not enlarged, and you can tell as valvulae conniventes extend all the way through the wall of the small bowel Large bowel: visible in peripheries (especially LHS), you can not see lines extending all the way through (haustra) Other organs: not usually visible. Can see kidneys and psoas muscles easily on this image. Stomach only visible if filled with air. Recommend radiology masterclass tutorials for identifying other organs on abdominal X -ray (XR not the best way to visualize them so main focus is on bowel) 6No evidence of obstruction, pneumoperitoneum, other pathology of bowel Will come back to this image for bones/ calcification and artefact 6 ABNORMAL XR – ANSWERS IN CHAT Small bowel obstruction https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_abnormalities/pathology_small_bowel_obstruction Centrally located dilated loops of small bowel Small bowel very much enlarged compared to normal image Valvulae conniventes visible Can’t see any gas in the large intestine Links at the end for quizzes and tutorials for more images – would recommend looking at lots because although it follows the above as a general rule it can have different appearances 7 SMALL BOWEL OBSTRUCTION CAUSES: 1. Adhesions (e.g.,following previous surgery) 2. Hernias PRESENTATION: • Severe centra/diffuse abdominal pain • N/V (bilious vomiting) • Constipation (not passing stool or flatus) • O/E:abdominal distention,‘tinkling bowel sounds’ ABDOMINAL XR: • First-line investigation • Dilated small bowel loops +/ - multiple central fluid levels • Small bowel > 3cm (Image from LITFL) 8 ABNORMAL XR – ANSWERS IN CHAT Large bowel obstruction Small amount of gas in rectum – not an absolute obstruction In this case due to a malignancy (can slightly see increased density at the level of the obstruction) Haustra visible – no valvulae conniventes Can see ascending, transverse, descending colon https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_abnormalities/pathology_large_bowel_obstruction 9 LARGE BOWEL OBSTRUCTION CAUSES: 1. Tumour 2. Volvulus 3. Diverticular disease PRESENTATION: • Features of obstruction • Absence of passing stools or flatus/ Pain/ Distention/ N/V are late signs • O/E bowel sounds initially normal and then become quiet • Features of underlying cause • E.g.,BG of weight loss,PR bleeding,change in bowel habit ABDOMINAL XR: • Diameter >9cm (caecum) or >6cm (remainder of large bowel) • Haustra do not extend all the way through • Little/no gas beyond obstruction Usually, CT scan will be needed too for an obstruction Patient will be NBM, IV fluids, NG tube to drain stomach contents, conservative management or surgery 10 ABNORMAL XR – ANSWERS IN CHAT https://www.radiologymasterclass.co.uk /quizzes/abdominal_x -ray-quiz_1 (tricky) Learning points Dilated loops of small and large bowel are visible indicating large bowel obstruction and reflux of gas from the large to the small bowel via an incompeteileocaecal valve. If it was small there would be no air in large 11 ABNORMAL XR – ANSWERS IN CHAT Coffee bean appearance = sigmoid volvulus https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_abnormalities/pathology_obstruction_volvulus 1213 SIGMOIDVOLVULUS =Torsion of the sigmoid colon around its mesenteric axis Results in compromised blood flow and obstruction Characteristic coffee bean sign on abdominal XR PRESENTATION: • Abdominal pain • Distention • Constipation (stools/ flatus) • Nausea/vomiting Really similar presentation to obstruction as this is what It causes Coffee bean sign on axr 14 ABNORMAL XR – ANSWERS IN CHAT More difficult Pneumoperitoneum – free air in the peritoneal cavity. This patient had a perforation due to Crohn’s disease Rigler’s sign: both sides of the bowel wall are visible due to air outside the bowel https://radiopaedia.org/cases/rigler-and-telltale-triangle-signs-pneumoperitoneum 15 RIGLER’S SIGN Image from radiology masterclass abdo XR tutorial 16 PNEUMOPERITONEUM = gas in the peritoneal cavity CAUSES: 1 line investigation for suspected pneumoperitoneum is an erect 1. Perforation of hollow viscus (stomach,bowel) 2. Tracking of gas from elsewhere e.g., pneumothorax Chest X ray – gas rises to below diaphragm PRESENTATION (if perforation): • V unwell / Septic patient • Epigastric pain (initially localized,becoming generalized) • O/E:generalized tender abdomen,rebound tenderness in 9/9 regions,tachycardia,hypotension ABDOMINAL X -RAY • Rigler’s sign • Gas outlining ligaments • Football sign • Air between liver edge and bowel loops (usually a triangle shape) Big RF for perforation = peptic ulcers 17 FOOTBALL SIGN Can also se Rigler’s sign Large volume of air risen to front of peritoneal cavity https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_abnormalities/pathology_bowel_gas_perforation 18 GAS OUTLINING LIGAMENTS Left: falciform ligament sign If there is enough gas to outline the falciform ligament – there is usually enough gas to produce Rigler’s sign too Falciform ligamentconnets liver to anterior abdominal wall – if the patient is lying flat, air will rise to anterior abdomen (which is where the ligament is) which is outlining the ligament https://radiopaedia.org/articles/falciform-ligament-sign- 1?lang=gb#image_list_item_2130934 19ERECT CXR - PNEUMOPERITONEUM https://www.radiologymasterclass.co.uk /quizzes/abdominal_x -ray-quiz_1 Second image: radiology masterclass tutorial Doing CXR on Thursday Should never be gas under right hemi -diaphragm Much easier to spot free air on erect CXR than AXR (pt sat upright for 15 -20 minutes prior to allow air to rise) 20 ABNORMAL XR – WHAT CONDITION DOES THIS PATIENT HAVE? ANSWERS IN CHAT Lead-pipe colon: seen in ulcerative colitis https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_abnormalities/pathology_inflammatory_bowel 21 LEAD PIPE COLON - UC • ‘Lead pipe’ colon occurs due to inflammation • Loss of haustra on distal colon • Other features that might be present in the history • Left sided abdo pain • Diarrhoea • Haematochezia • Weight loss • Fatigue 22OTHER ORGANS V briefly other organs because XR not very useful for soft tis– but might be incidental fidings 1) Enlarged kidneys (left is a lot easier to see)This patient has polycystic kidneys https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_bone_soft_tissue/bone_soft_tissue_solid_organs 2) Ascites: generalized hazy appearance https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_bone_soft_tissue/bone_soft_tissue_ascites 3) Large pelvic mass displacing small bowel https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_bone_soft_tissue/bone_soft_tissue_pelvic_mass 23 BONES • Be able to identify bones and quickly screen for pathology • Bones also provide useful landmarks for the location of soft tissue structures! 24NORMAL Third: bones Ribs Lumbar spine and sacrum Pelvis Femur Look for any fractures Comment on density 25ABNORMAL BONES PC:fall and pelvic pain in an elderly patient PC:pelvic pain and lower back pain PMH:breast cancer 1. Pelvic fracture and osteoarthritis (lumbar spine and hips have decreased density) also obviously some metalwork on right femur (would come into calcification and artefact) 2. Bony mets (multiple areas of increased density) Patient had PMH of breast cancer 3. Source for both: https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_bone_soft_tissue/bone_soft_tissue_bone_disease 26 CALCIFICATIONANDARTEFACT • High density areas can be due to soft tissue calcification,medical devices or other external objects • RUQ:gallstones • Flank:renal stones/staghorn calculi/renal cysts • Epigastrium:pancreatic calcification • Pubic region:uterine fibroids • Vascular calcification • Surgical clips • Jewellery 27NORMAL Normal – no calcification or artefact Where you would look: - 28 1 2 3 4 5 6 https://www.radiologymasterclass.co.uk /quizzes/abdominal_x -ray-quiz_1 https://www.radiologymasterclass.co.uk /quizzes/abdominal_x -ray-quiz_2 1) Pancreatic calcification (seen in chronic pancreatitis) 2) Calcified uterine fibroid 3) Naval jewelry and urinary catheter 4) Staghorn calculi https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_calcium/calcium_renal 5) Left ureteric stone https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_calcium/calcium_ureteric_calcification#top_1st_img 6) Bladder stones https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_calcium/calcium_bladder_stones _________ also remember can have gallstones (would be present in RUQ– no image) 29 7 8 9 Aorta and iliac vessels calcification https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_calcium/calcium_vascular_calcification Ureteric stent https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_calcium/calcium_artifact Colonic stent https://www.radiologymasterclass.co.uk /tutorials/abdo/abdomen_x- ray_calcium/calcium_artifact Other possibilities include ingested foreign bodies 30QUIZTIME! 31• The patient is in severe pain. What does the x -ray show? • A.ascites • B.lead pipe colon • C.normalgaspattern • D.rigler’s/double wall sign • E.thumbprinting 32• The patient is in severe pain. What does the x -ray show? • A.ascites • B.lead pipe colon • C.normalgaspattern • D.rigler’s/double wall sign • E.thumbprinting 33• The patient has a history of ulcerative colitis.What does the x-ray show? • A.ascites • B.lead pipe colon • C.normalgaspattern • D.rigler’s/double wall sign • E.thumbprinting 34• The patient has a history of ulcerative colitis.What does the x-ray show? • A.ascites • B.lead pipe colon • C.normalgaspattern • D.rigler’s/double wall sign • E.thumbprinting 35• What is the cause of the abnormal calcification? • A.adrenal calcification • B. appedicolith • C.gallstones • D. pancreatic calcification • E.staghorn renal calculus 36• What is the cause of the abnormal calcification? • A.adrenal calcification • B. appedicolith • C.gallstones • D. pancreatic calcification • E.staghorn renal calculus 37• What is the cause of the abnormal calcification? • A.adrenal calcification • B. appedicolith • C.gallstones • D. pancreatic calcification • E.staghorn renal calculus 38• What is the cause of the abnormal calcification? • A.adrenal calcification • B. appedicolith • C.gallstones • D. pancreatic calcification • E.staghorn renal calculus 39• Patient with acute abdominal pain.What does the x -ray show? • A.caecal volvulus • B.normal appearance • C.pneumoperitoneum • D. small bowel obstruction • E.toxic megacolon 40• Patient with acute abdominal pain.What does the x -ray show? • A.caecal volvulus • B.normal appearance • C.pneumoperitoneum • D. small bowel obstruction • E.toxic megacolon 41• 24 year old patient with suspected appendicitis.What does the image show? • A.caecal volvulus • B.normal appearance • C.pneumoperitoneum • D. small bowel obstruction • E.toxic megacolon 42• 24 year old patient with suspected appendicitis.What does the image show? • A.caecal volvulus • B.normal appearance • C.pneumoperitoneum • D. small bowel obstruction • E.toxic megacolon 43• Patient with severe abdominal pain.What does the image show? • A.caecal volvulus • B.normal appearance • C.pneumoperitoneum • D. small bowel obstruction • E.toxic megacolon 44• Patient with severe abdominal pain.What does the image show? • A.caecal volvulus • B.normal appearance • C.pneumoperitoneum • D. small bowel obstruction • E.toxic megacolon 45• Patient with abdominal pain. What does the image show? • A.ascites • B.bone metastases • C.pneumoperitoneum • D. poor quality image. Needs to be repeated • E.thumbprinting 46• Patient with abdominal pain. What does the image show? • A.ascites • B.bone metastases • C.pneumoperitoneum • D. poor quality image. Needs to be repeated • E.thumbprinting 47 EXAMPLE PRESENTATION “This is a supineAP abdominal radiograph of Jayne Lister,date of birth 11th April 1970. The film is of good quality with adequate exposure.No prior imaging is available for comparison.Both the small and large bowel appear within normal limits.Other abdominal viscera appear normal within the limits of this projection.No obvious bony pathology is identified.No abnormal calcification is visible.In summary,this is a normal plain radiograph of the abdomen.” Example of how to summarise (if normal!) https://geekymedics.com/abdominal-x- ray-interpretation/ 48 DON’T FORGETABOUTTHE OTHER MODES OF GI IMAGING • E.g.,barium swallow/meal/enema • CT/MRI • FAST scan/ ultrasound Check lecture 49 ABDOMINAL X -RAY SOURCES/ GOOD RESOURCESTO USE!! • Radiology masterclass abdominal XR quiz https://www.radiologymasterclass.co.uk/quizzes/abdo-ray-quiz_1 • Radiology masterclass abdominal XR quiz 2 https://www.radiologymasterclass.co.uk/quizzes/abdo-ray-quiz_2 • Radiology masterclass tutorials https://www.radiologymasterclass.co.uk/tutorials/tutorials • Geeky medics abdominal X ray interpretation https://geekymedics.com/abdominal -x-ray-interpretation/ 50 QUESTIONS? Someone asked on the feedback form what to expect in the OSCE for data interp How does it work with showing signs – are you meant to come up with a differential Data interp: what to revise, what often comes up, how it went for me Key organisms to know? https://app.medall.org /training/feedback/ anonymous?organisation =ace-clinical- education&keyword =8861320681fde40f484c13be 51
