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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