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Picture Here Dr Anish Mistry Slides by Dr James Cairns (ST1)• What is an abdominal x-ray? • When should you request an abdominal x-ray? • What can you see on an abdominal x-ray? • How should I present an abdominal x-ray in an OSCE station? • Exam style questions • Review some common surgical conditions and their management • Lots of abdominal x-rays A – AP Supine How AXRs are B – AP performed Erect C – Lateral Decubitus• Patient details, time, date • Previous x-rays • Image projection, field of view and quality • Obvious abnormality • BBC approach: • Bowels • Bones • Calcification and artefacts • Summarise • Management and further investigationsWhich of the following are indications for an abdominal x-ray? A. Upper gastrointestinal bleed B. PR bleed C. Acute abdominal pain D. Change in bowel habit without abdominal pain E. All of the aboveA patient on the surgical assessment unit has suspected bowel obstruction. Y ou have requested an abdominal x-ray. What is the radiation dose of an abdominal x-ray? A. 0.5 times the dose of a CXR B. The same dose as a CXR C. 2-5 times the dose of a CXR D. 30-50 times the dose of a CXR E. The same radiation dose as a year spent in Cornwall• Acute abdomen – ? bowel perforation or obstruction • Acute exacerbation of inflammatory bowel disease – ? toxic megacolon • Assess swallowed radiopaque objects • Prolonged post-op ileus - ? Bowel perforation/obstruction or just post op ileus • NOT routinely for constipationA 45 year old woman with abdominal pain and vomiting has an abdominal x-ray. How would you identify small bowel on her abdominal x-ray? A. It lies peripherally and demonstrates valvulae conniventes which span the width of the bowel loop B. It lies centrally and demonstrates valvulae conniventes which span the width of the bowel loop C. It lies centrally and demonstrates haustra which span the width of the bowel loop D. It lies centrally and demonstrates haustra which partially cross the bowel loop E. It is larger than the large bowelSmall bowel • Central • Valvulae conniventes which span the width of the bowel loop Large bowel • Peripheral • Haustra which partially cross the bowel loop • May contain faecal materialA 50 year old gentleman presents to the surgical assessment unit with severe acute abdominal pain. You are concerned he may have bowel obstruction or perforation and request an abdominal x-ray. What is the upper limit of normal diameter for the caecum on an abdominal x-ray? A. 3cm B. 5cm C. 6cm D. 8cm E. 9cmUpper limit of normal bowel diameter: • 3cm – Small bowel • 6cm – Large bowel (excluding caecum) • 9cm – Caecum (RIF) A lumbar vertebra is roughly 5cm wideA 55 year old gentleman presents to the surgical assessment unit with abdominal pain. He hasn’t opened his bowels in 5 days and has been vomiting profusely. He had an open cholecystectomy 10 years ago. An abdominal x-ray demonstrates small bowel obstruction. What is the most likely cause? A. Adhesions B. Intussusception C. Crohn’s disease D. Gallstone ileus E. Inguinal herniaA 50 year old gentleman with a history of previous abdominal surgery 7 years ago has presented with a 24 hour history of severe abdominal pain and distension with vomiting. There are tinkling bowel sounds on auscultation. You request an abdominal x-ray What is the most likely diagnosis? A. Small bowel obstruction B. Post-operative ileus C. Normal D. Perforation E. Sat on a strawAdhesions – 60% in western world Hernias: • Inguinal • Femoral • Umbilical • Incisional • Spigelian • Epigastric• Ileus is normal and expected following abdominal surgery • Recovery times for GI tract after abdominal surgery: • Small intestine: 0-24 hours • Stomach: 24-48 hours • Colon: 48-72 hours • Improving post operative ileus assessed clinically with oral intake and passing of flatus/faeces • Prolonged postoperative ileus (>72 hours) - concerning for small bowel obstruction, bowel perforation, peritonitis, and intra-abdominal abscess • Correct reversible causes: opiates, electrolyte derangement• Rare complication of recurrent cholecystitis • Biliary-intestinal fistula with impaction of a gallstone in the small bowel • Rigler triad: 1. Pneumobilia 2. Small bowel obstruction 3. Ectopic gallstoneWhite Arrow - Pneumobilia Yellow Arrow - CBD Stent Purple Arrow – IVC Filter• Drip and suck – Ryles tube, IV fluids • NBM • Catheterise • Anti-emetics • Analgesia • Examine hernial orifices • Alert surgical team – most likely conservative management (80%) for small bowel obstruction without perforation.A 65 year old man presents to the surgical assessment unit with abdominal pain, with BNO for 1 week. He also reports a 2 month history of weight loss and loose stool. You request an abdominal x-ray. A. Caecal volvulus B. Large bowel obstruction C. Small bowel obstruction D. Bowel perforation E. IntussusceptionColorectal cancer: 60% Diverticular stricture (from recurrent diverticulitis): 20% Volvulus (sigmoid or caecal): 5%• Drip and suck – Ryles tube, IV fluids • NBM • Catheterise • Anti-emetics (vomiting occurs later than SBO) • Analgesia • Alert surgical team – more likely to require surgical management than SBO • Colon resection with primary anastomosis or stoma formation • Stent insertion (temporary/palliative)A 36 year old male is admitted to hospital with severe abdominal pain. He is normally fit and well and has no past medical history or previous abdominal surgery. You request an abdominal X-ray A. Congenital diaphragmatic hernia B. Sigmoid volvulus C. Caecal volvulus D. Appendicitis E. Biliary colicAn 85 year old man is admitted to hospital with pneumonia. During admission she develops severe generalised abdominal pain. She suffers with chronic constipation and hasn’t opened her bowels in over a week. You request an abdominal x-ray A. Caecal volvulus B. Sigmoid volvulus C. Small bowel obstruction D. Perforation E. Artefact• Sigmoid volvulus • From left lower quadrant to right upper quadrant • Likely no haustra seen • Associated with distension of descending, transverse and ascending colon. • Elderly, chronic constipation • Manage with colonoscopy/flexi sig and flatus tube insertion • Caecal volvulus • From right lower quadrant to epigastrium/left upper quadrant extends towards the epigastrium or left upper quadrant • Haustra present • Distal colon collapsed, distended small bowel • Young, anatomical development abnormality or adhesions. • Management is most likely surgicalA 21 year old women with a history of ulcerative colitis presents with increased abdominal pain and passing frequent loose stools with blood. You request an abdominal x- ray. A. Sigmoid volvulus B. Acute appendicitis C. Toxic megacolon D. Gallstone ileus E. Acute appendicitisA 73 year old female is referred by her GP to the surgical assessment unit with a 5 day history of worsening colicky abdominal pain, distension and vomiting. The nurses inform you she is in more pain, has developed a temperature, tachycardia and is lying very still in the bed. You assess her and request an abdominal x-ray A. Small bowel obstruction B. Bowel wall thumbprinting C. Caecal volvulus D. Perforation secondary to large bowel obstruction E. Irritable bowel syndromeManagement of perforation • Analgesia • Anti-emetic • IV broad spectrum antibiotics • Urgent CT scan • Urgent anaesthetic review • Urgent laparotomy • Hartmann’s procedure for large bowel obstruction and perforation• Bowel obstruction •Small bowel obstruction – adhesions, hernia, gallstone ileus •Large bowel obstruction – cancer , volvulus, diverticular stricture • Post-operative ileus • Toxic megacolon – IBD • Bones – wedge fractures, metastases, sacroiliitis • Calcium and artefacts – pancreas, vascular , uterine, lymph nodes, renal calculi, various objects.◈ Radiopaedia: 🞚 Dr Jeremy Jones 🞚 Assoc Prof Craig Hacking 🞚 Dr Ian Bickle 🞚 Dr Varun Babu ◈ Radiology Masterclass: 🞚 Dr Graham Lloyd-Jones ◈ Geekymedics ◈ Teachmesurgery.com ◈ Radiology start Thanks again to Dr James Cairns for the slides Email anishmistry@doctors.org.uk Contact Details