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Cool. Hi guys, Blood. There's not a lot of us here. Um Hope everyone can hear me. Um But I'll just make a start um cause it's a three minutes past anyway. Um Hopefully you guys are here because you want to know or just revise a little bit about um abdominal x-rays. Um And if you're not then feel free to leave, there's no hard feelings, but if you are, then we will get started. Um So I don't know, I think usually for online sessions, I know it's difficult to, you know, engage with interactive elements and things. So I might just, I will just run through some stuff and this is kind of what I'm going to be talking through. So what is an Abdo x-ray first? How is it done? Why do we do it? When should you order one? Um Some key key things on like is this normal abnormal? Um And then just giving you guys just like an approach on how you can present it, for example, like in exam situations. And also just for whenever you're encountering an Abdo x-ray and so what you call like system approach to it as well Um So what is an abdominal x-ray is in the name? Obviously, we're kind of giving x-ray um images or getting x- images of the abdomen area uh and really like an abdominal examination that you do clinically. Um You, you can split it into kind of different quadrants that you're looking at as well. So what we want to see in an abdominal X ray is um you know, on really from your sternum all the way down to like kind of a pubic synthesis that area and also just as wide as d abdomen is in whichever patient you're taking it in uh when you're reporting kind of findings or um commenting on a specific area of the X ray. And you, you know, even if you forgot the name or um don't know how to describe it, you can still describe it in your quadrants um or the nine regions that you, you know the name of from the clinical examination. Ok. Um OK. And how is it done? So there are usually three kind of different positions. Um Two are probably more common than the other. Um So you might know of the um the supine one where you lie flat on the table, that's the first one over here. Um And uh then there's the er erect one ap and then there's this one called the lateral decubitus one uh where the patients can lying on the side. Now, which one do we do for which depends on the indication for them. So obviously, in an abdomen, X ray, you can see different organs, a main ones obviously been in the bowels, but you can also have a different indication such as like if you just looking at the kidneys and the ureter and things like that. Um uh So if in for bowel perforation or the things that we're mainly looking at for an abdominal X ray, we want to erect. Um So as in the kind of the middle uh picture here. Now, if the patient's too unwell to kind of obviously to be re you need to at least like sit up or if not stand up next to the X rays like the X ray table. Um then they put the patient kind of in this lateral decubitus position where um you would expect if they have um some sort of perforation as in kind of this abdominal x-ray here, you'd be able to see it at the top of the photograph still and obviously in an erect one, perhaps you might have heard that, you know, on the kind of above the liver, that's why you see some, some free gas. So this is how it's done. And essentially why positioning is I uh is important and perhaps at your trust when you request for an abdominal X ray, why they ask you what, which one you need? Um Now, so why an abdominal X ray? I'm just gonna go into a little quiz here to make sure just get everyone's attention if that's all right. So I'm just gonna switch to this. Um, if you've got, um, a fuel co Yeah, so I make that work. Ok. Um, enjoy, you can take it from there. Hopefully some people can, hopefully some, some of you can join quite fun. Once there's a sunlight it stay on and then like, whenever I have a quiz I'll just switch to the screen as you can see, there's only like three questions on there, see a couple more people joining. So it's just those who have just come in. We've just started. You've not missed too much. Um We're just having got a bit of a instructive bit here um with a quiz. So if you could join, that'd be great. Um Sorry, is that an I or is it a one in the code? Give you guys a couple of seconds just to draw you in two seconds as well? I hear some people join cos normally I'd say people anyway. Right. Maybe if I could start uh we can, we can shower until we'll type it in anyway. Um If it's not working. Um So if you can see the options on your devices, um which one is an indication for abdominal x-ray uh or if you can't then feel free to message on here, which I'll be able to see as well. Mhm. Could anybody, obviously the answer? Is there already. So foreign bodies just for the recording purposes. So, um according to the RCR guidelines, so none of the other options are indicated obviously in specific circumstances with certain other history, this is literally like a yes or no answer. Um The, the kind of only right one here radiates only foreign bodies. Um OK. Um And then our next question would be um So do we know what is a radiation dose of an abdominal X ray again? 30 seconds just to, I can see four people have joined. Now, does that mean you can click on the answers? It'd be exciting to know. Uh OK. We've got a 2 to 5 times of a chest X ray. Yeah. OK. OK. Um Seen some hands up, hands up two answers. All right, we'll see. Cool. It's actually like 35 chest X rays taken. So um yeah, it's quite a lot which is why we don't do it anymore. However, um on the basis of that, so kind of having said that obviously it's a quicker one then compared to like act er and you're still imaging um a area that obviously a chest X ray doesn't image. So which is why you still do it? Um And the reason I think actually for having such a higher dose and you know why, why is it like a multiple chest X ray? Why is it not the same is because you've got more organs to get through, haven't you like in the um in the abdomen area. So the dose that you have to give for any kind of radiation to get through to the body is higher. So it's quite a lot. So it's 35 is the answer. So 30 to 40 times here. OK. So back to the presentation. Um I enjoy uh so uh I was talking about the pros and cons of essentially um an abdominal X ray. It is quicker. Obviously, I think um you know, there are different things you can look at an abdominal X ray, but the main thing is ruling out kind of perforation or like essentially uh in the abdomen, like pneumoperitoneum and it's quicker than CT, but it doesn't tell you much. So lo loads more cons to it than, than, than all the pros the radiation dose, as we've just said, it's quite a lot. Um and then kind of with that bearing in mind. Um That's an also image quality that you get out of the abdominal X ray. It is not great. Um It's not safe in pregnancy as with any kind of er imaging that has radiation doses. Um and it's diagnostic value. So, yes, it rules out um something that you weren't. So if there is a specific question, if you just know, um you know, you don't wanna know whether there is air within the abdomen or not and then you're not worried about the patient, then an ab abdominal X ray is really good for that indication. You don't need to put them for a CT scanner, which is loads more equivalent like it will be more 100s, I'm sure of um chest X or like equivalent doses to a chest X ray. So um it's good in that sense, but otherwise it's, it's not that indicated. Now, here are the indications that um are indicated for an abdomen x-ray. So the ones are not, they're, they're not like split into two lists. I'll just kind of pop them on the screen, but the ones on the left, I feel like they're kind of straightforward. Um, and it's like, ok, that makes sense. Um, in terms of sort of the one that we've, I've already mentioned so much is, um, if you've got bowel obstruction and you're querying kind of perforation or you want to see which bit of the bowel is obstructed, um, exacerbation of inflammatory bowel disease. I think that's, that also makes sense. So if they've got, um, like an itis that is so severe that you're querying again, has it perforated abdomen x-ray is good for that. And, you know, kind of the reason why they're having, they would be at risk of having perforation as well or any kind of swallowed or retained foreign bodies. Um, you can, you can see that, um, only if they are obviously radio opaque. If they are not, uh, then they won't show up when they abdom, then it doesn't help either. Now, the other ones that um this is from the RC is um kind of like their guidelines on. When should you send someone for an abdominal X ray? Like if there's a palpable mass, if there's constipated, chronic constipation, acute and chronic pancreatitis, blunt and stab abdominal injuries. Now, I thought these are quite, they're not as straightforward. I think these ones, if you were considering them in a patient, I'd speak to a senior first and also obviously in bracket as specific circumstances for all of them. So um for mass and like in the or stab abdominal injury, especially, I would have imagined kind of most places would just say let's just send them into the CT scanner because then you know, exactly kind of what it is. Um So I think they do mean really specific circumstances when RCR has specific circumstances and also constipation definitely is not um like a common indication for just putting someone through an abdominal X ray. So again, specific circumstances. Um Yeah. So the other indications if anybody asks you ever um Now couple of II don't have a request for this one. Now it's just normal or abnormal abdominal X ray. So before we kind of go into an approach, what is your gut feeling on abdomen, abdominal X ray? Feel free to tap a message on there. Anybody? Oops normal. Ok. Thanks, Harsha. Uh Yeah, normal. OK. We see some, you know, not all of it is, is it sh, could have been lowered image a little bit but nothing overtly too abnormal. I don't see the red flag signs that we'll go through. Uh, looks. All right. Yeah, I agree. What about this one? Normal, abnormal? Yeah, I was, yeah, he was like, oh, after a normal movie is abnormal. No, there is also a normal one actually. Um, it's a bit gassy so clinically, I would imagine the patient might feel a bit kind of distended. Um, but there are actually no overt features of like, um, er, the things that I I'm expecting or I'm looking for on the abdominal. So, yes, the um, obviously you, you have to go through it in a systematic approach later, but this is also normal. Um I skipped, I was giving you this one but this one, this one's also normal. Now you see kind of more bits over here that you might be querying some kind of lines there or when the bowels look different. Is this a foreign object? Should I be worried about it? We'll go through it, don't worry. But essentially what I'm trying to say with these free normal um, abdominal X ray is like, it really depends. Sometimes organs can be seen on an abnormal x-ray and sometimes organs don't and they can still both be equally normal for the patient. It just depends on whether there is gas in the bowels. That, that's therefore you've got kind of the interface between, um, um, gas and liquid and solid or soft tissues or different type of soft tissues. Then that kind of essentially is why, how you can see things on an abdominal x-ray. And then if there isn't, so if your stomach was empty, uh, and it's all flattened, you won't see any of it, you won't see any like gasses in it. And there's, it's only the fact that if your bowels are moving, um you know, you, you see structures and things lying against each other because they've got a slightly different um kind of density for x rays to go through it. Um Which is why people, I guess hate abdominal x-rays. I don't really like them either. Um just going through um back to this one, which is just this one, that's the last one that is normal. Um We can see some structures here that quite nicely, I'm going to highlight them. So these two at the top, they're meant to be 22 things. So this bit at the, this is the liver on the, on the, the patient's, right. Um And this is the spleen. So how I say in blue here, um You might say, oh why is the liver like so low, like almost down to like the pelvis? Um That is quite normal. Um Some people have this like extra dominant lobe, they call it like the um what's it called the um riddle's lobe? Um And that's quite normal. Um, and then you've got the kidney, that's where you would expect them to be and try and go back to like an uncolored image so you can see what I mean. Um, and then the bowels so a way to kind of, you know, start knowing, like always in the middle, there's all the bowels, but where do you kind of start identifying them? I think a good place to start would be like a sequen because um that is meant to be in the right area fossa, you should know that is where it, it it is. So you kind of can you see kind of, that's where it starts and you try and trace it. So here, I'll kind of trace it in three bits. So the CCOM and then going up to the ascending colon to a transverse colon, that's kind of very loopy. And then going to the um probably because of the patient's liver is kind of in the way, isn't it? Um And then going to transverse colon, descending colon and then looping um more towards the back um in, in, in this way. So, and then down to the rectum if that makes sense. Um Yeah, and obviously with ap abdominal films as well, you can't really see like the front and back and what's at the top and what's at the back with it as well. So that's one of the other problems, but it does give you kind of outlines of the bowel. Um, even when it's normal but not exactly. So, you know, even these, I'm, I'm kind of guessing that is where they're going. I could be totally wrong. Um, and it could be that cos I can't see cos this person obviously doesn't have obstruction. Um, there's just gas in the bowels. It's hard to tell whether they are or which ones because we say normally the stuff in the middle should be smaller. Bowel shouldn't they? And then the ones on the side is large bowel. So it's hard to tell actually. Well, are they actually connected or am I just highlighting this wrong? I could be but bowel is bowel make sense so far? Any questions feel free to t in the chat? Um And then this is the final image of all the organs like it's superimposed on each other, right? Um I don't want to say on this one bones and that's what the other thing that you see on an abdominal x ray. So, um you should see like the bottom two ribs, maybe free. Um And then the spinal column that should be visible, that kind of shows that an abdominal x-ray has been like thoroughly. Um It has enough exposure. Um And then you can outline sometimes like each other kind of pedicle and transverse processes individually to see the ilium sacrum. Just give it a quick glance. It's obviously not the main thing on an abdomen X ray when you do the abdominal X ray, but just make sure someone's not got an obvious fracture somewhere. Um ok. So um a way, I think just the structure of presenting an abdominal x-ray, I think if you were here for the chest X ray last time that you've probably been given a structure and obviously in an osteo station as well. It's very important to double check like show that you're obviously checking the patient detail when the x-ray was taken. Um And then the other bits would be well, have they had the previous one and say you'd compare with it and then what the current abdominal X ray is indicated for like what is that that you're looking for and then you assess the image type and quality. So um projection wise. So ap as in like from kind of anterior to posterior, um that is always going to be the case for, you know, abdominal ones. Um But obviously in chest X ray, it is a little bit more important to note which side um any rotation, I'll go back to just this image. Um I think the radiographers and technicians, they try to obviously make sure the patient is not rotated. You might see, I don't think I have a good example here, but you might see that the spine is slightly curved. It might just be that the patient is slightly curved when they're on the on the table or when they when they stood up. But that is kind of it really for, for ation and exposure. Um as I was mentioning before, you should be able to see the spinal column at the back for to indicate that this is there is sufficient exposure of the radiation through. Um And then perhaps the next bit you want, you would want to say is any obvious optimality. And if there isn't, then you can start your kind of systematic approach to going through um each part of the abdominal X ray and then summarize that I, that is a normal one, if there wasn't any abnormality and then what your next management plan would be based on this. Um So that's kind of the outline of how I would maybe approach it. Now, there are two different approaches um to kind of um res that I researched and found both of them are quite useful. It's really up to you which one you want to choose? There's one called the BBC approach and then the other one is called ADO X which sounds kind of, you know, it makes sense, but it's up to you, which one you want to choose? So BBC stands for bowels bones and then calcification artifacts and ABDO X is air bowels density which brackets bones and calcifications, organs and any external objects. So up to you, which one you use, obviously kind of the things you talk about and look for might be in different order, but as long as you've kind of talk through both of them, I think you wouldn't have missed too much. Um, and in the rest of the presentation, um, I have, I'll keep like a little in the corner of both of the acronyms. So, you know, kind of which part of the acronym we're, we're talking about um, as you go through and you, and, and, you know, we've not missed anything now. Ok, so we'll just start air. Um, so I think the most, one of the, one of the most obvious, I honest to you see is probably like, ok, well, there's air in it, there is or isn't, um, if you see air in the stomach and bowels, that's don't do, not, do not be alarmed yet, that's normal, but anywhere else. So if you saw it at the top, um, well, you would need a chest X ray to see whether it's the top of the liver, obviously. But if you see air outside of the stomach or outside of the bowel, allowing you to see other structures within, um, the abdomen, then therefore that is abnormal. Um, and it's only when there's air outside of these structures, you see more of them. So in both of these, they are, um, these are gasses within the bowel that are normal. Um, and you don't, you know, it's quite subtle, you can't see exactly the outline and the shape of those bowels. Can, you like you can imagine the structure but you know, there's not a, an obvious loop. It's not like the anatomical diagram that you see in textbook where you've got your large bowel and then the small bowel in the middle, it's not like that. So that's kind of what, what we mean and obviously air in any other spaces um abnormal. Um So this is how we start in the ABDO X one. the other, where, where would you see abnormal air is? So this is the regular signs. So double war sign. Ok. So when you have air that is outside of the bowel, it allows you to see the wall of the bowel and that's called the regular sign. So, um, you see the, the, all these arrows pointing to the lines, you, you shouldn't see that essentially. Um If you go back, I'll just go back to the previous, um, slide as well. So you see all these kind of gas bubbles, they're just like gasp, there's no light on the outside of the gasp ball. There is not another, um, darkness i low attenuation, um, that showed the line of the, the bowel. So that's kind of the difference. Um, um, like I said, um, obviously there's not a X ray but this is uh gas outside, um, where it shouldn't be as well. It's below the diaphragm and between the diaphragm and the liver. And that's abnormal. Um, diaboral also is important to note um, having been on um, the, the surgical assesment assessment unit people have had or like, you know, ultrasound surgical wards as well. Um, after surgery, it is normal for them to still have some air when you take a chest X ray for whatever other reason and there's nothing to be alarmed about because, um, when you do laparoscopic surgeries, you, you, you inflate the abdomen so you can have access to the camera port and then do the surgery and you close up, you don't get rid of all the air once you close up the abdomen. So it's normal for some people to have a bit of air still remaining in, in, in their tummy. Um, so this is not an absolutely abnormal finding depending on the time you do it. Um, but obviously if someone hasn't had abdo surgery and then they print out with this, then that's no good. Um, ok. And in the extreme cases where there is, um, a lot of air within the abdomen, you can see. Now this is a very, I'm hoping everyone sees that this is like, oh, this is very full looking tummy. You're almost seeing like individual strand of the bowel, aren't you? So, um, and the tummy can be like, probably very distended. It doesn't even fit in the, the, the frame of, of, of the x-ray. Um, so this is like regular sign, like plus plus plus. Um, if it, if your tummy is also very distended. You can even call it like a football sign or something, I think. Um, and yeah, this is definitely air within and outside of, of, of the, of the bowels and this is no good contact surgical or surgery immediately. Um, it's gonna go into surgery. So, more on bowels. I had one question left on bowels, I think. So. That was my other thing. So this is the last, that's it. That's all the questions I have. Um, how do you identify small bowels on an abdominal X ray? So, um, I see people have left the quiz now. That's ok. Um, what are the key features? I've got like several options there. Um, obviously I can't see the rest of it. Um, I think it says which spans the width of the bowel. That is the last bit of the, of each of the answers. Come on on, sir. Thank you. Cool. Ah, close. Yeah. Ok. So the valvulae, I can never say it cones. Ok. They go across the whole width of the length and small bowels should be kind of more centrally as in when you imagine an anatomical diagram that you draw is in the middle. There was a bit of a trick, I guess to, uh, to make you read a lot of text. Well, um, so, ok, small bowels should be central. You see the, the, the valve really that like stretches across the whole of the bowel, large bowel on the opposite hand, it's more in the peripherally, generally speaking. Um, and they've got the, um, Haustra which, um, do not cross the bowel. So they're just like a little indent. Um, and you might see in the, uh, this next, uh, x-ray and I'm gonna show you some kind of fe fecal material. So that's what, that's what that is. Um, and I don't know if people will know the free 69 rule. So that is um I've not typed it up, but essentially the maximum kind of diameter when you do, when you use like a ruler on, on, on the image viewer that you're using maximum diameter for small bowels, three centimeters, six centimeters for the large bowel with a nine for like the cecum because it does, it can stretch quite a lot. Um And if any, if any part of the bowels exceed beyond the kind of limits, you can quite fairly certain say that they are um distended and querying obstructions or perforation somewhere. Um Yeah. So this one is just highlighting the fact that this is most likely because I can trace it that this is gonna be the large bowel, these small bits. This is a different X ray. Now, I'm just highlighting some light, OK. Um The large bowel, small bowels in the middle, small bowel in the middle and large bowel. Um So, yeah, and, and you, but you can see like why there's a difficulty of seeing telling difference between small bowel and large bowel in the middle because actually exactly in the middle cos that's where the large bowel kind of is at the back of the small bowel, isn't it? Um, but yeah, that's, if it was distended, then that's how you, you could tell you would go back to your, to the thing that we know of, which is, um, to, to hear if you see how it's dry, it's large bowel. And if you don't, you see cones instead small bowels. Um, right. So the main reason we're gonna spend a lot of time on bowels. I think it, obviously it's an abdominal X ray. Um, we're gonna spend a bit more time on looking at the causes of small bowel and large bowel obstruction. So small bowel causes wouldn't include like hernias, adhesions, ili s tumors and things like that. Um, so, um, hernias wise mostly would be because they've called, um, uh, well, it could be, could be, could be inguinal, could be, um, even incisional, um, and various other places where you can have it. But those are the ii can think those are the main two ones I can think of. Um, adhesions you would think of if they've had previous abdominal surgery as well, especially major ones, eus if they are recently POSTOP, um, and tumors are a bit less likely in the small bowel, but it can still happen. Um, so you can see these are they're very distended. Obviously, I don't have a, it's not on an imaging review, so I can't really measure it, but they look quite big and there's a rule of thumb as well. Actually, um, the width of the vertebra at the back. So from here to here, that's around five. So if your small bowel is the same width as that. So if I like kind of measured this to here and I measured this down from here to here, from the small bowel, they are pretty much the same to me, right? So that's larger than three. So that means this is descended. Um And so it is right to query small bowel obstruction in this picture especially, and you can see all of all of these like loops here. They have similar of the features that we were talking about for small bowel and same in this one even though this one looks even messier. Um So yeah, that's, that's, that's how small bowels obstruction um, present. Now, this one in especially, I don't know if you guys saw this here. So this is the hernia of bowel. Um You can tell whether it is hernia or not by knowing. Ok. Well, this is the ASIS, this is the pubic tubercle. If there's bowel below that point, it's a hernia. So in this one, it will be probably like an inguinal hernia, but you can obviously get like femoral hernia as well. Um So just go back to picture, to show you and then show you in the label. Ok. Moving on to management. Um, just to throw it in here for kind of clinical point. So once you've got this X ray, what do you do? Um, dripping socks or a tube to empty stomach content? Make sure they're on some like fluids, catheters more than the fluid out. Make sure they're not in pain. What? Relieve their pain, antiemetics, know by mouth and let the surgical team know. But, um, no doubt for small bowel obstructions that aren't perforated, 80% of them are managed kind of conservatively. You just essentially need to let the bowel rest up. Um, and, and, and take it from there. Ok. Moving on to large bowels. So large bowel causes very commonly, um, C RC carcinoma. It could be due to genital strictures as well and some, a bit more rare hernias. And, um, so I know we talk about, you might have heard that we talk about sigmoid, volvulus, coffee bean sign things like that quite commonly, but actually in, um, especially in the elderly population, if they've got large bowel obstruction, it's important that we rule out colorectal cancer instead. So in these two photos, we have similarly very dilated bowels. Ok. Which one are they, are they small or are they large? So you can see in this section you've got house dry and then here as well. It looks more like house dry. They're a bit more peripheral. So you, you would say that they are large bowels. Um, again, you know, width of the this spinal column. This is definitely more than 1.5 of these. So that's probably more than six centimeters, definitely distended, probably obstructed. That's how you, you kind of decide to think through it. Um, this one a bit harder to see. Um, but like this whole bit is the dilation and the distension and also kind of here as well. It's so dilated, but you can't see, but the good thing is you can't see. I know you can convince me to. So you can see both sides of the wall. But it's like soft tissue at the back here though, isn't it? It's not a line. So you've not got air war air. Um, so it's not, it's not technically a regular sign. It's just, um, very enlarged, large bowels. Um, and what do we do? Oh, no causes, uh, like I said, um, colorectal cancer actually is more common, most common cause of it. Um And then the other two are less common. Um, you do the same thing as you do for II don't have a sign on this, um, for small bowel obstruction and this one is more likely to need surgical management. So it's important that you alert the surgical team earlier so they can take them into theater and take out whatever is blocking them, their bowels moving on to just sigmoid and SVO here as well. Just give you a couple of minutes to appreciate a photo. We talk about the coffee bean sign, don't we? Um To me, I have to say these both look like coffee bean sign, but they're just tilted differently. Um And the thing to differentiate is if you imagine where, so where would you expect the sigmoid to be? And where would you expect the serum to be? So I would expect the, the s to be here, sigmoid to be here. So in this one, in this photo, first that I got my mouse pointed to uh it's hard to, I don't know if everyone gets this, but like in my brain, I'm like imagining like, well, if it's twisted, it's kind of like it would twist at the caecum and then like all the gasses and the bowel, they extend from the right fossa upwards towards um the left upper quadrant. So to me, this is like that, it looks like that. So I would call this one, a cecal ovulist and then this one, whereas it's more like, OK, there's a, I've got a little twisty point here. Um And that would be the sigmoid where the sigmoid is. So, and the kind of distention is going from this left uh fossa to the right, upper side, upper quadrant. So this would be a sigmoid ovulist to me. Um So those are kind of two ways to differentiate, but actually your answer might also be in the history as well. I didn't write it down. Ok. So more commonly in cecal volvulus, you might see and kind of not necessarily Children, but definitely in the younger population and you'll see sick more ovules in the elder elderly population more and they are more likely to be people who have chronic constipation. Um, and, you know, um, did it feel like the feelings of distension, um, and haven't opened the bowels for a couple of days rather than it being quite acute? Um, cecal fus would be in younger people or maybe they just had an anatomical development or a abnormality of some sort or even even, maybe even arts. Uh And you see in that. So, um and also one other thing um that I forgot to mention was, and the sigmoid ovules, you're less likely because it's the end of the large bowel. You're less likely to see the, the house, right? The, the little indentation of the large bowel that we talk about. Whereas in cecal, as you see here, there's more of the house drive that we talked about. Um So that's another kind of differentiating point. Um I would say if that makes sense. Um Got any questions so far anybody because as a, well, it's right at the start of the large bowel. Um And if you imagine that's where the cecum twists start off ascending colon, we have loads of the house dry and then that's where it gets distended. Sig sigmoid is like, it doesn't do a lot of absorption, does it? So it doesn't need a lot of the house dry. So anatomically it, it has less. Um, that is how I think about it. Oh, hi. Welcome to be on stage with me. Yeah. So that, that's the kind of 22 main main parts I would say, for example, like an, uh, a history for someone presenting with um the picture on the left on our left uh would be like maybe like we'll say like a 35 year old guy presented with severe abdo pain normally and well, and then no, no previous history can present like that. Whereas someone on, on the, on the right right hand side here, it could be like an 85 year old lady who's had five day history of chronic constipation and um n not opening the bowels uh and severe pain. So like, yeah, from the history, you can, you should be able to tell um the answers the question um can move on inflammatory bowel disease. So this would be one of the other indication for an abdominal x-ray, wasn't it? So, uh if they have an exacerbation, a cure exacerbation of the inflammatory bowel disease. So that includes ulcerative colitis or um uh the other one which is Crohn's disease. So, and then some of the features that you would see is called like one of them is called thumbprinting. I think it's just a keyword that they were thrown into an exam for you. Um Essentially there is thickening of the house, right? Because of the inflammation. So you, you, you see it on um an abdominal x-ray like that. Um They will probably be having a bit more nonspecific after pain when they're presenting like that or generalized after pain. Um And then some of the ones are, if the house dry are so thickened and so damaged, they become like less. Um And you've got a loss of the normal house dry, then it becomes a lead pipe. Um and A and D um cases where they've got toxic microcolon in inflammatory bowel disease. So it's mega as you can see, it's massive. Um Then that's we, we'll see that on the abdomen X ray as well. So the, the and the only kind of difference between these two because obviously they, you can see how they both kind of lost their house dry, haven't they? But this one is toxic. Me colon is, it's mega uh and it's very bad. Um And this one is just, yeah, you've got lots of House Drive, but it's like it's not that extender, so it's OK. Um That's the only thing we're going to have a quick run of the rest of the acronym as you can see with of TB. Now we'll talk about bones and calcifications if you're doing BBC. Um and talk about density if you're doing ABDO and kind of a bit of the external things and slash artifacts. So these two pictures, you've got some costochondral calcification as you can see here, highlighted yellow. In this picture, you can see some gallstones. You don't necessarily all see gallstones all the time. But on, in this person's case, they were like the uh constituents of them is radioopaque. So therefore you can see them, but you can get kind of non rad gallstones as well, which is why you don't do X rays to, to see gallstones as as the standard. Um And then this is a calcified mesenteric lymph node as you can see there, see some s clips. So this person's definitely had some previous surgery um and some fleb so this person is probably quite elderly um and has some calcifications essentially in the vessels. Um And that's what you're looking at. Um And then in abdo x, the organs, the O for organs, we also have, you can have a look at. Um But uh it is quite difficult to tell. So essentially, if it's normal, you can see the outline of the bits of the organ that you expect to see. So liver is liver. Um I think it's highlighting the soas muscle edges here. Uh On here, you can't even see the kidney because kidney muscle collapse of bowel are the same kind of con like density. So there's no outline of them. Um And it just sort of happens. Although I can kind of convince myself that you can maybe, I don't know, see it here. Um This was highlighted, pointing to the spleen, I guess the edge of the spleen here. And then you've got, this is pointing to what looks like, probably gonna be the bladder um, down here. Um And that's it. It's one of the key things though, if your organs have, you know, have fat, that's how it's different to this organ itself, soft tissue. So you see a bit of it. So it's normal to have for the liver to have a bit of fat. So therefore you can maybe can see or maybe you even see it worse because it is quite a clear liver edge. I wouldn't say this is the fatty liver at all. It might look a bit different if it's got more fat in it. Um And for the, so, Asma so and kidneys I think is one of the places where say, for example, like air can get to, um, again, if the contours a bit more obvious than this, then you should start worrying, but otherwise it'll be fine. Um This picture doesn't have the top of the lungs, but if it does, then just examine for any consolidation there because it can irritate and have some referred pain down to the tummy. Um So yeah, that, that's it really for ors and then artifacts, as you can see, I don't know if you can spot the artifacts in here. This one, we got a coin um in, in, in the esophagus most likely probably going all stuck up. The maybe. Did I know act, I don't know actually whether this is in the esophagus or whether it's gone into the stomach already, stomach will be obviously a bit more on this side. Has it gone to the next stage after the summit? Um Like a foreign body. This one here is just a coil that we've got and the rest of the um abdomen looks fine. Um The patient's a little bit fecally loaded as you can see here. So this is like gas within the fecal content um over here, but no signs of like other thing else too over. Um If they have pain down in the lower tummy, you might say, well, it's just dislodged it. Should it be in the should it is not the right place for it to be? You can also ask Gyne for an opinion if you're sure as well. Um Oh, and that's it. So I don't want to hear everyone for too long. Uh 40 minutes is enough, I think. Um in summary, really. So, um key things for on the X ray, we're just looking for bowel obstructions. Always go back to your patient's history to see like what is the most likely cause of the, whatever they have. You're most likely going to find the answer there. Um If you're worried about POSTOP ileus that is prolonged. And by that, I mean, over five days, like into seven days, that's prolonged, total bili, then maybe you can get an abdominal X ray. Um but within like five days, POSTOP, it's normal for the bowel to take time to get back into routine um Toxo query and toxic in inflammatory bowel disease as one of the other indications in abdominal X ray and then just making sure you go through and have that structure to check out all the other bones and bits and calcium and yeah, artifacts. So yeah, that's it. Really, hopefully that was helpful. I think it is a bit wide and I could go on to talk a bit a lot more about other things that you would find in Aboral xray. But it is for four years and I think you guys will be fine with just this knowledge. So having just a quicker structure that you like, whether it's BBC or ABDO X and go through it slowly, then you'll be fine in ay any questions anybody? How are any questions? Final word just saying? Thank you. No, it's OK. I was it was it, was it helpful? Yeah, it was, it really was. That's cool. Um But yeah, otherwise if no one else has any questions, then thanks for coming. Um Obviously, this is recorded. So I think so you will be able to view this back in your own time if you have any for your revision. Um And you can always contact, I didn't leave my contact there, but you can always contact me or where if you want and have any questions. I put my email in the chat. Um Yeah, all it for me. Thanks for arranging this. Um Thank you so much. Hi. Hi.