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Hi, everyone. Uh my name is Miriam and I am currently a radiology trainee uh based in West Midlands. So today I am going to talk about the abdominal radiographs. I know that dominant radiographs uh can be a bit daunting or maybe I was not uh that of a good student. Uh because I do think that we do not come across much of the radiology when we are med school or even when we are doing our internships or F one. because I remember when I entered radiology, it was just like going into the med school right up again and about the ABD dominant radiograph. As far as I remember, I do think that I used to be very scared to even open them with the chest radiographs. Yeah, we can say that, ok, we keep on listening to the pathology, we keep on discussing it. So maybe we have got a bit of an idea about the chest radiographs, but I don't think so much related to the abdominal radiographs again. Um as I said, ii, it's just my own experience what I feel. So talking about the abdominal radiograph and especially uh like based in UK, the first thing we need to understand why we are doing any kind of imaging and it comes down obviously uh because you might have got some interaction with your radiology department. Yeah, if not exactly in terms of radiographs because they are not uh rejected that frequently. But what I mean to say is that uh when I, when we are working as an, and the consultant or a registrar just normally just says, OK, we need the scan. And uh I remember those days when I would call the radiology department and any of the registrar and or the consultant who just roast me. And my answer would be, oh, the consultant asked it now, in retrospect, I can say, well, it's not a good answer because I remember there was this one consultant who said to me, yeah, your consultant told you to do, but you all are also doctor, you should have a medical knowledge. So the thing is that we really need to justify why we are requesting a scan. And again, I if I'm talking purely about based on the radiological uh guidelines, so we have got er uh which is kind of the legislation of the radiology. So in that you would come across that the referral as well as the one who is accepting the scan, both have the responsibility of justifying the scan. For example, if you are an and you are requesting a scan and I'm the one who's accepting. You can't just if something goes uh wrong and someone gets sued. So it won't be only the radiology uh consultant or the registrar. The uh file will also come towards the one who has referred it. So the responsibility goes to the referred as well as the one who has accepted. So from that point of view, we really need to understand what are the indication for an abdominal X ray. So we'll go through the indication for abdominal radiograph. We will go through the normal anatomy which we can uh appreciate an abdominal x-ray. Then the basic approach to review the abdominal x-ray. Uh Meanwhile, if you want to ask any questions, please uh put in the chat box. Uh Yeah, a few here. So um then I asked if um how she can contact you. Uh OK. And we can discuss that at the end of Yeah. And we review the present on. Oh OK. Yeah. Yeah. Yeah. Sorry, I did that if it's not changing, I'll let you know. Yeah. So that's fine. Now, I can't uh see the chat box for now. Yeah. OK. All right. Uh Is it clear now? No, it's not. It's not yet on the presentation for you. It's not. OK. No. Um OK. Can you see now? Mm Not yet. OK. I'll stop sharing and then I'll share again. OK? Is it OK? Now, are you on the slide view now? Yeah. It's still showing as like the normal. Just your powerpoint, not the actual slide show now. Oh, ok. Um, I think if, what do I do? I don't know. Yeah. Can you just try it again and see? Ok, I'll stop she again. And if it doesn't II think we'll just, um, sometimes it's, it's, um, gives issues. Ok. There is, uh, there are questions about what you've just, um, the introduction. Ok. So I didn't, I didn't say if a consultant, radiologist misses, I, I'm not talking about a critical finding. I'm talking about doing an imaging. So if you open up Ermer guidelines, it would specifically says, so it's I RM er Ermer guidelines, it was uh specifically says that um uh the referr and I'm missing the word which it says. Uh So I was uh let me just open it up and then so that uh I do not quote anything wrong. Yeah, so I'll just put in the link as you guys are. Obviously, we are not talking about um someone missing a finding. I was talking about justification of doing uh an imaging. And if in any case, a wrong imaging is done for someone, for example, uh what it means is that uh you have got some patient who has got uh for example, fracture of the right limb. And by mistake, you request an X ray of the left limb. So obviously, you are the clinical person who knows the clinical knowledge. I would just be uh like accepting the radiograph based on what you have told me. So in that case, a wrong site would be imaged. So that doesn't come under that. It's only the mistake of the radiologist who has uh accepted the request. It would also come under the Referrer who put in the wrong request. That is what it means. OK. Let's uh try again. OK. I was uh OK. Is it here now? Um No, I think we should just go on. Ok. OK. Uh So yeah, uh we were talking about indications for an abdominal X ray. Then we'll talk about how to appreciate the normal anatomy and the basic approach to assess the abdominal x rays. And in the end, I'll go through some of the cases. So indications for an abdominal X ray. So generally speaking, obviously, if someone comes with acute abdominal pain and obviously, we are thinking that this pain is something related to a surgical reason, for example, bowel obstruction uh and uh exacerbation of IBD and the uh renal calculi. Yeah. So obviously, in terms of renal calculi, the uh gold standard modality would be a CT ku. But in certain cases, if obviously our differentials are uh a bit broad, we can start off with doing abdominal x-ray. Yeah, then uh so these are the uh uh these are the guidelines according to the I refer refer, then there are few circumstances in which we may also justify doing, which involves that. Ok. Uh a palpal abdominal mass. Um, it really depends but not particularly for, but because for that reason, we would uh approach the ultrasound or the CT KUB. You will see a lot of people getting uh abdominal x-ray for constipation, we particularly are not happy to do them. But then again, if there is some elderly patient and the surgical registrar would go on and say that, ok, the patient has, hasn't opened the bowels for many days. And uh I am not worried a lot, uh a lot, but still I would like to be sure. So in that case, uh I would accept an abdominal radiograph, so I might be able to appreciate a lot of poo in the bowel or at least it, it can give us uh a rough idea that OK, the patient is not having any pneumoperitoneum. And uh then uh you can appreciate uh contraceptive devices on an abdominal X ray. We can do the abdominal x-ray particularly uh in Children in case we are suspecting necrotizing enterocolitis because obviously with small kids and especially the premature kids, the abdominal X ray and chest radiograph are done quite frequently because uh we, we are a bit reluctant to jump to CT S. Yeah. And the otherwise uh yeah, these are all I have got from there. Mm With some, I won't agree because uh when it says that renal or ureteric calculi, yeah, it can help in initial assessment. But for a ureteric calculi, you would ultimately go for a CT Kub. Uh when we do not do the abdominal x-ray, you, I come across a lot of uh request when the abdominal x rays are done for someone having right upper quad pain and the is cholelithiasis. Uh because the gold standard imaging for the gallstones is ultrasound and on abdominal radiograph, uh only like 10% of gallstones are visible. So it is not indicated if the differential diagnosis is cholecystitis or cholelithiasis. And then obviously we won't do it in case of acute I gi bleed because that would go for the gastroenterologist and the endoscopy. Then obviously, if, if you look towards the left side, this is how a an abdominal radiograph would come in front of you and everyone, I completely uh understand everyone gets scared. I am scared till date. All right. Just a question. Sorry. Yeah. Are you currently on your own presentation? Yeah. Uh OK. So it's not, I think it's lagging behind. So if, if you just leave it at your like the powerpoint, it um without the presentation you, then we'll be able to follow. OK. Or sometimes if we use a PDF, then I think it's usually easier that way, but I think we can just go on like this. Yeah. OK. Is it OK. Now, so yeah, we can see it now. Yeah. OK. It will be a bit problematic later on when we'll do the cases anyhow. Um OK. Yeah. Um where I was. Yeah. So that's how you will obviously see the abdominal radiograph. This is the annotated image. So let's go through the approach for the assessment of an abdominal radiograph. So I would follow like uh ABCD approach or ABDO X approach. So A for air and we really need to understand where the air is in the abdominal radiograph. And is it at the right position where it is supposed to be obviously in chest, there will be air all over the chest, within the chest, uh cavity part with the abdominal radiograph. We really need need to make sure that it is within the bowel. Then the next thing comes that we would see where the bowel is, where it is positioned. It is in, is it in its usual position or some thing is pushing it away from the usual position? Then we would go for the dense statures and organs later on with bones and any other abnormality we could see. So talking about the air, obviously, it should be within the bowel limit, not outside it. Then the next point would be that we know that small bowel is placed centrally and large bowel is peripherally. So this would be the ascending colon, transverse colon and the descending colon. Yeah. Then we have got, obviously in the right upper quadrant, we have got the liver. Then on the left upper cordon, we would have the spleen. We would look for all the vertebra, the pedicles along the vertebra, we would look for. Very importantly, the source shadow. Can you appreciate it in these radiographs? Obviously, I understand uh it might not be uh clear in all of the radiographs. But in this radiograph, you can see the source uh the outline of the sore muscle and then kidneys, we'll go through uh certain cases and then to uh identify the importance of looking at all the organs. So therefore, in our checklist, what we are going to make sure that uh the, the uh the air is within the bowel, then the bowel is of normal caliber, the bowel wall is not thickened, there is no gas within the bowel wall in the structures, there is no abnormal calcification. For example, you can incidentally find, for example, I'm doing an abdominal radiograph for someone coming with abdominal pain. And there I see that there are are uh dense structures uh or radio structures at the level of the kidneys. So obviously, it will give me the idea that the patient is suffering from renal calculi, OK. Obviously, than the source uh shadow if it is apparent. And you in ology, you always have to compare from the other side. If you see that on one side, the source uh shadow is not clear or it is widened, it can indicate that there is something going on uh with the patient and rec uh in the retroperitoneum, OK. So the so shadow is significant in that case. And then obviously, we will look for all the visualized bones so that we do not uh miss any fractures, especially this is important uh to look for in someone again uh based in UK because lots of people are, you know, in the elderly age group. So it's not like that you just comment on the abdomen and later on after two days, you come to know, oh the patient was having neck or femur fracture. Yeah, in terms of the air uh within the bowel lumen, as I explained, that air should only be within the bowel lumen. So there are three signs we look for in radiology, in an abdominal radiograph. So regular sign, falciform ligament sign and football sign, you would end theological exams. You would or even I II would think and someone who might be taking MCP or any surgical exams, I would think that they should know the regular sign and the pcim ligament sign. Ok. So, uh going back to the regular sign. So we are saying that the air should only be within the bowel wall. Regular sight arises when the air is seen within the bowel lumen as well as outside the bowel lumen. So what will happen is that it will outline the bowel wall and therefore, the appearance would come uh come up as double wall sign or the retina sign, which would indicate the patient is having pneumoperitoneum that is air in the abdominal cavity because it will be, as I said, outlining both sides of the bowel wall. And uh again, obviously, uh we would see on an abdominal radiograph when there is large amount of hemoperitoneum, uh very important uh thing that uh you cannot take an abdominal radiograph uh as uh like an indication that the patient is not having hemoperitoneum or bowel obstruction for the fact that it could be only uh localized perforation. So in that case, obviously, we will not be able to see uh signs like regular signs and falciform ligament sign. So yeah, if uh you can appreciate this uh radiograph, I understand that it would uh be coming as a very small image to you. Now, I can try to make it back from here. Can everyone sit now? So this is, oh, sorry, my mic was mute, sorry, my mic was on mute. It's clear. Yeah. OK. OK. OK. So, yeah, so you see how clear this is because what we are able to see is that the air is within the bowel wall and it is also outside the bowel wall. So it is outlining the bowel wall if we go back to the one we saw here, so we can see, you know, like the specks of air, not like outlining the bowel wall specifically, that's how a normal radiograph would come. But if it is coming as something like this, very crisp uh borders and you are able to see like uh uh air inside as well as outside. So it will be the regular sign. It's a bit more apparent in this one. Yeah. So we can see how the bowel uh uh is dilated as well as its role is sore loosened. Sorry, it's radio back. Not OK. Uh Any question until now. It, no, no. OK. The next thing I'm going to talk about is the falciform ligament sign. So where we have got falciform ligament. So basically falciform ligament, uh it connects the liver to the anterior abdominal mole. So what will happen is that if there is air in all over in the abdominal cavity, that ligament would be uh outlined by the air and it would appear as prominent. OK. So it will also obviously indicate that there is air within the abdominal wall. So if we can appreciate in this radiograph. So obviously, number one, I can see here here and I cannot appreciate that this air is within the bowel wall, not the sorry, I'm saying bowel wall within the bowel lumen in the wall, there shouldn't be the air. Yeah. So this is all the free air within the abdominal cavity. And then this bit is the falciform ligament sign. Football sign is again, in case of massive pneumoperitoneum, you would see something like this, that the abdominal cavity is outlined by the air. So the uh appearance would be of like a football. And obviously, in that case, you can also see irregular sign and falciform ligament. This is against when there is massive pneumoperitoneum. So, if you see this is a radiograph of a kid, we can see here this falciform ligament and we can see how big the tummy is just like football and obviously it is compressing the chest cavity too. Is it clear? Yes, it is. Let's go back here. Ok. Uh So, yeah, now we have maintained that where the ear should be, the next uh point is about the bowel. So bowel, as I said, we need to, uh appreciate that. Is it in its normal position? So small bowel would be central and it would have contis and large bowel would be peripherally placed and it would have cost. Now, can someone tell me the difference between hos and vol Conti, I'm looking at the chat box. Yeah, I'm also looking at the chat. Ok. Ok. Yeah. Yeah. Good. Yeah. Yeah, that's right. So why will a con con is basically grow through the whole circumference or the whole uh uh lumen of the small bubble while the uh ho are based in the large bowel? And they do not uh go through the whole length of, of the uh whole diameter of the bowel wall. So remember large bowel per with OTs and small bowel is centrally placed and has what wall even then comes the rule of 369, which mostly we register as uh use overnight. Uh We would have some radiograph in which uh medical registrar, someone would call us and say that. Do we think that it is bowel obstruction? First thing is that again, uh uh clinically, if there were, then they have to consider that is it, it is bowel obstruction, abdominal X ray might not be showing it. And the next thing is if there are apparent uh visible uh uh bowel uh lobes and what I would do, I would measure them. So central bowel loops if they are dilated more than three centimeter, which then it would indicate that the patient might have small bowel obstruction, large bowel, we take a cut off of six centimeter and cecum we take cut off as nine centimeter. So that is 369 rule three for small b bowel, six for large bowel and nine cecum. The next thing is uh wall thickness, wall thickness, particularly in my uh on CT S. But again, uh in abdominal radiograph, uh if it is very thickened edematous, it can be really prominent and can indicate that something is going on with the bowel, either it is edema, it is pneumatosis or some pathology is going on. So, yeah, as we discussed, the small bowel, these are the whole convenes which are seen through the transverse length of the small bowel and the peripherally placed large bowel loose with por. So as I was discussing the thickness of the bowel wall, if we can see this radiograph So this radiograph shows a quite a lot of uh pathology, this air I cannot. So you see this is all the bowel loops and this, this air, I cannot particularly say over here that it is within the uh lumen of any bowel. It and it is a position where we do have the liver and the appearance, it feels like that it is uh some air within the liver. Then the next thing is, look at how crisp and bright kind of in um bowel wall, I can see which is radio back. So I can see the air inside as well as outside over here, which is not within a bowel loop. So this is on the right very clear cut, regular sign. And then if um I was going to zoom in. So there were these small SPS along the bowel wall where I'm pointing, sorry, the over here. So these were uh these were raised as a suspicion of pneumatosis, intestinalis. What it means is that air within the bowel wall? Ok. So which can raise the suspicion of ischemic bowel and which is again a surgical emergency, uh shouldn't be missed. Yeah. Ok. Ok. And the next thing obviously, the dense touches, we would uh as I explained, look for all the organs. So we would look for the liver. As in previous example, I said that it was raising the suspicion that the air is within the liver. We would look for spleen uh kidneys. And obviously, if a long kidneys over uh where you suspect the ureters are going to be immediately, you see some calcification, you can suspect that they are ureteric stones. Then the source shadow sacroiliac joints, visible bones you have to look for and the lung bases. As I mentioned, we can look for surgical um uh clips. Uh in most of the radiograph, you would be able to appreciate the cholecystectomy clips, uh IUCD vaginal pessaries, any feeding tubes. Obviously, we do uh use a chest X ray for to localize the feeding tubes. Uh I'm sorry to localize the angio tube. In the same way, we can use the abdominal radiograph to localize the uh nasojugal or P tubes. Yeah. Yeah. It's uh just a question to follow up the um uh in the intestine. So is um asthma asked if CT should be done for suspected uh in the B war? Yeah. Yeah. So again, uh over here, obviously, uh one very important thing is CT should not uh sorry, the management should not be delayed. And the weight of the CT, we always say if uh there is clinical suspicion, the patient needs to go to the theater. Uh Talking about that, for example, overnight, I saw a chest X ray in which there was air under the diaphragm. It was not an abdominal radiograph, it was a chest radiograph of a kid. So obviously, the suspicion was pneumoperitoneum and the clinical picture was also going for the pneumoperitoneum, they asked for a CT and, uh, in the retrospect, if we, they have got enough evidence and surgically they are suspecting, I don't think so. There is even, obviously the CT confirms, but if a, a good surgeon suspects it, what I'm going to see again in the CT that is air. Yeah. So obviously they have to open the patient, they have to find which viscus has, uh, perforated. And, uh, yeah, again, in case of when we are talking about ischemic bowel, if, uh, there's a high suspicion and there is some delay in doing the CT, the patient needs to get to the theater ASAP because that bowel will actually die. So the management depends on the surgical team, how sure they are. Uh, because, uh, they do not want to take, uh, someone to the theater. Uh, we had an incident, uh, uh, a better go where an appendectomy was done for someone with a normal appendix. And as I said, that they were trying to push you to radiology. So we are the, uh, people who can guide. But again, uh, the thing is that if the clinical suspicion is high, take the patient who take, if it is not, then II do think the surgery can, uh, wait. So it, it goes both ways. Ok. So can we appreciate, uh, what's happening in the radiograph on the right? Uh, this one are we, if we are following the approach. Are we uh seeing the air within the bowel lumen? Yes, we are. Yeah, obviously it is a very uh limited imaging. The whole of the vertebra are aligned. I cannot see the source which I can see is fine. Yeah. And in the Pelvis, obviously, I can see this IUCD device. Mhm Yeah. Yeah. Yeah. Correct. And can we appreciate what is happening in this radiograph? So air is within the lumen bowel wall. No dilated bowel wall. The so shadow is going too. So shadow is here and they appear symmetrical kidneys are fine liver. What's this? Mm. Where is that? Where are you going? It's like at is that it looks like near the liver or the kidney? So it's that not? Yeah. Yeah. Ok. So it's it, it it it is not very dense so that I wouldn't say that it is a calculus and appearances like kind of a straight thing like a clip. OK. Right. What is happening in the this radiograph? The centrally the small intestine seems to be very well uh outlined. Yeah, but they do not appear dilated. They, they are placed centrally. Mhm. Uh In this not with the vertebra II wouldn't be putting anything about the vertebra that that only comes in the exams, those rare findings. So I don't I'm not sure which x-ray asthma talking about though. Was it this one, this one? Uh uh my my my my C is coming on both on the which, which says l the one on my right. No, this one, this one, he said the one, the one we just looked at previously with the patient that uh had the tip. Now, was there um something wrong with the vertebra and renowned stones? That one? No, no. Yeah, I didn't, I didn't see that. Ok. OK. And in this one, it's just this I II think my sa is coming on two screens maybe. Is it right now? Yeah. Now your cursor is only the one that has the left. Yeah. Yeah. Yeah. Yeah. So it's just this nail was ingested by a patient. Mm This radiograph. These are uh this is the large bowel and replaced small bowel. The only thing is these clips. This is bilateral tubal ligation and the vertebra looks like. Is it, is it scoliotic now? Uh Yeah, something over some vertebra right here. Mm But obviously we don't have the lateral one. So, yeah. OK. Uh Any questions till now, then we'll just go through the cases. Um No, no, so bad. OK. So, so if you want anyone to talk about the case, like I can invite them to stage if you would want. Yeah. Would anyone like I didn't want to pick up the right? No people want to do it, you know. So uh so case one is that the patient is coming with abdominal surgery, abdominal pain, vomiting and not opening bowels. What can we, how will we describe this abdominal radiograph, let's see the morning. So, so OK, I'll do this one. And the how we do is that this is an abdominal radiograph of a skeletally mature uh adult patient. What I could see is that there are multiple loops of dilated bowel, some of which are placed centrally. So it indicates that there is a small bowel. Also, I could see the prominent called condi, what I'm going to do is that I will measure it. So, uh because you know, when we are doing it on pas obviously, we can measure it, I can't on uh this one. So, uh but yet again, I'll just say that it is, the measurement comes as greater than three centimeter. So this indicates that the patient may have small bowel obstruction, uh causes include most commonly adhesions or hernia. I would call the referring uh doctor and I would ask them to have an urgent surgical input. OK. So that's how we also formulate our reports that uh you might have seen that, OK. There are multiple loops of centrally placed dilated small bowel indicating small bowel obstruction, urgent surgical in input, requested. So, a sorry what um Abdella put on the group page um as small dilated loops, but he also put like adhesive. Um It's not. And we really know though. Yeah, but the most common causes and he, I don't know why. My just, just a, just a second. My uh powerpoint has stopped just give me a second t OK. Let's share it again. Ok. Yeah. Yeah. So small bowel greater than three centimeter plus even central replace blue uh bowel loops common causes adhesion and hernia and the initial management would be IV fluids NG tube and then we'll have a CT for underlying cause. Yeah. To the next case. So the patient is coming with diarrhea, vomiting and abdominal pain. Yeah. Yeah. Ok. Sorry. What we could see is the bowel is kind of like, you know, interrupted in between. We call it as, as a thumb printing sign. If you, if you think that within the bowel wall, someone is placing their thumbs, the distance is like that. So what does thumb printing means? It means that the bowel wall is edematous. Yeah. So the wall is so thickened that the appearance comes like this. So there is some pathology going on uh due to which the ho are uh thickened and edim giving the look of thumb printing. So again, uh it indicates colitis, any inflammation or infection of the colon causes include infections, ischemia or IBD. And obviously we will look for what is the underlying cause uh someone wants to do this one or should I be doing the whole of them? Um I in the chat box actually, they, they Yeah, they've been answered. So, um the last one. Yeah, last um good, good. So, so distended life car someone has put on the pink, pink And yeah, so it would be pretty much like, uh, a large bowel obstruction and in case of, because obviously, we always say that small bowel obstruction is more common. Uh, large bowel obstruction, they normally occur in elderly patients. And the reason could be cancer most common commonly or it can be volvulus or diverticulitis. And these are the, uh, uh, radiograph, it's mostly come during our exams. So, uh, this is a dilated bubble loop which you can see is arising somewhere from the left lower quadrant and going to the right upper quadrant. Uh You may say it is arising from the pelvis. This is if you think is giving and appearance of coffee beans sign. Yeah. So you would come across a lot of uh questions during your exams when they will say coffee bean sign or a dilated loops arising from the left lower quadrant pointing towards the right upper quadrant and it would indicate sigmoid voids. Yeah. Then going back to what we discussed, if you get such a radiograph with a classical clinical history of abdominal pain distension patient is vomiting. Patient is really unwell. You really don't need to ask for a CT, Abdo, a good surgeon will actually take the patient to the theater because the Abdo uh Abdo CT is going to show pretty much what you are looking with the an abdominal radiograph. So the management is basically surgical. You have to take the patient to the theater, open up the patient and see what's going on when we're talking about uh volvulus. So there's obviously sigmoid volvulus and the cecal volvulus. So sigmoid volvulus arising from the arising from the lower quadrant, uh left, lower quadrant, going to the right upper quadrant, cecal volvulus would be the other way around if you see this picture. So something is arising from the right lower quadrant and going to the left upper quadrant. So marked especially distension of the loop of the large bowel from the right lower quadrant to the left, upper quadrant, cecum would be more than nine centimeter. And management includes that uh you decompress via colonoscopy and then obviously you will go for surgery. Ok. Severe abdominal pain, high lactate history of af someone needs to do this, please. Ok. I've already showed this. Uh Yeah. Yeah. Has put pneum in. Yeah. Yeah, diagnosis BDU. So in this one, we uh gave the suspicion of ischemic bowel because we could see thickened bowel wall, air outside the lumen and within uh the portal venous system. So striculus senses across the small bowel gas in the bowel wall and poo gas urgency T ap and urgent surgery for bowel resection. You will take out the ischemic bowel part before it goes to nec necrosis, sudden onset of abdominal pain. Di this is only in the reputation, multiple dilated loops and air outside the lumen positive, regular sign. One for small bubble obstruction. Mhm. Yeah. Yeah. This is an interesting one. The patient is coming from left loin to groin pain, fever and hematuria e coli. So we put Raynaud Coli. Yeah. And where about right or left? You always say the side in radiology left. He could what about the right? Good. So if you see this is, this is so this is the kidney, this is something here too. And this is like these are bilateral staghorn calculi, OK. You know, so findings bilateral staghorn calculi more prominent on the left. And obviously II for the ST you will go for nephrolithotomy, lithotripsy would be for the smaller ones. Ok. All right. Abdominal pain and distension over a few weeks, 25 year old female b sorry what fecal infection? OK. And where? Um OK. And there is fe um I think the other answer was for the previous one left on stone. OK. Previous one, can someone see something is going on here this bit which is not here, as I said, we always compare. So this is like the bowel. Mhm. Sauce is fine. Other things over here are OK. Uh Bones, I'm telling her. OK. But you see sacro joints. OK. This is something going on here. This which is not here. I mean if it's normal, it should be bilateral. Yeah. And the hint is it is 25 year old female. Thank you. So the other in hint is you didn't do a UD. That's it pregnancy test. Yeah. Mhm. So this is basically and this actually uh a similar case did happen. So second trimester fetus with its head in the abdomen and spine projected this is the spine. Mm And now if you see, you will see that it is the spine, it is actually yeah, someone put on the page but and and yeah, one thing why, why the bowel is pushed so up. Yeah. Mhm Yeah. Pregnant. OK. So the question is it in this radiograph? So there's something in the pelvis? Yeah. Mhm. Circular in shape. That's Yeah. Yeah. So it was basically someone uh did put an orange from the rectum. Mhm And obviously there is air around it. So you're worried that the per there is some localized perforation. Mm OK. That's all. So uh ovarian cyst uh it would uh like, yeah, I mean uh fibroids can be calcified but uh again, it was a bit about the where was it Pelvis? Where would be somewhere around here? It's uh but yeah, uh uh uh clinical history which was like that there is some foreign body. OK. OK. Yeah. Any questions. Mhm Yeah. So most uh commonly you would just encounter the questions related to uh abdominal obviously uh in your clinical practice, ab abdominal pain, query obstruction. And the other thing most commonly you would do would be uh query foreign body because you need to, if, if obviously the foreign body, someone or basically the kids have ingested, you keep on doing the abdominal radiographs to look at the progression that if it is moving, if it is moving, that you would expect that it would come out of the po if not. And then obviously the patient needs to go to the. So if anyone wants to, I think my mic is messing up, but if anyone wants to speak, um I can invite you to this stage otherwise you can just put it on the chat box. Um Number of five that will tell it is uh not, no, we don't. Uh I kind of give the numbers that they are. Uh we also have multiple air fluid levels. OK? OK. So I put the feedback form to on the chat box and at the end of the event, it will automatically get sent to all the attendees. So please, um we need you to fill the feedback but for um the organization and our speaker to you to be very helpful to everyone. And yeah, someone asked me how they can contact you then uh next year. Uh Yeah. And uh OK, so you can contact me on, uh I don't know if you guys are part of the UK RST group that is on Facebook. You guys can contact me or from there, le leave a message on my messenger and I should be able to get back if I do not uh get back sooner, I will do it later. Yeah. OK. And otherwise I do think I II got into radiology in 2020. So I'm quite old. I do think you can tell them better than me. Yeah, we, we've done the, yeah, like, yeah, we've done some symptoms and continuously like if anyone has um anything they need, we provide the guidance and if anyone is around West Midlands then yeah, they might be able to see me around putting on drawn reports for the patients. Thank you so much. Thank you. Yeah, I guess it was helpful but any kind of feedback if even if it wasn't, please let me know. Ok. Yes, thank you. Thank you so much. Thank you guys. Yeah, thanks. Bye.