ClinicalRadiology (1980) 31, 87-93

0009 9260/80/01460087502.00

1980 Royal College of Radiologists

The Plain Abdominal Radiograph in Acute Pancreatitis

sTANLEY DAVIS, SANTILAL P. PARBHOO and MICHAEL J. GIBSON*

Department of Radiology and Academic Department of Surgery, Royal Free Hospital, London, and
Department of Radiology, Frenchay Hospital, Bristol
The radiographs o f 100 patients with acute pancreatitis were reviewed and compared with 100 controls by
two radiologists and a surgeon. Our aim was to assess the frequency and usefulness of the signs described in the
literature. Calcification of the pancreas was seen in one case only. Abnormalities of the biliary tree (visible
gallbaldder, biliary gas and gallstones) were seen in 10%. The left psoas shadow was more frequently absent in
the pancreatitis series. Paucity o f gastrointestinal gas although observed in 12 cases was ascribed to vomiting.
A more important sign was the gaseous outline of an adynamic duodenal loop which was seen in half o f the
patients examined in the left lateral decubitus position. Dilated jejunum was seen in 31 cases, associated with
sentinel loops in 10 and multiple fluid levels in 25 patients. Dilatation of the transverse colon was the most
constant colonic sign (18%), but the colon 'cut-off' sign was not seen. It was concluded that the most prominent signs in order of importance are a gaseous distension of the duodenal loop, gas in the duodenal cap, a
dilated transverse colon and the sentinel loop. The gasless abdomen is a striking but rare sign and in our series
was always associated with severe pancreatitis.
There have been a number of previous reviews on the
radiological changes in acute pancreatitis, some involving a large number of cases but virtually none
systematically assessing each radiograph for the signs
described in the literature. Most of these, however,
have been undertaken in North America where it is
known that, in general, the disease has a different
aetiology to that in this country. In the United
Kingdom acute pancreatitis is most commonly a
sequel to biliary lithiasis, whereas in the United
States of America, alcoholism plays a prominent
role. A large number of radiological signs have been
described and the purpose of this study was to determine the frequency of these Findings on the plain
films of the abdomen. Assurance was also sought that
the plain radiograph was in fact of assistance in
recognising the condition, as well as being a means of
excluding other causes o f the acute abdomen.

METHODS
The plain abdominal radiographs and the records
of 100 cases o f acute pancreatitis, as defined by the
Marseilles Symposium (Sarles, 1963) were reviewed.
The diagnosis was based on the clinical presentation
of the acute abdomen, associated with a significantly
raised
serum
amylase
(> 1000 i.u./litre/> 1000
*Current address: Sir Charles Gairdner Hospital, Nedlands,
Western Australia 6009.
Reprint requests to S_P.P., Academic Department of
Surgery, Royal Free Hospital, Pond Street, London NW3
2QG.

Somogyi units), the findings at laparotomy or at post

mortem. The sex, age and aetiology and basis o f diagnosis of pancreatitis in our patients are shown in
Table 1. There were 10 deaths in the series, six
patients had biliary tract disease (average age 77
years), three had alcoholic pancreatitis (average age
51) and one patient ruptured his aortic aneurysm
following bouts o f acute pancreatitis. In every case a
supine Film was available, in 67 an erect film and in
24 a lateral decubitus film with the right side raised.
These films were taken on the day of, or within.24 h
of, admission, i.e. during the acute presentation of
the illness. Since some of the signs attributed to acute
pancreatitis may also be seen in the 'normal'
abdomen, the above series was compared with a similar number of examinations in which pancreatitis
was not the cause of the patient's symptoms. For this
purpose, use was made of the preliminary films of
100 intravenous pyelograms.
It is appreciated that these controls are not altogether satisfactory, since the patients obviously had
some symptoms, and would also have had bowel
preparation. Another disadvantage was the absence
of an erect or decubitus film. A list of the radiological signs in the literature was made and to this
was added other signs which previous experience
had suggested might be of value, giving a total of 35
possible signs (Table 2). All the films were examined
by the authors, and the radiological signs were
accepted only if there was complete agreement. A
large number of signs have been described in the
literature, and many of these are self-evident. There is
however variation in the literature, with regard to

88

CLINICAL RADIOLOGY
Table 1 - (a) Clinical details. (b) Aetiology of pancreatitis. (c) Basis for Diagnosis

(a)

No.

Sex

Age range

Average age

Mortalio'

57
43

M
F

19-83
17-95

50.4
59.4

4
6

(b) Aetiology of panereatitis

Biliary tract disease
Alcohol
Trauma
Familial pancreatitis
Hyperlipidaemia
Contraceptive pill
Viral infections
Post-operative
Unknown

54
26
1
1
3
2
3
1
19

(Two factors, e.g. alcohol and biliary tract disease, contraceptive pill and hyperlipidaemia were associated in 10 patients.)
(c) Basis for diagnosis
Clinical features and raised serum amylase
Clinical feaures and raised urinary amylase
Operative findings
Post-mortem findings
certain o f these signs and some clarification o f these
is required.

Sentinel Loop
This t e r m was first used by Levitin (1946) w h o
described an isolated, dilated loop o f adynamic b o w e l
visible on the supine film. It was accepted in our
series o n l y if the dilated loop also showed fluid levels

Fig. 1 - Sentinel loop on erect film.

87
2
9
2

on the erect or decubitus film (Fig. 1), thereby

excluding its diagnosis on the supine series and
c o n t r o l films. Small b o w e l o f greater t h a n 3 crn
diameter was considered to be dilated.
Colon Cut Off Sign
Different versions o f this sign are to be found_ The
t e r m was first used b y Price ( 1 9 5 6 ) t o indicate gaseous

Fig. 2 - Dilated colon.

THE PLAIN ABDOMINAL RADIOGRAPH IN ACUTE PANCREATITIS

Table 2 - List of radiological signs
A. Directly related to the Pancreas
1. Enlarged pancreas
2. Gastrocolic separation
3, Gas within the pancreas
4. Calcification in the pancreas
5. Mottling from fat necrosis

13. Gas troin testinal.sign s

Paucity of gas
Displacement of the stomach
Dilated stomach
Gas in the duodenal cap
Gas in the duodenal loop
Dilated duodenal loop
Indentation of duodenum by the gallbladder
Gas in the jejunum or ileum
Dilated jejunum
Sentinel loop
More than three small bowel fluid levels
Gas in the hepatic flexure
Gas in splenic flexure
Dilated hepatic flexure
Dilated splenic flexure
'Colon cut off' sign
Dilated ascending colon
Dilated transverse colon
Dilated descending colon
Indentation of hepatic flexure by gallbladder
Gas in the caecum and terminal ileum

C. Other changes
1. Loss of psoas shadows
2_ Loss of renal outline
3. Elevated diaphragm
4. Gallstones (opaque)
5. Absent preperitoneal fat line
6. Gas in the biliary tract
7. Ascites
8. Gas/fluid levels outside the bowel

The colon varies considerably in calibre under normal

circumstances and a precise assessment of calibre is
n o t possible. For the purposes of this study a colon
with a diameter of greater than 6 cm was regarded as
dilated (Fig. 2).

Fat Necrosis
Baylin and Weeks in 1944 described areas of faint
mottling and increased density representing fat
necrosis and saponification. This sign has been considered as pathognomorLic for severe pancreatitis b y
Berenson e t al. (1971). It is reputed to be best shown
on a film taken with a low kilovoltage. The condition
may be associated with a precipitous drop in serum
calcium and metastatic fat necrosis, and is associated
with a high mortality.

Pancreatic Enlargement
A soft tissue shadow in the upper abdomen representing the swollen pancreas has been described but is
rare. When there is gas in the stomach and transverse
colon this becomes more apparent. This has also been
referred to as the 'trumpet sign' (Benson, 1974) in
which a wedge-shaped shadow is seen separating
stomach and transverse colon.

RESULTS
These are shown in Tables 3-5_
Table 3 - Incidence of extra gastrointestinal tract signs
Control

distension of the ascending colon and hepatic flexure

with sharp limitation of the gas shadow just beyond
the flexure. In the same year Stuart described the
transverse colon 'cut off' sign as gas-filled hepatic
and splenic flexures which appeared to be cut off
from the central transverse colon segment. A third
version of the 'cut off' sign was reported by Brascho
et al. (1962) in which the cut off occurred at the
splenic flexure. These descriptions were preceded by
that of Baylin and Weeks (1944), who described an
area of 'spasm' occurring either in the transverse
colon or the splenic flexure. Because of this confusion
we specifically noted the gas distribution in the colon
and the presence or absence of dilatation was recorded.

89

Enlarged pancreas
Pancreatic calcification
Opaque gallstones
Elevated left diaphragm
Elevated right diaphragm
Absent left psoas shadow
Absent right psoas shadow
Absent preperitoneal ratline
Visible gallbladder
Gas in biliary tree
Ascites
Gas within pancreas
Mottling from fat necrosis
Localised gas fluid levels
outside bowel

0
0
1
0
0
6
14
2
0
0
0
0
0
0

Pancreatitis
Supine

Erect/
decubitus

0
2
5
3
0
17
23
2
2
3
0
0
0
1

1
1
1
0
0
4
5
0
2
0
2
0
0
1

90

CLINICAL

RADIOLOGY

Table 4 - Incidence of upper gastrointestinal tract signs

Control

Pancreatitis
Supine

Paucity of normal gas

shadows
Displacement of stomach
Dilated stomach
Gas-filled duodenal cap
Duodenal loop gas
Dilatation of duodenal loop
Indentation of duodenum
by gallbladder
Gas in jejunum or ileum
Dilated jejunum
Sentinal loop
Over three bowel fluid
levels

Erect/
decubitus

14

0
0
7
2
0
0

0
4
26
8
4
0

0
3
16
14
5
0

79
8

75
30

36
9
10
25

Table 5 - Incidence of colonic gas signs

Control

Gas in hepatic flexure

Gas in splenic flexure
Dilated hepatic flexure
Dilated splenic flexure
Colon 'cut off' sign
Dilated ascending colon
Dilated descending colon
Dilated transverse colon
Indentation of hepatic
flexure by gallbladder
Caecal and terminal ileal gas

pancreatitis, and Sades et al. (1965) relate it to the

intake o f alcohol.
Pancreatic Enlargement

Pancreatic enlargement indenting the duodenal

loop was seen in one patient only, which is in keeping
with Benson's Fmdings. Other authors (Hulten, 1928;
Goldman, 1931) place some value on this sign,
Gastrocolic separation due to an enlarged pancreas is
claimed to be a common sign. Ransom et al. (1974)
reported that gastrocolic separation occurred in 15%
o f cases in their series, while in a recent paper Moren0
and Rivera (1976) claimed that the sign occurred in
at least 49% o f cases. Unfortunately that latter study
is vitiated b y the absence o f a control series despite
the known marked variation in the position of the
gastric air bubble.
Psoas S h a d o w

Pancreatitis
Supine

Erect/
decubitus

22
20
0
0
0
0
0
2
0

28
33
1
1
0
4
0
18
1

23
26
0
0
0
1
0
3
0

DISCUSSION
From the results it is shown that most o f the signs
investigated are o f little or no value in the diagnosis
of acute pancreatitis. A number o f them were not
seen in either the control series or in the 'pancreatitis'
series. Others showed a similar incidence in both
series and are unhelpful. There were, however, a
number of signs which were seen more commonly
in the patients with pancreatitis and these, together
with the signs most frequently emphasised in the
literature, are discussed individually.
Pancreatic Calcification

Two patients showed pancreatic calcification. This

low incidence is similar to that recorded by Cantwell
and Pollock (1959), Ransom et al. (1974) and Benson
(1974). There seems to be agreement that calcific a t i o n is a manifestation o f recurrent or chronic

Although Poppel and Bercow (1949) drew atten.

tion to a poorly defined left psoas shadow as being
evidence o f acute pancreatitis, other authors disagree
(Stein et al., 1959; Cantwell and Pollock, 1959;
Weens and Walker, 1964). In our series an absent
psoas shadow was recorded more frequently in the
pancreatitis series than in the control, particularly on
the left side. However, the high incidence o f this sign
in the control group detracts from its value in the
individual case.
Paucity o f Normal Gas Shadows

This was found twice as frequently as in the

controls. We agree with Felson ( 1 9 6 8 ) t h a t vomiting
plays a major part in the production o f this sign. All
patients who showed paucity of gas on the plain
film (Fig. 3) had severe pancreatitis and persistent
vomiting as a prominent symptom.
Gas in the Duodenum
The amount of gas in the duodenum will depend
on the intensity o f the inflammatory process (Poppet,
1968) and the position o f the patient. The presence0f
a duodenal ileus allows gas to remain in the duodenum and the high incidence o f duodenal gas is in
accordance with Findings reported in other series
(Weens and Walker, 1964; Bathazar and Lutzker;
1976). Gas in the duodenal loop was seen in half the
cases when the left lateral decubitus film projection
was used. In four o f these cases the duodenal lo0p
was also dilated. On the erect film the gas tends to
remain in the duodenal cap. This contrasts with only

THE PLAIN

ABDOMINAL

RADIOGRAPH

four of 62 cases in which gas was seen in the duodenal loop in the erect film with no evidence of dilatation (Fig. 4). Our Findings suggest that the left
lateral decubitus projection is the most useful film for
demonstrating an inflammatory lesion in the duodenal loop. This sign is often missed in the supine
fdrn (Fig. 5a, b). Since the decubitus projection can
be carried out even in the ill patient, it should be
included in any radiographic assessment of the acute
abdomen-

Pancreatic Abscess
Although an uncommon sign, the presence of gas
in the pancreatic substance is regarded as a pathognomonic sign of pancreatitis. Felson (1957)reported
six cases, the pro_gnosis in these patients being very
poor. Altemeier and Alexander (1963) found two
cases in a series of 32 patients and agreed that the
sign was pathognomonic. Stephens (1973) believes
that this sign is rarely detected. It was not possible
to identify mottled gas within the pancreas in any of
our patients, but in one case there was a fluid level in
the lesser sac due to abscess. This patient died 4 8 h
after admission.

Gas in the Caecum and Terminal Ileum

The spread of inflammation can be widespread,
and as pointed out by Meyer and Evans (1973) it may

IN ACUTE

PANCREATITIS

91

extend to the caecal region. This then gives rise to an

ileus with gaseous distension of the terminal ileum
and caecum. It was seen in seven patients (Fig. 6).

Dilated Jejunum and Sentinel Loop

When Levitin (1946) described the 'sentinel loop'
he referred to the changes on a supine film only, and
showed that the appearances could be differentiated
from mechanical obstruction by taking serial films.
Ransom e t al. (1974) found segmental small bowel
dilatation in 40% of their cases, and Benson (1974)
found it to be the most frequent plain film finding
(34%). Stein e t al. (1959) found that 55% o f their
patients had loops of small bowel measuring over
3 cm in diameter. On the other hand, Weens and
Walker (1964) and Stephens (1973) found an incidence of less than 10%. In this series a dilated loop
of small bowel was seen on the supine film in 30% of
the cases (compared with 8% of controls); in all but
two of these, an erect or decubitus film was available
but in only 10 of these were fluid levels demonstrated. It would seem that the incidence of 'sentinel
loop' in any of these particular series will depend on
the way in which the term is defined. It is difficult
to evaluate the significance of dilated bowel in the
20 patients who did not show fluid levels, especially
as eight patients in the control series were shown to
have a dilated small bowel loop. In the absence of

Fig. 4 - Gas-filled duodenal cap and faint outline of duodenal loop (erect film).
Fig.3 - Paucity of normal gas shadows.

92

CLINICAL

RADIOLOGY

(b)

(a)

Fig. 5 - (a) Supine and left lateral deeubitus projections_ (b)

Shows gas-filled duodenal loop not visible on erect film.
fluid levels or a further film to show persistence of
dilatation, caution should be exercised in the inter.
pretation of this sign.

Colon 'Cut Off'

Fig. 6 - G a s in t h e t e r m i n a l i l e u m a n d c a e c u m .

The presence of gas in the hepatic and splenic

flexures occurred with similar frequency in the
control and survey series. This casts doubt on the
value of Stuart's version of the 'cut off' sign (Stuart,
1956). There was no example in this series of the
colon 'cut off' sign as described by Price (1956)
although dilatation of the ascending colon was seen in
four patients. Cantwell and Pollock (1956) and Weens
and Walker (1964) found the colon 'cut off" sign in
2% of patients. However in 18 patients, compared
with two in the control group, there was dilatation of
the transverse colon with relative absence of gas in
the descending colon (Fig. 2). Brascho e t al. (1962)
described similar appearances in his distal 'cut off'
sign which he found in 50% of patients.

THE PLAIN A B D O M I N A L R A D I O G R A P H IN A C U T E P A N C R E A T I T I S

coNCLUSION

The signs which are most likely to be present on

the plain abdominal radiograph in a patient with
acute pancreatitis are a gas-filled duodenal loop with
or without dilatation, absent (left)psoas shadow,,
sentinel loop, dilated jejunum, dilated transverse
colon, dilated ascending colon, gas in the terminal
ileum and caecum. None of these signs is specific
and may be seen in other conditions, e.g. dilatation
of the duodenal loop is seen in acute cholecystitis.
However, when these signs are present on a plain film
examination of the abdomen (which must include a
decubitus film with the right side raised) the possib~ity of acute pancreatitis should be remembered
andthe appropriate biochemical tests performed.
Acknowledgements. We thank the clinicians of the Royal
Free Hospital and Frenchay Hospital, Bristol, for access to
their clinical records and Dr P. M. Bretland oftheWhittington
f[0spital for additional X-ray material.
REFERENCES
Alterneier, W. A, & Alexander, J. W. (1963). Pancreatic
abscess. A study of 32 cases. Archives o f Surgery, 87,
80-89.
Bathazar, E. J. & Lutzker, S. (1976). Radiological signs of
acute pancreatitis. CRC Critical Reviews in Clinical
Radiology and Nuclear Medicine, 199-242.
Ihylin, G. J. & Weeks, K. D. (1944). Some roentgen aspects
of pancreatic necrosis. Radiology, 4 2 , 4 6 6 - 4 7 0 .
Benson, G. (1974). Plain film findings in acute pancreatitis.
Journal o f the National Medical Association, 66, 1 4 8 159.
Berenson, J. E., Spitz, H. B. & Felson, B. (1971). The
abdominal fat necrosis sign. Radiology, 1 0 0 , 5 6 7 - 5 7 1 .
8rascho, D. J., Reynolds, T. N. & Tanca, P. (1962). The
radiographic 'colon cut-off sign' in acute pancreatitis.
Radiology, 79, 763-768.
Cantwell, l). F. & Pollock, A. V. (1959). Radiology of acute
pancreatitis. Journal o f the Faculty o f Radiology, 10,
95-99.

93

Felson, B. (1968). Gasless abdomen. Letters from the Editor,

Seminars in R oen tgenology , 3 , 2 1 5 - 2 1 6 .
Goldman, C. H. (1931). Ein Beitrag zur R6ntgendiagnostik
der akuten Pankreatitis. Roentgenopraxis, 3 , 7 9 3 - 7 9 6 .
Hulten, O. (1928) Beitrag zur R6ntgendiagnose der akuten
Pankreasaffektionen. Acta radiologica (Stockholm), 9,
222-254.
Levitin, J. (1946). Scout film of the abdomen. Radiology,
47, 10 29.
Meyer, M. A. & Evans, J. A. (1973) Effect of pancreatitis on
small bowel and colon: spread along mesenteric planes_
American Journal o f Radiology, 1 1 9 , 1 5 1 - 1 6 5 .
Moreno, G. & Rivera, H_ (1976). Evaluation of gastrocolic
space in 100 cases of acute pancreatitis. Radiology, 118,
535-538.
Poppel, M_ H. & Bercow, C. (1949). The roentgen manifestations of pancreatitis complicating mumps. American
Journal o f Roentgenology , 6 1 , 2 1 9 - 2 2 2 .
Poppel, M. H. (1968) Roentgen manifestations of pancreatitis. Seminars in Roentgenology, 3, 227-241.
Price, C. W. R. (1956). The colon cut-off sign of acute
pancreatitis. Medical Journal o f A ustralia, 1, 3 1 3 - 314.
Ransom, J. H., Rifkind, K. M., Rose, D. F., Fink, S. D. &
Eng, K. (1974). Objective early identification of severe
acute pancreatitis. American Journal o f Gastroenterology,
61,443-451.
Sarles, H. (Ed.) (1963). Pancreatitis. Symposium, Marseilles,
April 1963.
Sarles, H., Sarles, J. C., Camatte, R., Muratore, R., Gaini, M.,
Guien, G., Pastor, J. Leroy, F_ (1965)_ Observations on
205 conf-trmed cases of acute pancreatitis recurring and
chronic pancreatitis_ Gut, 6 , 5 4 5 - 5 5 9 .
Stein, G. N., Kaiser, M_ H., Sarian, N. N. & Finkelstein, A.
(1959). An evaluation of roentgen changes in acute
pancreatitis correlation with clinical findings. Gastroenterology, 3 6 , 3 5 4 - 3 6 1 .
Stephens, D. H. (1973). Roentgenological findings in pancreatitis. In Pancreatitis, (ed_ Gambil, E.E.), Chap. 10.
Morby, Chicago.
Stuart, C. (1956) Acute pancreatitis. Preliminary investigation of a new radiodiagnostic sign. Journal o f the
Faculty o f Radiology, 8, 50 57.
Weens, S. & Walker, L. A. (1964). The radiological diagnosis
of acute cholecystitis and pancreatitis. Radiologic Clinics
o f North America, 2, 89--106.