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Abdominal x-ray - an approach (summary)


Dr Owen Kang and Dr Jeremy Jones et al.

Abdominal radiographs can be challenging examinations to look at. It is always best to approach radiographs in a
systematic way.

On this page:

Article:
Bowel gas pattern
Abdominal organs
Calcification/artifacts
Bones and joints
Playlist
Related articles

Images:
Cases and figures
Imaging differential diagnosis

Bowel gas pattern


Gas within the bowel forms a natural contrast with surrounding tissues since it has a very low density. Bowel can
only be seen if it contains air/gas. If it is completely fluid-filled, bowel will be indistinguishable from its surroundings.
stomach
left of midline, beneath hemidiaphragm
sometimes just a small volume of gas in the fundus
do not mistake a rim of gas for pneumoperitoneum
small bowel
less than 3 cm wide
tends to be central
only seen if it contains gas
mucosal folds (valvulae conniventes) traverse the bowel lumen
large bowel
less than 6 cm wide, caecum and sigmoid up to 9 cm
peripheral
ascending and descending colon in fixed positions laterally
transverse
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contains faeces - mottled appearance

3/6/9 rule
In general terms, small bowel should measure less than 3 cm, large bowel less than 6 cm and the caecum and
sigmoid colon should measure less than 9 cm.
If the bowel measures greater than this, there is bowel dilatation - think mechanical obstruction or adynamic ileus.

Abnormal gas pattern


A supine radiograph is not the best test to do to look for free gas (look for an erect chest radiograph). However, with
practice, it is possible to see free gas within the peritoneal cavity.
Gas outside bowel will make bowel wall much easier to detect because loops with gas on either side of the bowel
wall are seen very clearly. See pneumoperitoneum.

Abdominal organs
The parenchymal organs within the abdomen absorb x-rays as they pass through the patient and therefore alter the
appearance of the radiograph. These changes are subtle, but with practice, you should be able to make out several
organs and muscles.
liver
right upper quadrant
extends to the hemidiaphragm and past the midline
spleen
left upper quadrant
extends to the hemidiaphragm
psoas muscle
symmetrical triangles either side of the lumbar spine
narrowest near the diaphragm, widest at the pelvis
kidneys
sit on the psoas muscles
often just see the rounded lower pole
lung bases
pulmonary vessels in the bases projected over upper abdomen

Calcification/artifacts
Look out for abnormal calcification and metal in or on the abdomen. It is worthwhile looking specifically for an
abnormal density and working out what it represents.
pathological calcifications
vascular, e.g. aorta, splenic artery, phleboliths
renal tract: renal calculi, bladder calculi
calcified gallstones in right upper abdomen
uterine fibroids
calcified mesenteric lymph nodes
hepatic/splenic granuloma

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gluteal injection site granuloma
iatrogenic artifacts
lines and tubes
NG/NJ tubes
ECG leads
oesophageal stent
PEG/ileostomy/colostomy tube (and bag)
femoral line
nephrostomy and cholecystostomy tubes
biliary and urinary stents
urethral catheter
Tenckhoff catheter for peritoneal dialysis
penile implant
surgical
surgical clips, e.g. cholecystectomy, sleeve gastrectomy, nephrectomy, pelvic surgery
vascular clips
anastomosis sutures
embolisation coils
LAGB band, tube, and port
aortic/iliac stent grafts
colonic transit study rings
skin staples
intrauterine device (IUD)
vaginal pessary
orthopaedic hardware, e.g. posterior spinal fusion, distraction rods, plates and screws for pelvic fractures,
THR, femoral neck fixation devices (dynamic hip screw, intramedullary nail with cannulated screw)
spinal electrode
clothing/jewellery
navel/nipple piercing
metal from clothing, e.g. metal rings from jogging bottoms, beads, sequins
metal objects in shirt/trouser pockets: cellphone, car keys, lighter, pen
printed shirts

Bones and joints


A host of bones and joints can be seen on an abdominal radiograph.
spine
lower thoracic and lumbar spine should be of similar height
intervertebral disc spaces should be similar
spinous processes should be visible
lower ribs
sacrum and pelvis

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Sacroiliac joints and hip joints are often visualised on abdominal radiographs. Make sure that you look at the bones
to check for other causes of abdominal pain. Evidence of discitis, bony metastases etc.

Playlist
Example normal cases: playlist

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Cases and figures

Figure 1: large bowel

Figure 2: large and small bowel

Figure 3: liver and spleen

Figure 4: kidneys

Figure 5: composite

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Imaging differential diagnosis

Large bowel obstruction

Sigmoid volvulus

Bowel infarction and perforation

Abdominal aortic aneurysm

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