Unit 1 RDSC 233

Plain Film Radiography of the Abdomen

Bontrager pp. 98-116

Anatomy seen on the plain

Film Critique
abdomen radiograph
Exposure Factors
Radiographic anatomy
Radiographic
Pathology
Positioning of:

Plain film abdomen (KUB), flat and: What in the World?

Upright abdomen Miscellaneous, but significant,
Left lateral decubitus abdomen odds and ends
Dorsal recumbant (Rt or Lt)
Maternal abdomen
Atlas of Human Anatomy
Third edition (260)
Need to know
Four quadrants intersect umbilicus
(RUQ, LUQ, RLQ, LLQ)

Nine regions

Right hypochondriac
Right lumbar
Right inguinal (iliac)

Epigastric

+
Umbilical
Pubic (hypogastric)
Left hypochondriac
Left lumbar
Left inguinal (iliac)
Atlas of Human Anatomy
Third edition (260)
Need to know

Seven landmarks

Iliac crest
Anterior superior iliac spine (ASIS}
Pubic symphysis

Greater trochanter
Xiphoid tip (T9-T10)
Inferior costal margin
Ischial tuberosity

+
Atlas of Human Anatomy
Third edition (245)
Need to know
Peritoneum

Falciform ligament

Diaphragm

Transversus abdominis M.*

Internal & external oblique M.*

* Muscles of the flank stripe

Atlas of Human Anatomy
Second edition (266) Need to know
Abdominal viscera

Kidneys

Adrenal (suprarenal) glands

Pancreas (head, body, tail)

Duodenum
Rectum

Bladder
Esophagus
Aorta (left sided)
Inferior vena cava (right sided)
Atlas of Human Anatomy
Second edition (301)
Need to know

Liver

Gallbladder & bileducts

Stomach

Colon (parts of covered in colon

unit)

Spleen

Jejunum and ileum (not

shown)
Portal vein
What is normally visible
Conditions

1. Spleen Y
2. Gallbladder N
3. Stomach Y with gas
4. Veins N
5. Arteries N if calcified
6. Small bowel N gas is pathological
7. Colon (gas) Y with gas

8. Bladder Y with urine

9. Pancreas N
10. Ureters N
11. Kidneys Y
12. Adrenal glands N
13. Flank stripes Y
14. Liver Y
 Radiographic Anatomy

Be prepared to identify these anatomical

structures in lab.
 Radiographic Anatomy of
the plain film abdomen

A radiograph of the kidneys,

ureters, and bladder (KUB)
demonstrates the:

1. Size
2. Shape
3. & Position

of some, but not all the

organs in the abdominal &
pelvic cavities.

Why (in two words or less,) is

it difficult to differentiate
abdominal organs, and not
possible to visualize others
at all?
Subject Contrast
An old term was
flat plate of the abdomen
Radiographic Anatomy of What is normally visible
the plain film abdomen
1. Liver
2. Spleen
3. psoas muscles
4. kidneys
5. flank stripes
6. bone (like crazy)
7. Calcifications
What is sometimes visible
1. Stomach and colon (gas)
2. Bladder (urine filled)
3. Arteries (calcified aorta)
What is not visible
1. Gallbladder
2. Pancreas
3. Small bowel (unless
pathological, with gas)
4. Ureters
5. Adrenal glands
6. Veins
7. Everything else
 Liver (homogeneous
shadow in RUQ)

Spleen

Stomach (c gas)

Parts of colon (c gas)

hepatic flexure

transverse colon

cecum & ascending colon

Gas, though natural,

is a negative contrast
media. In the history
of radiography, gas (air)
was injected in the bladder
and ventricles of the brain.
Carbonated soda is given
to children to create a
window to the kidneys
Radiographic Anatomy of the plain film abdomen
 Radiographic Anatomy of
the plain film abdomen Entire colon, from
cecum to sigmoid,
More Gas filled with gas.
Patterns Unless obstructed,
distention of this
degree should be
relieved by
flautulence

A childs stomach
and colon filled with
gas and feces, (speckled
appearance).

Note how the hepatic Gas filled transverse

flexure and transverse colon demonstrating
colon define the liver haustrations.
Detail of liver in RUQ Radiographic Anatomy of
the plain film abdomen
Detail of spleen in LUQ
Detail of flank stripe Detail of urine filled bladder Radiographic Anatomy
of the plain film
abdomen

Flank stripes are not

always seen due to
lack of contrast or
clipping on larger
persons.

When visible, bowing

of the stripes may
be a sign of a mass.

The bladder is
often seen, if
contrasted by
urine.

Gas in the
sigmoid colon
may obscure it
 Radiographic Anatomy of the plain
film abdomen

Kidneys
Subject contrast of the
kidneys is enhanced by the
perirenal fat capsule. They
are best seen in the asthenic
body habitus

= Psoas muscles
Placement of Rt marker is less than desirable
 Radiographic Anatomy of the plain
film abdomen
Calcifications
Calcifications can form
in various tissues, and
especially fluid filled
organs where minerals
consolidate. In the
plain film abdomen
those seen are:

* gallstones (calcium
not cholesterol)
* kidneystones
* bladderstones
Large gallstone in RUQ * arteriosclerosis
If not in the RUQ, where else could it be? (mostly of abdominal
aorta)
Anatomy Review: Where is it, or, at least, where should it be?
Radiographic Positioning of the Abdomen
 Positioning of:

AP KUB (flat plate of the abdomen)

Upright abdomen
seated or standing
Left lateral decubitus

including

Film Critique

Beginning with the routine KUB

Review the ARRT Standard Terminology
for Positioning and Projections
Standard KUB Positioning But first, when using the
bucky
1. Put the tube in detent
And leave it alone
2. Align the tube to the bucky
(longitudinally)
And leave it alone*
3. Put a film in the bucky, mark it, close the tray
And leave it alone
4. To position, float the table, move the patient, but
dont disturb steps 1-3
5. Shield

When positioning in lab, follow these steps. Someone will critique your efficiency

*If views in a routine require angles, do them last if possible.

Standard Abdomen Positioning
Preparation
1. Evaluate the order
2. Greet the patient
3. Take History
Plain film radiography of the abdomen
may be used to diagnose acute
abdomen, or provide preliminary
information for further studies.
Pertinent Hx includes:
Abdominal pain: chronic or acute,
location (quadrant or region). Times?
(i.e. after eating). Previous hx? Known
cause? Bloating, constipation, diarrhea.

4. Remove jewelry, check attire, snaps, pins, NG tubes, etc.

5. Explain the exam in laymans terms
6. Questions?
7. Set technique before positioning
Routine KUB Positioning Setup

1. 40 SID (relatively standard)

2. Reciprocating bucky
12:1, 16:1 grid

3. 70-80 kVp range

4. 14 x 17 film, lengthwise

5. ID marker at bottom

6. Rt marker above ID marker

Routine KUB Positioning Positioning

1. CR to iliac crest
2. Entire spine
straight
3. No rotation on hips
(check ASIS)

4. Arms away from sides (with sheet covering

patient, watch for wandering hands)
5. Exposure at end of respiration (hold it)
Film Critique for KUB film * Patient ID
* Rt/Lt, special marker
* Contrast & density
* Motion *
* Artifacts
Clipping: Superior ramus and
pubic symphysis must be
included.

Centering (left to right)

including

Rotation: Ala of ilium are

symmetrical. Vertebral bodies
are vertical (no side bending)
and not rotated.
* Peristalic activity may create
motion of the gas pattern.
KUB Positioning: 2 films method

When the patient is tall, two films

used lengthwise may be necessary.

When the patient is wide, two

transverse.

Note the overlap

as evidenced by
the iliac crest
Take first exposure of the pelvis.

After changing films, place finger on

top of light field, float table top
to the the upper abdomen collimated
field overlaps the previous field by
3 or 4 inches.
Non routine positions:

Upright abdomen
Left lateral decubitus
Dorsal recumbant decubitus
Routine Upright Positioning Setup and Preparation
Same as supine, expect upright.

And, patient must be in position

for at least 5 minutes prior to
exposure. Bring by WC if possible

Positioning
CR

4. 1. Same as KUB,
but center top
of film to axilla.
 Standard Upright Abdomen Positioning

What (else) does the upright

demonstrate?
1. Air-fluid levels in the
bowel
2. Free air in the abdomen
(peritoneal cavity) under the
diaphragm

Residual barium x 3 weeks

3. Ptosis (Change in position)

Might a change in technique be
called for on the upright?
Standard Upright Abdomen Positioning

Criteria: In addition to the

criteria for a supine KUB, the
upright film must demonstrate
lung tissue above the diaphragms

and plenty of it. Visualizing the pelvic

cavity to the symphysis is not criteria
Standard Left Lateral Decubitus Positioning
The left lateral
decubitus film is done
when the patient is unable
Flash marker to stand or sit.

Set up/Positioning
Same as for the upright, except
the grid film is in a film holder
(not a reciprocating bucky)
Check the patients
measurement. Too Lt flank
many double bacon
CR

Sponge cheeseburgers may

make it like this Rt flank

A horizontal beam projection to demonstrate free air, and air fluid levels.

A left lateral, and only a left lateral, is the decubitus position

because of the air bubble that is normally in the stomach
 Standard Left Lateral Abdomen Positioning

Whats the big deal with the stomach bubble?

To evaluate free air, it is important to not have the
stomach bubble under the flank stripe.

Rt side
Criteria: Mid portion
of the abdomen, along
the flank (not symphysis
or diaphram) visible.

Iliac crest

Stomach bubble
Dorsal decubitus (Rt or Lt) Abdomen Positioning
The dorsal
decubitus film is done when that
Flash marker position is all the patient is able
to tolerate, or for evaluation of
the aorta in arteriography

Set up/Positioning
Same as for the decubitus
CR
A horizontal beam projection
Sponge to demonstrate free air, and
CR

air fluid levels.

In the dorsal decubitus position free air layers out under the
anterior abdominal muscles. Air fluid levels, and the
abdominal aortic aneurysms may be seem, but due to part
thickness, this projection is not optimal.
Review of Abdomen film Critique On all films
Patient ID
Rt or Lt marker
The KUB film must demonstrate all anatomy within the Contrast & density
abdominal cavity Motion
Artifacts
The upright, left lateral decubitus, and dorsal
decubitus positions demonstrate free air, and air-fluid
levels.

The upright also demonstrates ptosis of the abdominal

organs.
 Exposure Factors
From the Rules of Thumb

Based on: 3 phase, 100 RS film, 12:1 grid, 40 SID

Abdomen/Pelvis

Frontal
(2 x cm) + 35 =kVp @ 50 mAs

Lateral (4x frontal)

(AP + 10 kVp @ 100 mAs

Oblique

(AP + 40% - 60% of frontal

technique
 Exposure Factors
From the Rules of Thumb

Based on: 3 phase, 100 RS film, 40 SID

Maternal Abdomen
On occasion a radiograph of the pregnant
abdomen is ordered during labor, to check
for a breech presentation.

Every radiology department should

have at least one high speed
film/screen system for this purpose.
What is required in terms of kVp and
mAs?
High kVp (110 or higher), low mAs.
 Exposure Factors
From the Rules of Thumb

Based on: 3 phase, 400 RS film, 40 SID

Calculate a maternal abdomen
technique for a 35 cm measurement

1. (2 x 35) + 35 = 105 kVp @ 50 mAs

2. 40 mAs / 4 = 12.5 mAs (film speed)

3. 15% of 105 = 16.5 =

Answer 121 kVp @ 6 mAs

Critique critera: For presentation, only

gross anatomy need be visualized.
Maternal abdomen films are rarely
repeated.
 Significant Pathologies or Pathologic Indicators
of the abdomen
and their
Radiographic Appearances

Mass Ascites

Institutional colon
Ileus

Pneumoperitoneum
An example of how the knowledge of the normal size, shape, and position
of abdominal anatomy is used to diagnose disease on a KUB.

This film demonstrates a bowing of the right psoas muscle, and increased
opacity. The diagnosis was abdominal aortic aneursym (AAA), unusual in
that it is on the right, rather than the left, where the aorta is.
Another example: size, shape, or position.

10 cm mass on the
right of midline
In the right lumbar
region
Normal variants If a mass is not pathologic, it may be an anomaly.

The detail in this LUQ shows anatomy not normally

seen there. Lateral to the kidney, only the stomach,
spleen, and colon are expected possibilities.
The radiologist determined this to be the
tongue of the liver (long tip of left lobe),
interposed between the spleen and splenic
flexure
Institutional Colon
Fecal stasis or fecal
impaction are terms that
describe what is commonly
called constipation.

Institutional colon in found in

bedridden, elderly patients,
whose eliminations
have not been monitored
 Air in the abdominal cavity,
Pneumoperitoneum (outside of the alimentary
tract) comes from perforated
Diaphragm viscus, a puncture wound, or
recent surgery.

Gastric or duodenal ulcers

can perforate and allow air
and stomach contents to
escape, leading to peritonitis

Liver

Stomach

In the upright position free air layers out under the

diaphragm. Large quantities may be obscured if
the top of the film is not high enough.
Free air
Stomach bubble
Ascites

Fluid accumulation in the

abdominal cavity, secondary
to serious disease.

Ascites creates a gray, low

contrast effect, and as in this
film, may make gas in the
bowel look trapped, or encased
by the extrinsic pressures from
the fluid.
 Ileus
An ileus is a failure of intestinal
contents to move through the
bowel, for reasons catagorized as

Mechanical ileus: caused by a

physical obstruction such as a
tumor, adhesions, volvulus
(twisting) intussusception
(telescoping), or hernia.

Dynamic ileus: muscular constriction

Adynamic ileus: lack of motility, paralytic

x Gallstone ileus
Postoperative ileus

Gas in the stomach, normal from aerophagia,

is relieved by eructation. Gas in the colon,
normal from the action of e-coli, is relieved
High grade mechanical obstruction. Gas by flatulence. Gas in the small intestine is
avoids pelvis indicating possible mass. pathological.
 Ileus
Gas in the colon, normal from the
action of e-coli, is relieved by
flatulence.

Gas in the small intestine is

pathological.

Mild to moderated ileus. In addition to distention of

the colon, note the gas pattern in the small bowel
 What in the World?

Miscellaneous, but significant, odds and ends

 Identifying ingested or inserted
What in the World? foreign bodies are another
use for the KUB film
What in the World?

Badmitton champion presents

with abdominal pain.

This Greenfield caval filter is in

the inferior vena cava for the
purpose of catching clots from
leg veins. If the filter were not
present, clots would travel to the
right heart, pulmonary artery, and
the arterioles of the lungs,
causing pulmonary embolism.

(Kidding about the badmitton)

 There is something odd
What in the World? about the gas pattern
In the area of the sigmoid
colon
And its shaped like a tooth
brush holder
What in the World?
Is this Melvin the
Moonman, or...

A Cheese Whiz
jar UTB
What in the World?

Illustration from The Compete

Idiots Guide to Home Medical
Treatment, or what?
The End
 Quiz 1

Name the 9 regions

of the abdomen
and pelvis
1 4 7

2 5 8

3 6 9
What can be visualized Y ( if needed to see) or N
Gas? Urine?

10. Spleen
11. Gallbladder
12. Adrenal glands
13. Stomach
14. Veins
15. kidneys
16. Colon (gas)
17. bladder
18. Pancreas
19. Ureters

Liver Y N N
Sm. Bowel Y Y N