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Interpretasi

Foto Abdomen
Mashuri
Department of Radiology Faculty of Medicine
University of Lambung Mangkurat/
Ulin Hospital, Banjarmasin
GI Imaging
 Konvensional: BNO, BNO 3 Posisi
 Konvensional + Kontras: OMD, Esophagography, Colon in loop,
Cholangiography, BFT, Appendicogram
 USG Abdomen
 CT scan
 Angiography
 MRI 1.5 T abdomen (0.3T yang ada saat ini)
Terminologi

 Foto Abdomen AP = BNO (supine)


 BNO (Blass Nier Overzicht)
 Foto Abdomen 3 posisi:
 Foto Abdomen Supine (supine)
 Foto Abdomen Erect/semierect
 Left Lateral Decubitus
ABDOMEN PRESENTATION BY SUDIL 11/15/18
Evaluasi Foto

 Verifikasi
 Validasi
 Interpretasi
 Verifikasi
 Nama/Usia/Jenis
kelamin
 Tanggal
 No MR
 Validasi (Acceptabel criteria)
 Penetrasi: psoasmuscle
dan proc transversus
lumbar spine tervisualisasi
kanan dan kiri, lumbar
spine jelas
 Rotasi: no rotasi, 2 pelvic
wing kanan dan kiri
simetris
 End thoraces, costae 2
terakhir harus terlihati
 Margin: liver margin dan
ren terlihat sesuai usia
 Inferior: simfisis pubis
terlihat (bila
memungkinkan)
 Validasi (Acceptabel criteria)
 Penetrasi: psoasmuscle
dan proc transversus
lumbar spine tervisualisasi
kanan dan kiri, lumbar
spine jelas
 Rotasi: no rotasi, 2 pelvic
wing kanan dan kiri
simetris
 End thoraces, costae 2
terakhir harus terlihati
 Margin: liver margin dan
ren terlihat sesuai usia
 Inferior: simfisis pubis
terlihat (bila
memungkinkan)
Interpretasi

 Intraluminal gas
 Extraluminal gas
 Calcification
 Soft tissues
 Bones
Interpretasi
BNO/BNO 3 posisi
 Tampak distribusi gas berlebih
dalam smallbowel/largebowel
dengan dinding menebal………..
 Tampak distribusi gas bowel
normal
 Pada foto Erect dan LLD: tampak
air fluid level, udara bebas
subdiafragma
 Tak tampak / tampak konkremen
opak atau calcified density di
daerah……
 Tak tampak osteofit
 Intraluminal
gas
 Extraluminal gas
 Calcification
 Soft tissues
 Bones
Normal Intraluminal Gas

 Stomach : Always
 Small Bowel : Two or three loops of non-
distended bowel
 Normal diameter < 3.5 cm (jejunum)
 Normal diameter < 2.5 cm (ileum)
 Large Bowel : Almost always in
rectum/sigmoid
 Normal diameter < 5 cm (colon)
 Normal diameter < 9 cm (caecum)
Stomach gas

Gas in
ascending
colon Gas in a few
loops of small
bowel

Gas in
rectum
Large or small bowel?

Small Bowel Large Bowel

 Peripheral
 Centrally placed
 Only a few loops
 Narrow angle of
 Mucosal folds only cross part of
curvature the bowel width (haustra)
 Multiple loops
 Mucosal folds cross the
full width of the bowel
(valvulae conniventes)
Small Bowel

Mucosal folds
go all the way
across
Large Bowel
The retroperitoneal structures of the colon :
ascending colon,
descending colon, and
rectum are relatively constant in position.

Transverse colon or sigmoid colon which are more variable in position.


 Intraluminal gas
 Extraluminal
gas
 Calcification
 Soft tissues
 Bones
Extraluminal Gas

 Invariably abnormal

 Exceptions
 Recent laparotomy / laparoscopy (<5 days)
 Gas in biliary tree after biliary intervention

 Only seen if large (>1 litre) amount of gas


BNO (Supine)

 Riglers sign
 Football sign
 Falciform lig sign
Rigler’s Sign
Bowel wall visualised on both sides due to intra and extraluminal air
Usually large amounts of free air
May be confused with overlapping loops of bowel, confirm with
upright view
Can see both sides of
the bowel wall

Gas outlining
peritoneal cavity
Football SIgn

Seen with massive


pneumoperitoneum

Most often in
children with
necrotising
enterocolitis
In supine position
air collects
anterior to
abdominal
viscera

Paediatric
Adult
Falciform ligament sign
Normally
invisible.

Supine film,
free air rises
over anterior
surface of
liver
 Intraluminal gas
 Extraluminal gas
 Calcified
density
 Soft tissues
 Bones
 Foreign objects
 Periphery of film
Normal structures that Abnormal structures
calcify containing calcium

Costal cartilage Pancreas


Mesenteric lymph nodes Blood vessels/aneurysms
Pelvic vein clots (phleboliths) Uterine fibroids
Prostate gland Calculi:
• Biliary
• Bladder
• Renal
Costal cartilage
Mesenteric LN
Phlebolith
Prostatic calcif
Pancreatitis
Pancreatic
calcification
Aorto-iliac calcif
Calcified
Aortic
Aneurysm
Chinese Dragon Sign

Calcified splenic
artery
Fibroid
Renal calculi
Calculi also within left ureter
Staghorn Calculi
Bladder calculi
Calcified gallstones
 Intraluminal gas
 Extraluminal gas
 Calcification
 Soft tissues
 Bones
Soft Tissues

 AXR relatively insensitive unless very large enlargement


 May see bowel displacement
 Foreign body
 Periphery
Bowel loops displaced

Large pelvic mass


2 hours
later
….after bladder
catheterisation
Foreign objects (med
instrumentation)
 Sterilisation Clips
 Should both lie in the pelvis
 Surgical Clips
 Cholecystectomy
 Hip prostheses
 Retained swabs / needles very rare
Periphery of Film

 Lung bases
 Hernial orifices
 Subcutaneous tissues
Small and large bowel obstruction

Strangulated right inguinal


hernia
 Intraluminal gas
 Extraluminal gas
 Calcification
 Soft tissues
 Bones
Bone

 Jumlah tulang v lumbal


 Normal 5 buah
 Jumlah v lumbal =6Lumbalisasi
 Jumlah v lumbal = 4 sacralisasi
 Scoliosis
 Osteofit
Clue : 77 year old with known colon cancer and
lower back pain
3 Way Abdomen Series

 Supine (BNO)
 Erect/semierect
 Left decubitus (LLD)

• Supine (BNO)
• Erect/semierect
• Chest erect
2 Way Abdomen Series

 Supine (BNO)
 Erect/semierect

• Supine (BNO)
• LLD
BNO (Supine)

 Looking for
 Scout film for gas pattern
 Calcifications
 Soft tissue masses
 Substitute – none
Erect

 Looking for
 Free air
 Air-fluid levels
 Substitute – left lateral decubitus
BNO-ERECT
Erect Chest

 Looking for
 Free air
 Pneumonia at bases
 Pleural effusions
 Substitute – supine chest
BNO-LLD
Abnormal Gas Patterns

Paralitik
 Localized ileus
 Generalized ileus (paralitik)
Obstruktif
 Mechanical SBO
 Mechanical LBO
Important Points

 Look for air in the rectum/sigmoid first


 Identify the most dilated loops-are they large bowel or small bowel?
 Sentinel loops are 1-2 dilated loops of small bowel
 Generalized adynamic ileus almost always occurs in immediate post-op
patients
 Always correlate the clinical findings with imaging findings
Localized Ileus

 One or two persistently dilated loops of large or small bowel


 Gas in rectum or sigmoid
Supine Prone

Sentinel Loops
Sentinel Loops
Cholecystitis Pancreatitis
Ulcer

Appendicitis Diverticulitis

Ulcer
Ureteral calculus
Generalized Ileus

 Gas in dilated small bowel and large bowel to rectum


 Long air-fluid levels
 Only post-op patients have generalized ileus
 small intestine: 0-24 hours 
 stomach: 24-48 hours
 colon: 48-72 hours
Supine Erect

Generalized Adynamic Ileus


Mechanical SBO

 Dilated small bowel


 Fighting loops
 Little gas in colon, especially rectum
 Key: disproportionate dilatation of SB
Mechanical SBO
Causes

 Adhesions
 Hernia*
 Volvulus
 Gallstone ileus*
 Intussusception

*Cause may be visible on plain film


SBO
Mechanical SBO
Pitfalls

 Early SBO may resemble localized ileus -get F/O


BNO
LLD
Mechanical LBO

 Dilated colon to point of obstruction


 Little or no air in rectum/sigmoid
 Little or no gas in small bowel, if…
 Ileocecal valve remains competent

• Incompetent ileocecal valve


▫ Large bowel decompresses into small bowel
▫ May look like SBO
▫ Get BE or follow-up
Mechanical LBO
Causes

 Tumor
 Volvulus
 Hernia
 Diverticulitis
 Intussusception
LBO
Supine Prone

Carcinoma of Sigmoid – LBO – Decompressed into SB


Distinction between SBO and LBO

Small bowel Large bowel


Haustra Absent Present
Valvula conniventes Present in jejenum Absent
Number of loops Many Few
Distribution of loops Central Peripheral
Radius of curvature of loop Small Large
Diameter of loop 30-50 mm 50 mm+
Solid faeces absent May be present

Greinger,Allison. Diagnostic Radiology


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