Abdominal X ray

Abhishek V
Never trust a radiologist.

Abhishek V #128 Vijay doctors colony konanakunte Bangalore 62 9980579089

[Type the fax number] Abhishek V

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Key to not miss any diagnosis is systematic approach Checklist for systematic viewing of an AXR: 1.Technical assessment - (name, gender, age, date, view, side labelling; exposure, rotation, field of view) 2. Diaphragms - free air, pleural effusion 3. Liver - size, shape 4. Spleen - size, shape 5. Kidney, Ureter, Bladder - size, shape, calcifications 6. Uterus in females, prostate in males - calcifications 7. Psoas muscle - clear outlining 8. Bowel gas pattern - normal or abnormal 9. Abnormal extraluminal gas - free air, biliary system, portal venous system, bowel wall 10. Bones - osteoarthritis, fractures, metastasis, Paget's disease 11. Extra-abdominal fat and soft tissue - gas or calcifications 12. Calcifications - normal or abnormal 13. Artefacts - iatrogenic, accidental, projectional

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2. Look at the diaphragms

Are they raised or flattened? Are the costophrenic angles clear? Is there any air/gas in the stomach? Is there any free intra-abdominal air? (better to be judged if erect or decubitus)

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Difference of more than 3 cm between two diaphragms significant.

Stomach gas or pneumoperitoneum? Look at the thickness of left diaphragm normal diaphragm is 1-2mm when stomach wall included thickness >3mm.

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Above x ray on left u can see pneumoperitoneum with diaphragm and stomach wall separate thickness <3mm. 3. Look at the liver

Is enlarged? Is it shrunk? Is it displaced? Is there any air in the biliary tree or portal venous gas? Are there any signs for a Chilaiditi's syndrome (interposition of the colon between the right hemidiaphragm and the colon)? Are there any calcifications?

The liver is a soft tissue organ located in the right upper quadrant. The liver usually displaces the bowel preventing itself from overlying bowel/bowel gas. There may be, however, an interposition of the colon between the liver and the right hemidiaphragm, called Chilaiditi's syndrome, that may mimick free intra-peritoneal air under the right hemidiaphragm. As a normal variant you may also find an extension of the right liver lobe down to the right flank or iliac fossa, resembling a shark's fin, which is also called Riedel's lobe.

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X ray showing hepatomegaly.

Chiliaditi sign

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Portal vessel gas: in mesentric ischemia and pneumatosis intestinalis.

Air in biliary tree: gall stone ileus. Pneumobilia is commonly seen after biliary instrumentation but can be seen due to other causes such as Incompetent Sphincter of Oddi, Biliary enteric surgical anastomosis, Spontaneous biliary enteric fistula (Cholecystoduodenal ~70%), Infection(emphysematous cholecystitis), Bronchopleuralbiliary fistula (rare) and Congenital anomalies.

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4. Look at the spleen

Is it enlarged? Is it shrunk? Has it been removed? Are there any calcifications?

The spleen is a soft tissue organ located in the left upper quadrant. The size is usually comparable to the size of the patient's heart or fist and measures approximately three vertebrae in length diameter. It may be difficult to delineate this soft tissue organ due to overlying gas. In fact, mostly the spleen will not be visible at all. If splenic enlargement is greater than 15 cm displacement of adjacent organs may be caused. Enlargement of the spleen can be in medial but also in latero-inferior direction.

5. Look at the kidneys, ureter and baldder

Is there position normal? Are they enlarged or shrunk? Are there any calcifications? Is there a normal variant? (e.g. horseshoe kidney)

It may take some effort to detect the outline of the bean-shaped kidneys on a plain abdominal film. Usually, due to overlying gas, they cannot be delineated in their entirety completely. In relation to the thoracic and lumbar spine, they extend from T12 on the left side down to L3 on the right side. The left kidney is located slightly higher as compared to the right kidney. he left kidney is also slightly bigger (approx. 1.5 cm longer) than the right kidney. The upper poles of both kidneys are closer to the spine than their lower poles (approximately 12 degree angle compared to the spine, supero-medially down to infero-laterally). The kidneys are relatively mobile. They can move down with inspiration, and drop several centimetres in the erect position. If there is a full bladder it usually will be visible as a soft tissues density (water density equals soft-tissue density radiographically), and will be outlined by the perivesical fat. In particular in females a full bladder (up to 2 litres volume) may cause upwards displacement of the bowel loops, and may render the differentiation to a real tumour mass difficult. Therefore, if possible, the bladder should have been emptied before a plain abdominal film is taken.

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Renal calculi

6. Look for the uterus in female patients, and the prostate in male patients Rarely, the uterus may be visible on a plain AXR. But there may be an intrauterine contraceptive device (IUCD) or a calcified fibroid visible. If the uterus is visible it may be seen on top of the bladder, possibly identing the bladder. The prostate is deeply located in the pelvis. Usually the prostate becomes visible on a plain AXR when calcified.

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Prostatic calculi

7. Look for the psoas muscle

Are the lateral borders of the iliopsas muscles sharply demarcated or are they obscured?

The psoas muscle originates from the lumbar spine and extends downwards and inferolaterally before finally inserting on the lesser trochanters of the femora. Obscuration of the psoas muscle may allude to a pathological retroperitoneal process, e.g. retroperitoneal fluids/ascites, retroperitoneal haemorrhage/haematoma, retroperitoneal abscess, retroperitoneal tumour.

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NORMAL PSOAS SHADOW

Obliterated psoas shadow in retro peritoneal hematoma

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8. Look for the bowel gas pattern

Where are the bowel loops located (central vs. peripheral)? Is there too much intraluminal gas? What is the distribution of the gas in the abdomen? What is the intraluminal calibre of the small and large bowel? Are there any dilatations of the small and/or large bowel? Can you identify any air-fluid levels? Are there any areas of faecal loading

Look systematically at the whole gastrointestinal tact, starting with the stomach, via small bowel, caecum, ascendingcolon, hepatic flexure, transverse colon, splenic flexure, descending colon and sigmoid colon down to the rectum, provided that those are visble. Note that any gas on a normal AXR will belong to a part of the gastrointestinal tract. Remember that the transverse colon frequently drops down to the pelvis. Remember the normal intraluminal gas pattern

Stomach - small amount of gas Small bowel - very little amount of gas Large bowel - usually some gas, very variable, from almost none to large amount of gas

9. Look for abnormal extraluminal gas

Free intra-abdominal air Under the diaphragm - If extraluminal, consistent with free air on an erect or lateral decubitus view - If intraluminal, consider Chilaiditi's syndrome, i.e. the interposition of the colon between the right hemidiaphragm and the liver. In the biliary tree - Normal after sphincterotomy or biliary surgery - Otherwise pathological, e.g. due to fistula between the biliary tree and the intestine In the portal venous system - Always pathological Within the bowel wall

Remember: Gas in biliary tree is located more centrally projected on the liver as opposed to the more peripheral location of the portal venous gas.
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10. Look at the bones

Check bones for general bone density, cortical outline, trabecular pattern, joint and disc space, osteolysis, fracture, sclerosis, epiphyseal lines. Check for fractures, metastases (osteolytic, osteoplastic, absent pedicles) or degenerative changes in the lower rib cage, lumbar spine, sacrum, pelvis, ilio-sacral joints, hip joints. Check for Paget's disease Screen from superior to inferior.

The shape of the pelvis may allude to the patient's gender. Loss of bone density may indicate osteopenia due to osteoporosis, osteomalacia and Rickets (vitamin D deficiency) or hyperparathyroidism.

11. Look at the extra-abdominal fat and soft tissues/muscles

Is there any gas or calcification indicating e.g. subcutaneous emphysema, abscess, calcified injection sites, in particular in the area of the buttocks.

12. Check for calcifications in the following areas:

Cartilage of ribs Gallbladder Pancreas Kidneys , ureter and bladder Intra-abdominal arteries, predominantly the aortoiliac , mesenteric and renal arteries Pelvis (most commonly phleboliths ).

Normal calcifications

Costal cartilage Mesenteric lymph nodes: - Usually they are oval shaped, granular opacities in the mesentery. - They appear to be quite mobile and change position if you acquire several AXRs at several points of time. - Sometimes they may be confused with and need to be differentiated from renal or ureteral calculi.
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Pelvic phleboliths ('Lithos' is Greek and means stone): - They usually appear as small round opacifications in the pelvis some of which can also be more transparent centrally. - They represent calcified pelvic veins. - There can be one or several of those venous stones in the pelvis. - There is no known clinical significane to them. However, they may be confused with ureteric or bladder calcifications necessitating an intravenous urogram (IVU), also referred to as KUB (Kidneys, Ureters and Bladder), or a computed tomography (CT) or Magnetic Resonance (MR) urogram may be necessary to rule out ureteric or bladder calculi. Prostate gland: - Calcifications can occur in the prostate, in particular in the elderly. - The calcifications are usually benign but may also accompany malignant processes in the prostate.

Abnormal calcifications

Gallbladder: - Radiographically gallstones are visible in 10-20% of cases only. Ultrasound would be superior to an AXR to rule out gallstones. - A porcelain gallbladder may result from several episodes of cholecystitis that, in turn, may become malignant (11%). Pancreas: - Calcifications indicate chronic pancreatitis. - The pancreas lies across the midline at the level of the vertebrae T9 to T12.
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Renal parenchymal tissue: - Calcifications indicate diseases such as medullary sponge kidney, renal tubular acidosis and hyperparathyroidism. Renal pelvic and ureteral system: - Single and multiple calcifications may be visible as well as staghorn calculi ; filling the calices and renal pelvis and obstructing the ureter. - The most frequent locations for ureteral calculi are the pelvi-ureteric junction, brim of the pelvis, and vesico-ureteric junctions. Bladder: - Usually bladder calculi are quite large and multiple. - Rarely, a bladder tumour may show calcifications too. Blood vessels and vascular aneurysms (aortoiliac arteries (Fig. 10)): - Over the age of forty, usually some calcifications in the aorto-iliac arteries can be seen. Premature calcifications can allude to underlying diseases such as diabetes or chronic renal failure. - Look over the lumbar spine for speckles of linear opacifications, sometimes running in parallel, resembling railway tracks. - Aorta can be elongated and tortouous, bending to the right or to the left of the spine (without evidence of an aneurysm). Splenic artery : - Calcifications of the splenic artery may resemble a 'Chinese dragon' due to the tortuous course of the splenic artery to the splenic hilum. Mesenteric arteries Tumours: - Uterine fibroid - Ovarian teratoma

Vascular calcifications may allude to atherosclerotic lesions, frequently associated with the metabolic syndrome (high blood pressure, diabetes, obesity, elevated serum triglycerids, dyslipoproteinaemia), and overall morbidity.

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Pancreatic calcification

Staghorn calculi

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Aortoiliac calcification

13. Look for artefacts

Artefacts e.g. surgical clips, interuterine contraceptive device, renal or biliary stents, endoluminal aortic stent, or inferior vena cava filter. Projectional , i.e. objects are projected into the abdomen but, in fact, lie in front of or behind the abdomen, e.g. pyjama buttons, coins in pockets, body piercings.

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Now lets come to the main part surgeon stuff

The small bowel has a wall pattern that is known as valvulae conniventes (white arrow). The muscular bands encircling the small bowel are usually seen to traverse the bowel wall at right angles to the long axis of the bowel

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The large bowel wall features pouches or sacculation that protrude into the lumen that are known as haustra(black arrow .In between the haustra are spaces known as plicae semilunaris- white arrow (semilunaris refers to their semi-lunar shape).

The abdominal cavity has a lining of fat of variable thickness known as the properitoneal fat. This is often seen as a fat density stripe along the lateral wall of the abdomen on an AP abdominal plain film(white arrow).

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Abdomen is gasless or featureless

A gasless abdominal plain film refers to an absence or minimum of gas in the gastrointestinal tract. A featureless abdominal plain film is one in which there is little or no visualisation of the normal abdominal viscera. The Gasless Abdominal Plain Film Gas in the gastrointestinal tract can commonly accumulate from two sources. Firstly, gas in the stomach and small bowel can be ingested with food. Some patients habitually air swallow or may air-swallow when in pain. Gas in the large bowel can be endogenous, resulting from fermentation processes of faecal material. An absence of gastrointestinal gas on abdominal plain film is not specifically abnormal (but is suspect). However, consideration should be given to the possibility of a gasless obstruction. Equally, a check of the patient history may reveal relevant information such as total colectomy. Causes A gasless abdomen could indicate Patient is not an air-swallower Mesenteric ischaemia Obstruction of the stomach or oesophagus Persistent vomiting from conditions such as pancreatitis or gastroenteritis

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This patient has a gasless rather than featureless abdomen. Note that the renal, liver, psoas muscles and urinary bladder outlines are visualized

This appearance is a gasless small bowel obstruction and the opaque looking small bowel loops (white arrow) are filled with normal succus entericus, and/or ingested fluid

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The normal abdominal viscera are not demonstrated. Apart from the prominent bowel, the abdomen is featureless. The cause of this appearance is a large quantity of ascites. Note that the liver, spleen, kidneys, psoas and urinary bladder outlines are not seen. The reason that the bowel is somewhat centrally located is that it isfloating in the ascites.

This is more likely to be tumour than blood or ascites Bowel loops look more like they are pushed down by tumour(s) rather than floating in fluid

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The supine abdominal plain film demonstrates a featureless pattern. There are no clearly defined psoas, kidneys or spleen. A CT abdominal scan revealed extensive laceration of his left kidney and spleen.

Normal bowel characteristics Characteristic Position Stomach Small Bowel Large Bowel circumferential- the large bowel tends toframe the small bowel

Left Upper Quadrant Central abdomen Fundus directly under left hemidiaphragm obliquely orientated attached to transverse colon via gastro-colic ligament (variable in length) fluid and air fluid-like succus entericus and air Can have a random faceted/tessellated appearance when airfilled (but not dilated).

Contents

faeces of variable consistency from liquid to hard formed Haustral folds interspaced with Plicae semilunaris

Mucosal/Wall Pattern

Rugal folds (can be effaced if distended)

Encircling valvulae

Wall pattern can be effaced if distended

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conniventes visible depending on degree of air filling/distention.

Valvulae conniventes more widely spaced in ileum

Wall pattern can be effaced if distended Size Variable Up to 30mm Up to 50-60mm Up to 90mm for the caecum

The stomach can be equally characteristic in its appearance on an erect abdominal plain film. The often smoothly radiused contour of the airfilled gastric fundus under the left hemidiaphragm and the characteristic air-fluid level make for easy identification.

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The Small Bowel Normal Gasless Small Bowel

Normal Air-filled Small Bowel The appearance of the small bowel visualised in the left iliac fossa is a result of normal air swallowing (white arrow). The bowel diameter has been measured at 30mm which is the upper limit of normal. This patient is likely to be in pain and is therefore more likely to air-swallow resulting in this appearance. The appearance has been likened to crazy paving or the pattern on a giraffe. It appears as an interlocking, random, tessellated pattern.

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Moderately Dilated Air-filled Small Bowel

The small bowel demonstrated in this image is moderately dilated (36mm). There is evidence of loss of the normal random tessellated pattern associated with undilated air-filled small bowel. Instead, the bowel is showing signs of a pattern which is more organised rather than random. There are, for example, multiple loops of small bowel which have become aligned or parallel. This appearance is typical of an early small bowel obstruction or a partial small bowel obstruction.

Severely Dilated Air-filled Small Bowel (Coiled Spring Sign) The coiled spring appearance only occurs in dilatedair-filled small bowel. It also is most noticeable in the jejunum where the valvulae conniventes are tightly spaced.

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String-of-Pearls Sign The curvi-linear arrangement of air bubbles visualised on this image is known as the string of pearls sign. The appearance is considered to be diagnostic of obstruction (as opposed to ileus) and is caused by small bubbles of air trapped in the valvulae of the small bowel

A similar appearance is sometimes seen in the large bowel but can usually be differentiated by the fact that the gas bubbles are larger and have flat under-surfaces.

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The Large Bowel Haustral Pattern

The air-filled large bowel commonly features a haustral pattern as shown. The haustral folds are thicker than the valvulae conniventes of the small bowel. They also commonly do not appear to completely traverse the bowel. This distinction is unfortunately unreliable- air dilated large bowel can have a haustral pattern that does traverse the bowel. Furthermore, in some cases, the haustral pattern can be lost completely. The large bowel will normally contain air. This is air produces partly from fermentation processes within the large bowel. The transverse colon and sigmoid colon are the least dependent segments of the large bowel in the supine position and will tend to fill with air.

Feces in large bowel..

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The Large Bowel String of Pearls Sign

The large bowel has its own version of the small bowel string of pearls sign. Because the plicae semilunaris of the large bowel are larger than the valvulae of the small bowel, the pockets of air tend to be larger. Also, because they are larger in the large bowel, surface tension is unable to render them completely round- instead they tend to have a flat underside. They look more like a string of air-fluid levels. One of the functions of the large bowel is to absorb water from the faecal content. The faeces should not be able to form an air/fluid level by the time it gets to the splenic flexure. An extensive arrangement of these small air/fluid levels in the large bowel may simply indicate that the patient has diarrhoea.

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The large bowel (white arrows) can be seen to frame the abdomen. The prominent air-filled ileum (black arrow) occupies a more central location within the peritoneal cavity. These distribution features can be helpful in differentiating large bowel from small bowel.

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Normal Variation of Large Bowel Distribution This patient's transverse colon (white arrow) dips low into the pelvis. Note the characteristic haustral pattern of the large bowel.

Dilated Sigmoid Colon The dilated sigmoid colon is often difficult to positively identify. This patient has dilated colon which is sited mid to low abdomen. The maximum diameter is 88mm. Small bowel rarely dilates to more than 50mm. The position, size and ambiguous wall pattern suggest that this is dilated sigmoid colon.

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The Gastrocolic Ligament The gastrocolic ligament is the major apron-like part of the greater omentum which attaches the stomach to the transverse colon. Unfortunately, this ligament can vary in length up to 15cm. Despite this variable length, if you can identify the greater curve of the stomach, you can hazard a reasonable approximation of where the transverse colon should be.

This patient has a dilated stomach which has been treated with a naso-gastric tube. The transverse colon can be seen to be following the greater curve of the stomach.

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Generalised Adynamic Ileus The appearance of generalised adynamic ileus on plain film is quite characteristic . The large and small bowel are extensively airfilled but not dilated. With air in rectum.

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Reflex Ileus Reflex ileus refers to a secondary ileus in response to some type of insult. The causes of reflex ileus are numerous including abdominal inflammations and infections, chemical and pharmacological causes, trauma and abscess.
X ray shows reflex ileus secondary to renal calculi

Localised Ileus (Sentinel Sign) This patient has a segment of inflamed transverse colon (white arrow). The cause of the inflammation is unknown but would be typical of ulcerative colitis or Crohn's disease. This appearance is known as "thumbprinting". Just inferior to the diseased segment of colon are a few prominent air-filled loops of jejunum. It is possible that this is localised ileus of the jejunum associated with the diseased colon. This is known as "sentinel sign".

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Plain Film Signs of Pneumoperitoneum

The plain film signs of pneumoperitoneum are well established in the literature as follows 1 Anterior Subhepatic Space Air 2 3 4 5 6 7 8 9 10 11 12 Doges Cap Sign (free Air in Morrison's Pouch) Air Anterior to Ventral Surface of Liver Riglers sign on supine AXR (also known as double-wall or bas-relief sign) Falciform Ligament Sign The football sign The cupola. Air accumulation beneath the central tendon of the diaphragm Continuous diaphragm sign The triangle- air trapped between three loops of bowel Air under diaphragm on erect cxr Air outlined against liver/flank on decub AXR Otherdiaphragmatic muscle slips, ligamentum teres air, Double Gastric Fundus sign, The Inverted-V sign, Scrotal air Abscess Gas Pneumoretroperitoneum

13 14

RUQ/liver signs on supine AXR There are 3 separate signs of free air around the liver as follows.

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Pneumoperitoneum: Importance of Right Upper Quadrant Features 1. Anterior Subhepatic Space Free Air (RUQ sign 1)

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Anterior subhepatic space free air tends to be vaguely linear in shape (arrowed). A visible medial border of the liver is often seen outlined by fat. A careful examination of this image (left) shows the arrowed density to be air density rather than fat density.

Pneumoperitoneum: Importance of Right Upper Quadrant The differentiation between fat and air density becomes easier Features with experience. This image of normal fat surrounding the liver shows a consistent density continuous with the properitoneal fat stripe.

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2. Doges Cap Sign (RUQ sign 2) Doges Cap sign refers to free air in Morrison's pouch. Morrison's pouch is normally a potential space between the right kidney and the liver. This is a particularly difficult sign of pneumoperitoneum for several reasons. Firstly, it may be the only sign of pneumoperitoneum and may be very subtle. Secondly, it can be easily misinterpreted as gas in the duodenum. Gas in Morrison's pouch may have the following features

Triangular in shape concave medial border positioned inferior to the right 11th rib positioned superior to the right kidney

Pneumoperitoneum: Importance of Right Upper Quadrant Features

This sign is known as Doges Cap sign. The Italian Doges wore this distinctively shaped cap. Gas in Morrison's pouch is only loosely shaped like a Doges cap and should not be taken too literally. Bear in mind that the "triangle Sign" was already taken!

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Morrisons pouch free gas demonstrated on supine Radiographs typically show the following Characteristics 1.Typically triangular shaped 2.The lower lateral corner is commonly sharp 3.The lateral border is typically concave and outlines the medial border of the liver 4.It is positioned inferior to the 11thrib 5.It is positioned superior to the right kidney

3. Air Anterior to Ventral Surface of Liver(RUQ sign 3)

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Air sitting against the ventral surface of the liver can be any shape and, as in this case, is frequently "geographical" in shape. The liver is a homogenous organ and should be homogenous in density on plain film. If the liver is seen to demonstrate an uneven density, pneumoperitoneum should be considered. Note also Rigler's sign

4. Decubitus Abdomen Sign

This patient is in the left lateral decubitus position. It is conventional in radiography to mark the side the side that is up. There is evidence of free air between the abdominal wall and the liver (white arrow). There is also evidence of free fluid in the peritoneum (black arrow).

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5. Riglers Sign on supine AXR Rigler's sign is named after Leo G. Rigler. The sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air (arrowed). The extraluminal air is free peritoneal gas.

6. Falciform Ligament Sign The falciform ligament connects the anterior abdominal wall to the liver. The ligament continues to extend inferiorly beyond the liver where it becomes the round ligament (white arrow). Given that the falciform ligament is situated against the anterior abdominal wall, it is not surprising that it becomes outlined with air in a supine patient with free abdominal gas.

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7. The football sign The football sign likens the massively airfilled peritoneum to an American football. To extend the simile a little further, the falciform ligament has been likened to the seam in the football, and the rarely seen medial and lateral umbilical ligaments are likened to the football laces. This neonatal patient has massive pneumoperitoneum and could reasonably be said to display football sign. There is also falciform ligament sign, Rigler's sign and air in the scrotum.

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8. Continuous Diaphragm Sign Another manifestation of massive pneumoperitoneum is the continuous diaphragm sign. Where there is sufficient air beneath the diaphragm, the continuous nature of the diaphragm is demonstrated. Note that the left and right hemidiaphragms contrasted by the free gas appear as a continuous structure.

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9. Double Bubble Sign

The double bubble sign is an appearance of subdiaphragmatic gas under the left hemidiaphragm in which there are two collections of overlapping gas- one of these collections is subdiaphragmatic free gas and the other is normal gas within the fundus of the stomach. Note that the diaphragm (black arrow) is a thinner walled structure than the stomach wall (white arrow). This distinction is sometimes useful in distinguishing between the two structures. Note also free subdiaphragmatic gas under the right hemidiaphragm

10. The Cupola Sign. The Cupola Sign refers to an air accumulation beneath the central tendon of the diaphragm (white arrows)

The term cupola comes from a dome such as this famous dome of the Duomo in Florence.
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11. Lesser Sac Gas This image of free gas has a cupola sign (white arrows) and a lesser sac gas sign (black arrows). The lesser sac is positioned posterior to the stomach and is usually a potential space. There is free connection between the lesser sac and the greater sac through the foramen of Winslow.

12. The Triangle Sign The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)

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12. The Others Sign Notes

Leaping Dolphins Air under hemidiaphragm and diaphragmatic muscle slips visible Sign Urachus Sign Air contrasted urachus. Appears as vertical line between bladder and umbilicus. Outline of medial umbilical ligament

The Inverted V " in infants the inverted V is undoubtedly caused by the large umbilical Sign arteries, in adults I believe it is the inferior epigastric vessels that produce the inverted V sign. Air in the Fissure Air in the Fissure for the Ligamentum Teres. May appear in isolation. for the Appears as a lucent vertical stripe over liver Ligamentum Teres Coronary Ligament Outlined by Air Pneumo-gall bladder The coronary ligament is sited anterior to the liver.

Air in the gall bladder fossa outlining the gall bladder

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14. Pneumoretroperitoneum This patient has free air in the retroperitoneal space. The air is seen surrounding the lateral border of the right kidney (white arrow). There is other evidence of free gas including Rigler's sign. If you are not confident that the appearance is pneumoretroperitoneum, you can try an erect and decubitus view to see if the gas moves. If the gas is seen to move, it's not in the retroperitoneum.

It is useful to be able to distinguish between the appearance of air under the right hemidiaphragm, colonic interposition and pneumothorax.

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Leaping dolphin sign. Air under hemidiaphragm and diaphragmatic muscle slips visible

This paient has a pneumothorax. The right hemidiaphragm contrasted with air in the pleural space resembles the liver contrasted with free air in the peritoneum
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This appearance of colonic interposition does bear some similarity to the appearance of pneumoperitoneum.The white arrowed structure is probably a haustral marking and the black arrowed structure is diaphragmatic

Always get a left lateral when in doubt

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The 3,6,9 Rule The maximum diameter of the bowel is shown below Maximum Normal Diameter small bowel large bowel caecum 30mm 50-60mm 90mm

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Geometric Magnification Issues Geometric Magnification of Small Bowel (exaggerated)

The 3,6,9 rule is for uncorrected measureme nts. The error associated with an uncorrected measurement is usually not a problem. Where it can be a problem is in morbidly obese patients where the small bowel is situated close to the LBD/focal spot. If you perform erect abdominal images PA rather than AP you may identifying small bowel affected by geometric enlargement demonstrated on the supine image

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Bowel obstruction

High-grade SBO. Plain abdominal radiograph shows multiple air-fluid levels (arrows), some with a width of more than 2.5 cm. In addition, there is a differential vertical height of more than 2 cm between corresponding air-fluid levels in the same bowel loop (circled area). There is also distention of the small bowel diameter to more than 2.5 cm and a small bowelcolon diameter ratio of greater than 0.5

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Slit/Stretch Sign

This patient has a small bowel obstruction. Apart from the solitary air-filled dilated central loop of small bowel, there is also evidence of slit sign or stretch sign (white arrows). Slit sign is a result of small amounts of air caught in the valvulae of fluid-filled bowel. The subtle fluid filled loops of small bowel and the slit sign are highly suggestive of small bowel obstruction. This appearance is deserving of an erect abdominal projection. This patient had one of the best string of pearl signs you will ever see!

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Even a single dilated bowel loop > 10 cm is obstruction.

Dilated bowel with parallel patterning in obstruction

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Large bowel obstruction.

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Caecal and Sigmoid Volvulus Caecal Volvulus

Sigmoid Volvulus

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Caecal Volvulus Uncommon caecum is characteristically relocated to the mid-abdomen or left upper quadrant accompanying SBO is rare characteristically, the walls are smooth and the haustra are preserved Persistent dilated distal colon is rarely seen

Sigmoid Volvulus extends into the right upper abdomen to T10 or higher The colon proximal to the twist distends The rectum usually empties Gas distended sigmoid usually shows Coffee bean sign in common with other closed loop obstructions At the point of the twist a barium enema demonstrates a characteristic beak-like termination

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Cecal volvulus

Sigmoid volvulus

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Plain Film Signs of Appendicitis

Sign Appendicolith

Comment Also known as coproliths, fecaliths and stercoliths Appendicoliths are common Can appear in various locations with variation in location of the appendix Not all appendix stones are calcified This is not necessarily a sign of appendicitis- can be seen in the normal appendix There can be a general increase in opacity in the right lower quadrant associated with an appendiceal abscess Can also be seen as bubbles of gas in the abscess Seen as dilated caecum Separation of the bowel from the right flank stripe by the lateral accumulation of pus and ascites Reflex ileus Scoliosis of lumbar spine

Gas in Appendix Abscess RIF mass Caecal Ileus Flank Sign SBO Scoliosis

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Appendicolith

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Dilated caecum in appendicitis

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Localised small bowel ileus in appendicitis.

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