3. Approach to AXR
• Bowel gas pattern
• Extraluminal air
• Soft tissue masses
• Calcifications
4. Normal AXR
11th
rib
Hepatic flexure
Gas in
stomach
T12
Gas in caecum
Iliac crest
Femoral head
SI joint
Gas in sigmoid
Transverse colon
Splenic flexure
Psoas margin
Sacrum
Left kidney
Liver
Bladder
5. Gas pattern
• Stomach
– Almost always air in stomach
• Small bowel
– Usually small amount of air in
2 or 3 loops
• Large bowel
– Almost always air in rectum
and sigmoid
– Varying amount of gas in rest of large bowel
What is normal?
6. Normal fluid levels
• Stomach
– Always (upright, decub)
• Small bowel
– Two or three levels
acceptable (upright, decub)
• Large bowel
– None normally
(functions to remove fluid)
7. Large vs small bowel
• Large bowel
– Peripheral (except RUQ occupied by liver)
– Haustral markings don’t extend from wall to wall
• Small bowel
– Central
– Valvulae conniventes extend across lumen and are
spaced closer together
8. Radiographic principles
Series of films for acute abdomen
• Obstruction series/ Acute abdominal series/
Complete abdominal series
– Supine (almost always)
– Upright or left decubitus (almost always)
– Prone or lateral rectum (variable)
– Chest, upright or supine (variable)
9. VIEW LOOK FOR
SUPINE ABDOMEN Bowel gas pattern
Calcifications
Masses
PRONE ABDOMEN Gas in rectosigmoid
Gas in ascending and
descending colon
UPRIGHT ABDOMEN Free air, air-fluid levels
UPRIGHT CHEST Free air, lung pathology
secondary to intraabdominal
process
Acute abdominal series
What to look for
Substitutes: Prone Lateral rectum
Upright Left lateral decub
Upright chest Supine chest
10. Obtaining views
• Supine
– Patient on back, x ray beam directed
vertically downward, casette
posterior, x-ray tube anterior (AP)
• Prone
– Patient on abdomen, x-ray beam
directed vertically downward, cassette
anterior, x-ray tube posterior (PA)
• Upright
– Patient stands or sits, x-ray beam
directed horizontally, cassette
posterior, x-ray tube anterior (AP)
• Upright chest
– Patient stands or sits, horizontal x-ray
beam, cassette anterior, x-ray tube
posterior (PA) 1900s X-Ray-based fluoroscopy machine
in which radiation is shot directly through
the patient and into the doctor’s face.
11. Abnormal Gas Patterns
• Functional ileus
– One or more bowel loops become aperistaltic usually
due to local irritation or inflammation
• Localised “sentinel loops” (one or two loops)
• Generalised (all loops of large and small bowel)
• Mechanical obstruction
– Intraluminal or extraluminal
• Small bowel obstruction
• Large bowel obstruction
12. 3, 6, 9 RULE
Maximum Normal Diameter of bowel
Small bowel 3cm
Large bowel 6cm
Caecum 9cm
13. Localised ileus
Key features
• One or two persistently dilated
loops of small or large bowel
(multiple views)
• Often air-fluid levels in sentinel
loops
• Local irritation, ileus in same
anatomical region as
pathology
• Gas in rectum or sigmoid
• May resemble early SBO
14. Causes of Localised Ileus
by location
SITE OF DILATED LOOPS CAUSE
Right upper quadrant Cholecystitis
Left upper quadrant Pancreatitis
Right lower quadrant Appendicitis
Left lower quadrant Diverticulitis
Mid-abdomen Ulcer or kidney/ureteric calculi
15. Colon cut off sign
Explanation:
Inflammatory exudate in acute
pancreatitis extends into the
phrenicocolic ligament via lateral
attachment of the transverse
mesocolon
Infiltration of the phrenicocolic
ligament results in functional
spasm and/or mechanical
narrowing of the splenic flexure at
the level where the colon returns
to the retroperitoneum.
Abrupt cutoff of colonic gas column at the splenic flexure (arrow). The colon is
usually decompressed beyond this point.
16. Generalised ileus
Key features
• Entire bowel aperistaltic/hypoperistaltic
• Dilated small bowel and large bowel to rectum
(with LBO no gas in rectum/sigmoid)
• Long air-fluid levels
CAUSE REMARK
*Postoperative Usually abdominal surgery
Electrolyte imbalance Diabetic ketoacidosis
* almost always
17. Generalised adynamic ileus
The large and
small bowel are
extensively airfilled
but not dilated.
The large and
small bowel "look
the same".
18. Mechanical SBO
• Dilated small bowel
• Fighting loops (visible loops, lying
transversely, with air-fluid levels at different
levels)
• Little gas in colon, especially rectum
23. String of pearls sign
Considered diagnostic of obstruction (as opposed to ileus)
and is caused by small bubbles of air trapped in the
valvulae of the small bowel.
25. Closed loop obstruction
• Two points of same loop of bowel obstructed
at a single location
• Forms a C or a U shape
– Term applies to small bowel, usually caused by
adhesions
– Large bowel, called a volvulus
28. Mechanical LBO
• Colon dilates from point
of obstruction
backwards
• Little/no air fluid levels
(colon reabsorbs water)
• Little or no air in
rectum/sigmoid
29. Large bowel obstruction
Bowel loops tend not to
overlap therefore
possible to identify site
of obstruction
Little or no gas in small
bowel if ileocaecal valve
remains competent*
* If incompetent, large bowel
decompresses into small bowel, may
look like SBO
31. Note on volvulus
• Sigmoid colon has its own mesentry therefore
prone to twisting
• Caecum usually retroperitoneal and not prone
to twisting; 20% people have defect in
peritoneum that covers the caecum resulting
in a mobile caecum
32. Volvulus
A volvulus always extends away from the area of twist.
Sigmoid volvulus can only move upwards and usually
goes to the right upper quadrant. Caecal volvulus
can go almost anywhere.
34. Hernia
Lateral decubitus of value
The advantage is that there may be a greater chance of air entering the
herniated bowel because it is the least dependent part of the bowel in the
supine position.
35. Apple core sign
• Radiologic manifestation of a
focal stricture of the bowel
usually at contrast material
enema examination. The
stricture demonstrates
shouldered margins and
resembles the core of an
apple that has been partially
eaten. The most common
cause is an annular carcinoma
of the colon.
36. Thumbprinting
The distance between
loops of bowel is increased
due to thickening of the
bowel wall.
The haustral folds are very
thick, leading to a sign
known as 'thumbprinting.'
38. Extraluminal air
• TYPES
– Pneumoperitoneum/free air/intraperitoneal air
– Retroperintoneal air
– Air in the bowel wall (pneumatosis intestinalis)
– Air in the biliary system (pneumobilia)
39. Upright film best
• The patient should be positioned sitting
upright for 10-20 minutes prior to acquiring
the erect chest X-ray image.
• This allows any free intra-abdominal gas to
rise up, forming a crescent beneath the
diaphragm. It is said that as little as 1ml of gas
can be detected in this way.
40. Free Air
Causes
• Rupture of a hollow viscus
– Perforated peptic ulcer
– Trauma
– Perforated diverticulitis (usually seals off)
– Perforated carcinoma
• Post-op 5-7 days normal, should get less with successive
studies *NOT ruptured appendix (seals off)
42. Crescent Sign II
Free air under the diaphragm
Best demonstrated on
upright chest x rays or
left lat decub
Easier to see under
right diaphragm
43. Chilaiditis sign
• May mimic air under
the diaphragm
• Look for haustral folds
• Get left lat decub to
confirm
In patients who have cirrhosis
or flattened diaphragms due to
lung hyperinflation, a void is
created within the upper
abdomen above the liver. This
space may be filled by bowel. If
this bowel is air filled then it
may mimic free gas.
44. 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
45. False Rigler’s Sign
• The Rigler sign can sometimes be simulated by
contiguous loops of bowel, whereby
intraluminal air in one loop of bowel may
appear to outline the wall of an adjacent loop,
which results in a misdiagnosis of free air.
• Measure distance of interface if unsure
46. Football SIgn
Seen with massive
pneumoperitoneum
Most often in children
with necrotising
enterocolitis
Paediatric
Adult
In supine position air
collects anterior to
abdominal viscera
49. Inverted V sign
• On the supine radiograph, an inverted "V"
may be seen over the pelvis in a patient with
pneumoperitoneum.
• While in infants this is produced by the
umbilical arteries, in adults it appears to be
created by the inferior epigastric vessels
51. Lesser sac Sign Cupola Sign
Lesser sac
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
Cupola
sign
– (white
arrows)
Air superior to
left lobe of
liver
Double Bubble Sign
52. Cupola Sign
The term cupola comes from a dome such as
this famous dome of the Duomo in Florence.
Air beneath the central tendon of the diaphragm
53. Triangle Sign
• The triangle sign
refers to small
triangles of free gas
that can typically be
positioned between
the large bowel and
the flank
54. Retroperitoneal Air
• Recognised by:
– Streaky, linear appearance outlining
retroperitoneal structures
– Mottled, blotchy appearance
– Relatively fixed position
• May outline:
– Psoas muscles
– Kidneys, ureters, bladder
– Aorta or IVC
– Subphrenic spaces
55. Causes of retroperitoneal air
• Bowel perforation (appendix, ileum, colon)
• Trauma (blunt or penetrating)
• Iatrogenic
• Foreign body
• Gas producing infection
56. 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.
57. Air in the bowel wall
• Signs
– Best seen in profile producing a linear lucency that
parallels the bowel
– Air en face has a mottled appearance resembling
gas mixed with faeculent material
58. Causes of air in bowel wall
• Primary Pneumatosis cystoides intestinalis (rare)
– usually affects left colon
– Produces cyst-like collections of air in the submucosa or serosa
• Secondary
– Diseases with bowel wall necrosis
– Obstructing lesions of the bowel that raise intraluminal pressure
• Complications
– Rupture into peritoneal cavity
– Dissection of air into portal venous system
60. Air in the biliary tree
• One or two tube-like branching lucencies in
the RUQ, conform to location of major bile
ducts
61. Causes
• “Normal” if Sphincter of Oddi incompetence
• Previous surgery including sphincterotomy or
transplantation of CBD
• Pathology (uncommon)
– Gallstone ileus: gallstone erodes through wall of
GB into the duodenum producing a fistula
between the bowel and the biliary system.
– Stone impacts in small bowel = mechanical SBO.
“ileus” misnomer
62. Biliary vs Portal Venous Air
• Portal venous air
usually associated
with bowel necrosis
• Air is peripheral
rather than central
• Numerous
branching
structures
63. Soft tissue masses
• Organomegaly
– Know normal landmarks
2 ways to identify soft tissue masses/organs:
– Direct visualisation of edges of structure
– Indirect by displacement of bowel
CT, US and MRI have essentially replaced conventional
radiography in the assessment of organomegaly and soft
tissue masses
73. Lamellar or laminar
• Formed around a nidus inside hollow lumen
• Concentric layers due to prolonged movement
of stone inside hollow viscus
– Renal stones
– Gallstones
– Bladder stones
76. Staghorn Calcification
Renal stones are often small, but if large
can fill the renal pelvis or a calyx, taking on
its shape which is likened to a staghorn.Tubular
77. Nephrocalcinosis
Uncommonly the renal
parenchyma can become
calcified.
This is known as
nephrocalcinosis, a condition
found in disease entities such
as medullary sponge kidney
or hyperparathyroidism.
Renal calculi
Parenchymal calcification
Flocculent
78. Putty Kidney
• "Putty kidney" –
sacs of casseous,
necrotic material
(TB)
• Autonephrectomy
– small, shrunken
kidney with
dystrophic
calcification
Flocculent
80. Conclusion
• Approach to AXR should include gas pattern,
extraluminal air, soft tissue and calcifications
• Named radiological signs are a useful way of
remembering, identifying and reporting on
films
81. References
• Herring, W. Learning Radiology 2nd
Ed, 2012
• Begg, J. Abdominal X-rays Made Easy, 1999
• http://www.wikiradiography.com
• http://www.radiopaedia.org
• http://www.imagingconsult.com
• Roche, C et al. Radiographics: Selections from the buffet of food signs in Radiology. Nov 2002, RG,
22, 1369-1384
• Young, L. Radiology Cases in Paediatric Emergency Medicine. Vol 1 Ca 2. The Target, Crescent and
Absent Liver Edge Signs.
• Raymond, B et al. Radiographics: Classic signs in uroradiology. RSN 2004
• http://www.swansea-radiology.co.uk Radiology Teaching Site. Introduction to abdominal
radiography
• Mussin, R. Postgrad Med J 2011: 87:274-287. Gas patterns on plain abdominal radiographs
• http://www.radiologymasterclass.co.uk/tutorials/abdo/abdo_x-ray_abnormalities
• Mettler: Essentials of Radiology, 2nd
Ed, 2005
• http://www.learningradiology.com/radsigns
• Muharram Food signs in radiology. International Journal of Health Sciences Vol 1 No 1. Jan 2007.
Lung pathology – pacreatitis assoc with left pleural effusion, ovarian tumour assoc with right or bilateral effusion, subphrenic abscess assoc with right pleural effusion