abdominal x ray radiology

diagnostic radiology

1. ABDOMINAL RADIOGRAPH Moderator Dr Sunil kumar Jain

2. Overview Technical factors Indications Bowel gas patterns Abdominal organs Acute abdomen protocol and different abdominal x ray views

3. The initial inspection of any X-ray begins with a technical assessment. Establishment of the name, date, date of birth, age and sex of the patient is crucial.

4. Technical Factor The patient should be immobilized, and exposure is made on arrested respiration, usually after full expiration. FFD 115 (100–150)cm Radiographic voltage 75–90 kVp with 30-40 mAs Exposure time 200-250 ms Coverage of the whole abdomen to include diaphragm to symphysis pubis and lateral properitoneal fat stripe. Breath-hold is vital as very slight movement will cause unsharpness and will obscure small calculi and larger calculi of lower visibility.

5. Position of patient and cassette ( patientstanding ) The patient stands with their back against the vertical Bucky. • The patient’s legs are placed well apart so that a comfortable and steady position is adopted. • The median sagittal plane is adjusted at right-angles and coincident with the midline of the table. • The pelvis is adjusted so that the anterior superior iliac spines are equidistant from the imaging tabletop. • A 35x 43-cm cassette is placed in the Bucky tray with its upper edge at the level of the middle of the body of the sternum so that the diaphragms are included. • The horizontal ray is directed so that it is coincident with the centre of the cassette in the midline.

6. Radiographic examination of the abdomen is performed for a variety of reasons, including: • obstruction of the bowel; • perforation; • renal pathology; • acute abdomen (with no clear clinical diagnosis); • foreign body localization • toxic megacolon ; • aortic aneurysm; • prior to the introduction of a contrast medium, e.g. intravenous urography (IVU) to demonstrate the presence of radioopaque renal or gallstones and to assess the adequacy of bowelpreparation ; • to detect calcification or abnormal gas collections, e.g. abscess; When?

7. What to Look Overall gas pattern(check for any extraluminal gas). Dense structures viz. vertebral, pelvic bones, ribs and any abnormal calcification Soft tissue outline(renal, liver, iliopsoas muscle). External objects.

8. Normal Bowel Gas Pattern Loops of bowel that contain a sufficient amount of air to fill the lumen completely are said to be distended. Distension of the bowel is normal. Loops of bowel that are filled beyond their normal size are said to be dilated. Dilatation of the bowel is abnormal. There will always be air in the stomach and rectosigmoid part except in recent vominting , NG in situ attached to suction or film taken with vertical rays.

9. 2-3 air fluid level in non dilated small bowel is normal finding. Variable air in remainder part of bowel loops. Normal diameter of small bowel is 2.5cm There may be many air–fluid levels present in the colon if the patient has had a recent enema or if the patient is taking medication with a strong anticholinergic, antiperistaltic effect.

10. Swallowing large quantities of air may produce a picture called aerophagia , characterized by numerous polygonshaped , air-containing loops of bowel, none of which is dilated.

11. Recognizing small and large bowels Large bowel Small bowel .Peripherally located. .Centrally located . Haustral markings do not . Valvular marking extends extent across the wall. across the lumen . Spaced widely apart than .Spaced much closer valvulae conniventes A rough rule of 3-6-9 is followed to determine the diameter of small and large bowel.

12. Large Bowel

13. Small Bowel

14. Pneumoperitoneum (crescent sign) Recognizing abnormal Air

15. Masquerades of crescent sign Chiladiti syndrome

16. Falciform ligament sign

17. Seen in massive pneumoperitoneum in supine position

18. Pseudo Rigler’s sign- dilated bowel loops abut each other causing double wall sign

19. Bones and calcifications Carefully looks for vertebrae, visualized ribs, bilateral SI joint And bilateral hip joints. There are two abdominal calcifications that should not be confused with pathologic calcifications. Phleboliths are small, rounded calcifications that represent calcified venous thrombi and occur with increasing age, most often in the pelvic veins of women. They classically have a lucent center, which helps to differentiate them from ureteral calculi. 2.Calcification of the rib cartilages occurs with advancing age and can sometimes be confused for renal or biliary calculi when these calcifications overlie the kidney or the region of the gallbladder. Calcified cartilage tends to have an amorphous, speckled appearance, and the calcified cartilage will occur in an arc corresponding to that of the anterior rib cartilage as it sweeps back toward articulation with the sternum.

20. Phlebolith having lucent centre

21. Calcified ribs cartilage occurs with advancing age

22. Organs(soft tissue shadows) There are two fundamental ways of recognizing the presence, and estimating the size, of soft tissue masses or organs on conventional radiographs of the abdomen: ♦ The first is by direct visualization of the edges of the structure, which can only occur if the structure is surrounded by something with a density different from that of soft tissue, such as fat or free air. ♦ The second is to recognize indirect evidence of the mass or enlarged visceral organ by recognizing pathologic displacement of air-filled loops of bowel or obscuring the normally visualized borders of abdominal soft tissue.

23. Liver The liver normally displaces all bowel gas from the right upper quadrant. Occasionally, a tongue-like projection of the right lobe of the liver may extend to the iliac crest, especially in women. This is called a Riedel lobe and is normal.

24. On conventional radiographs, an enlarged liver might be suggested if there is displacement of all bowel from the right upper quadrant down to the iliac crest and across the midline

25. Spleen The adult spleen is about 12 cm in length and usually does not project below the 12th posterior rib. A s a general rule, the spleen is about as large as the left kidney. If the spleen projects well below the 12th posterior rib the spleen is probably enlarged.

26. Kidneys Portions of the kidney outlines may be visible on conventional radiographs if there is an adequate amount of perirenal fat present. The kidney length is approximately the height of four lumbar vertebral bodies, or about 10 to 13 cm in size in an adult. The liver depresses the right kidney such that the right kidney is usually lower in the abdomen than the left kidney

27. Enlarged left kidney

28. Enlarged bladder and uterus

29. Psoas muscle shadow psoas muscles may be visible if there is adequate extraperitoneal fat surrounding them. Inability to visualize one or both psoas muscles is not a reliable indicator of pathology but may give clue to some pathologies like psoas abscess or any retroperitoneal tumour.

30. Right sides psoas abscess

31. Acute abdomen protocol 1. Supine view Overall appearance of the gas pattern • The overall appearance of the bowel gas pattern, ♦ Identifying the presence or absence of calcifications ♦ Identifying the presence of soft tissue masses

32. Prone view ♦ Identifying gas in the rectum and/or sigmoid colon • Because the rectum and sigmoid colon are the highest points of the large bowel when the person is lying prone on the x-ray table, air will rise into the rectosigmoid colon. ♦ Identifying gas in the ascending and descending colon

33. Upright or erect view What it’s good for ♦ Seeing free air in the peritoneal cavity ♦ Seeing air–fluid levels within the bowel lumen

34. Alternate to erect film Frequently, patients with the signs and symptoms of an acute condition in the abdomen cannot tolerate standing or sitting up for an upright view of the abdomen. ♦ In such cases, a left lateral decubitus view of the abdomen can be substituted for the upright radiograph. For a left lateral decubitus view, the patient lies on his or her left side on the x-ray table. This is done so that any “free air” will distribute itself at the highest part of the abdominal cavity, which will be the patient’s right side.

35. Lateral Dorsal decubitus Done in a case in which pt even not able to move

36. Upright chest To see free air Lower basal lung for effusion, pneumonia as they can sometimes present as upper abdominal pain

37. Thank You