Abdominal X-ray Interpretation 1. Check patients name, date of birth, hospital number. 2.

Check the date and time of the film taken. 3. Adequate penetration ( upper lumbar spine will be visible ), alignment ( sacroiliac joints are visible on both sides ), apparatus ( surgical clips, renal or biliary stents, intrauterine contraceptive device, inferior vena cava filter, foreign bodies ) 4. Bones any fracture, bone deformity, lytic lesions ( multiple myeloma, metastases ), Pagets disease ( cortical bone thickening, accentuation of trabecular pattern, increased density of the bone ) 5. Cartilage and joints osteoarthritic changes of the joint ( narrowing of joint space, osteophytes, subchondral sclerosis, bone cyst ), ankylosing spondylitis ( fusion of the sacroiliac joints, bamboo spine with evidence of syndosmophyte formation and calcification of the longitudinal spine ligaments ) 6. Soft tissues any gas in the stomach, small and large bowels, kidneys ( lateral to T12 and L2 vertebrae ), psoas shadows ( absence shadow might suggest retroperitoneal hemorrhage or retroperitoneal mass ), calcifications ( calcification of the cartilage of ribs, calcified blood vessels, chronic pancreas, kidney stones, gallstones, calcified lymph nodes, appendicolith )

Small bowel Smaller calibre Dilated bowel 3 to 5 cm Centrally placed loops Mucosal folds transverse full diameter ( valvulae conniventes ) Many loops Content : Fluid Causes of small bowel obstruction : 1. Adhesion 2. Hernia 3. Crohns Disease Symptoms develop rapidly. Abdominal cramps, vomiting followed by constipation

Large bowel Larger calibre Dilated bowel > 5cm Peripherally placed loops Mucosal folds cover partial diameter (haustra) Few loops Content : Faeces Causes of large bowel obstruction : 1. Tumour 2. Diverticulitis 3. Volvulus Symptoms develop gradually. Abdominal distension, constipation followed by vomiting
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1. Pneumoperitoneum is best demonstrated in an upright x ray. Free gas may appear on one side, usually the right. The gas is more easily observed in an upright chest x ray than in an upright abdominal x ray, because the x ray beam is more horizontal in the chest x ray than in the abdominal x ray. As little as 1 ml of gas may be demonstrated, though CT is regarded as the gold standard for the recognition of free gas. 2. If the patient is too ill to stand, lateral decubitus views must suffice to demonstrate free gas. A left-side down lateral decubitus is better than a right-side down lateral decubitus, because intestinal gas may mimic free gas on a right-side down decubitus. At least five minutes should be spent with the patient in the appropriate position to allow any free gas to track up to the flank. 3. Riglers sign gas on both sides of bowel wall indicative of bowel perforation perform erect CXR for pneumoperitoneum (check gas under diaphragm). 4. Acute diverticulitis CT scan is the test of choice for acute diverticulitis. Look for diverticula, localized colonic wall thickening (>5 mm), abscesses, fistulas, and pericolic fat inflammation, and exclude other pathologies, such as a tubo-ovarian abscess or aortic or other vascular blood leakage.

5. Acute appendicitis Abdominal ultrasonography shows an outer diameter of greater than 6 mm, noncompressibility, lack of peristalsis, or periappendiceal fluid collection. CT scans have become the modality of choice for diagnosing appendicitis. Dilated ascending colon and an abrupt cut off of the colonic gas at the hepatic flexure (colon cut off sign) suggests acute pancreatitis An amylase level that is five times the upper limit of normal is almost always diagnostic of acute pancreatitis. Acute cholecystitis and a perforated peptic ulcer can also cause a raised amylase level.

6. Acute mesenteric ischemia Angiography has been considered to be the criterion standard for the diagnosis of acute arterial occlusion. CT scan findings of acute mesenteric ischemia included mesenteric arterial or venous thrombus, mesenteric venous gas, pneumatosis intestinalis ( gas in the bowel wall indicates gangrene ), bowel-wall thickening, increased or decreased enhancement of the bowel wall, bowel dilatation, mesenteric or perienteric fat stranding, pneumoperitoneum, and solid
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organ infarction. Plain abdominal radiographs are generally normal or nonspecific and therefore should not be used to rule out mesenteric ischemia. Thumbprinting, pneumatosis intestinalis, or portal venous gas raises the suspicion for mesenteric ischemia, though these are findings that are found later in the disease process. Radiology in Biliary system 1. Causes of air in the bile duct (pneumobilia) post ERCP, biliary-enteric fistula, ascending cholangitis with gas-forming organisms 2. Ultrasonography is the most sensitive, specific, noninvasive, and inexpensive test for the detection of gallstones. In acute cholecystitis, ultrasonography may demonstrate edema of the gallbladder wall and pericholecystic fluid. 3. Routine ultrasonography is less effective for diagnosing stones in the common bile duct, because the distal bile duct passes behind the duodenum and is hidden from view by intestinal gas. Dilatation of the common bile duct on ultrasonographic images is an indirect indicator of bile duct obstruction. 4. Endoscopic retrograde cholangiopancreatography (ERCP) permits x-ray imaging of the bile ducts. Stones in bile appear as filling defects in the opacified ducts. ERCP is usually performed in conjunction with endoscopic retrograde sphincterotomy and gallstone extraction. 5. Because of its cost and the need for sophisticated equipment and software, magnetic resonance cholangiopancreatography (MRCP) is usually reserved for cases in which choledocholithiasis is suspected. 6. The main role of plain x-ray films in evaluating patients with suspected gallstone disease is to exclude other causes of acute abdominal pain, such as intestinal obstruction, visceral perforation, renal stones, or chronic calcific pancreatitis. 7. Classic findings of clostridial cholecystitis (emphysematous cholecystitis) include the presence of gas in the right upper quadrant outlining the gallbladder wall, an air-fluid level in the gallbladder lumen, pericholecystic air or air in the bile duct. 8. Calcification in the gallbladder wall (porcelain gallbladder) is indicative of severe chronic cholecystitis. 9. 4. Riglers triads in gallstone ileus include peumobilia, small bowel obstruction and gallstone.
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Investigations in Esophageal Disorders 1. Achalasia i. ii. Barium swallow demonstrating the bird-beak appearance of the lower esophagus, dilatation of the esophagus, and stasis of barium in the esophagus. Esophageal manometry is the criterion standard in helping to diagnose the classic findings of achalasia.
o o o

Incomplete relaxation of the LES in response to swallowing High resting LES pressure Absent esophageal peristalsis

iii. iv.

Esophageal pH monitoring is important a. To rule out gastroesophageal reflux disease Perform an esophagogastroduodenoscopy to rule out cancer of the gastroesophageal junction or fundus. If a tumor is suspected, perform an endoscopic ultrasound at the same time. 2. Diffuse esophageal spasm

i. ii. iii.

Barium swallow demonstrating characteristic appearance of multiple simultaneous contractions (corkscrew appearance). CT scan demonstrating thickening of the esophagus (muscular hypertrophy). Esophageal manometry is the best modality to help diagnose DES. The classic definition is more than 2 uncoordinated contractions during 10 consecutive wet swallows. 3. Malignant stricture

i. ii.

Barium esophagram provides information about the location, length, and diameter of the stricture and the smoothness or irregularity of esophageal wall. Esophagogastroduodenoscopy can be used to establish or confirm the diagnosis of esophageal stricture, to seek evidence of esophagitis, to exclude malignancy, to obtain biopsy and brush cytology specimens, and to implement therapy. CT scans can be used to stage malignancies that produce esophageal strictures. Endoscopic ultrasound is the most accurate means of identifying the extent of local invasion of an esophageal malignancy.
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iii. iv.

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Benign stricture Peptic stricture (GORD) Dysphagia of slow progression minimal weight loss Symmetrical Longer Smooth outline

Malignant stricture Esophageal carcinoma with Dysphagia of rapid progression with significant weight loss Asymmetrical Shorter Irregular outline

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