William Herring, M.D.

2002

Plain Films Of the Abdomen

An Approach
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What to Examine

Gas pattern Extraluminal air Soft tissue masses Calcifications GESC

Normal Gas Pattern

Stomach

Always

Small Bowel

Two or three loops of non-distended bowel Normal diameter = 2.5 cm = 1 US quarter In rectum or sigmoid almost always

Large Bowel

Gas in stomach

Gas in a few loops of small bowel

Gas in rectum or sigmoid

Normal Gas Pattern

Normal Fluid Levels

Stomach

Always (except supine film)

Small Bowel

Two or three levels possible

Large Bowel

None normally

Always air/fluid level in stomach

A few air/fluid levels in small bowel

Erect Abdomen

Large vs. Small Bowel

Large Bowel

Peripheral Haustral markings don't extend from wall to wall Central Valvulae extend across lumen Maximum diameter of 2"

Small Bowel

Complete Abdomen
Obstruction Series

Supine
Prone or lateral rectum Erect or left decubitus Chest - erect or supine

Complete Abdomen
Supine

Looking for

Scout film for gas pattern Calcifications Soft tissue masses

Substitute none

Complete Abdomen
Prone

Looking for

Gas in rectum/sigmoid

Gas in ascending and descending colon

Substitute lateral rectum

Complete Abdomen
Erect

Looking for

Free air Air-fluid levels

Substitute left lateral decubitus

Complete Abdomen
Erect Chest

Looking for

Free air

Pneumonia at bases
Pleural effusions

Substitute supine chest

Abnormal Gas Patterns

Functional Ileus

Localized (Sentinel Loops)

Generalized adynamic ileus

Mechanical Obstruction

SBO LBO

Air in Rectum or sigmoid Localized Ileus Generalized Ileus SBO LBO

Yes

Air in Small Bowel

2-3 distended loops Multiple distended loops Multiple dilated loops None-unless ileocecal valve incompetent

Air in Large Bowel

Air in rectum or sigmoid YesDistended No YesDilated

Yes

No

No

Localized Ileus
Key Features

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

Localized Ileus
Pitfalls

May resemble early mechanical SBO

Clinical course Get follow-up

Generalized Ileus
Key Features

Gas in dilated small bowel and large bowel to rectum Long air-fluid levels Only post-op patients have generalized ileus

Supine

Erect

Generalized Adynamic Ileus

Is It An Ileus?
Is the patient immediately post-op?
Are the bowel sounds absent or hypoactive?

If no, then it isnt an ileus

Patients dont present to the ER with a generalized adynamic ileus!

Mechanical SBO
Key Features

Dilated small bowel

Fighting loops
Little gas in colon, especially rectum Key: disproportionate dilatation of SB

SBO

Mechanical SBO
Causes

Adhesions
Hernia* Volvulus

Gallstone ileus*
Intussusception

*Cause may be visible on plain film

Mechanical SBO
Pitfalls

Early SBO may resemble localized ileus get F/O

Mechanical LBO
Key Features

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

Supine

Prone

LBO

Mechanical LBO
Causes

Tumor Volvulus

Hernia
Diverticulitis Intussusception

Mechanical LBO
Pitfalls

Incompetent ileocecal valve

Large bowel decompresses into small bowel

May look like SBO

Get BE or follow-up

Supine

Prone

Carcinoma of Sigmoid LBO Decompressed into SB

Air in Rectum or sigmoid Localized Ileus Generalized Ileus SBO LBO

Yes

Air in Small Bowel

2-3 distended loops Multiple distended loops Multiple dilated loops None-unless ileocecal valve incompetent

Air in Large Bowel

Air in rectum or sigmoid YesDistended No YesDilated

Yes

No

No

Aunt Minnie Diagnoses

SBO

Air in biliary tree

Gallstone

Gallstone Ileus

Post-op C-section Adynamic Ileus

Sigmoid Volvulus

Cecal Volvulus

Mesenteric Occlusion

Abnormal Gas Patterns

Ileus and Obstruction

Localized ileus Generalized ileus

Mechanical SBO
Mechanical LBO

Extraluminal Air
Free Intraperitoneal Air

Signs of Free Air

Air beneath diaphragm Both sides of bowel wall Falciform ligament sign

Crescent sign

Free Intraperitoneal Air

Air on both sides of bowel wall Riglers Sign

Free Intraperitoneal Air

Falciform Ligament Sign

Football sign

Free Intraperitoneal Air

Free Air
Causes

Rupture of a hollow viscus

Perforated ulcer
Perforated diverticulitis Perforated carcinoma

Trauma or instrumentation

Post-op 57 days NOT perforated appendix

Air in Lesser Sac

Extraperitoneal Air

Soft Tissue Masses

Soft Tissue Masses

Hepatosplenomegaly

Plain films poor for judging liver size

Tumor or cyst

Bowel displacement

Paucity of gas
Pad sign

Extrinsic compression of bowel

Splenomegaly

Myomatous Uterus

Hours later

Bladder Outlet Obstruction pre- and post- cath

Mass in Cologastric Space - Pancreatic Pseudocyst

Right Renal Cyst

RLQ Abscess

Free Peritoneal Fluid- Bladder Ears

Abdominal Calcifications

Abdominal Calcifications
Patterns

Rimlike Linear or track-like Lamellar Cloudlike

Rimlike Calcification
Wall of a hollow viscus

Cysts

Renal cyst

Aneurysms

Aortic aneurysm

Saccular organs e.g. GB

Porcelain Gallbladder

Renal Cyst

Gallbladder Wall

Linear or Track-like

Walls of a tube

Ureters Arterial walls

Atherosclerosis

Calcification Vas Deferens

Lamellar or Laminar

Formed in lumen of a hollow viscus

Renal stones Gallstones Bladder stones

Stone in Ureterocoele

Staghorn Calculi

Cloudlike, Amorphous, Popcorn

Formed in a solid organ or tumor

Leiomyomas of uterus Ovarian cystadenomas

Nephrocalcinosis

Myomatous Uterus

What to Examine

Gas pattern Extraluminal air

Soft tissue masses

Calcifications

The End