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   A system for reporting an abdominal X-Ray Hide   

    • Technical details/Demographics: Name, patient number, date of X-Ray

    • Whether x-ray is supine or erect (for fluid and gas levels), correct orientation (Right/Left)

    • Location of bowel (small = central, large = peripheral). Valvulae conniventes seen as ridge pattern throughout the diameter of small bowel only. Haustra in large bowel

    • Bowel loop diameter:

      1. Normal small bowel: Less than or equal to 3cm

        Normal large bowel: Less than or equal to 5cm

        Caecum > 9cm is abnormal

    • Intraluminal gas: Mainly seen in transverse colon and rectum. Speckled appearance in rectum indicated faecal matter

    • Extraluminal gas: Seen in perforated viscus or post ERCP sphincterotomy

    • Comments on soft tissue and bone, including kidneys, bladder, psoas muscle shadow and liver. Describes size and appearance. Are bony lesions present?

    • Calcification: Seen in vessels and certain organs in pathology or ageing process

    • Comment on iatrogenic artefacts: Stents, sternotomy clips and sterilisation clips

    Common pathology

    • Gas pattern:

      • Luminal gas

        1. Most gas present in large bowel, unless incompetent ileocaecal valve. In case of blockage, proximal dilatation is seen, and is described as a cut-off point. Bowel dilated is determined by positioning and anatomical markings as described above

          Small bowel obstruction is seen in adhesions, Crohn's, intussusception, volvulus, hernias and malignancy (rare). Rarely a gallstone ileus can create fistula into small bowel and cause a gallstone ileus

          Paralytic ileus is absent peristalsis, and a cut off point is not seen on radiograph

          A volvulus (U shaped loop) can be seen as dilated bowel loop due to mesenteric twisting, with caecum and rectum most common sites. Caecal volvuli can be shifted from RLQ to LUQ, leaving an empty caecal region. Treated by deflation or surgery.

          Always look for a distal obstruction in large bowel. An apple core lesion/ shouldering appearance is indicative of Ca large bowel. Causes of large bowel obstruction: Malignancy, volvulus, diverticular disease

          Toxic megacolon in IBD, Shigella, C Diff (pseudomembranous colitis) and ischaemic bowel demonstrates thumb printing. Mainly affects transverse colon. Thumb printing is due to deep muscular oedema. A higher risk of perforation is associated. Seen mainly in transverse colon

      • Extra luminal gas

        1. Pneumoperitoneum seen in perforated viscus, clearly seen as gas under right diaphragm as a crescent shape. Falciform ligament is seen more clearly. This can also move in a superior direction and create a pneumomediastinum

          Rigler's sign: Gas intra and extraluminal, hence serosal layer is more clearly defined (seen as a white wall)

          Chilaiditis syndrome: Air under the left diaphragm, which is not due to perforated viscus or pneumoperitoneum, but transverse colon lumen (haustra seen)

          Biliary gas is seen post sphincterotomy, cholangitis and in fistulas (biliary-bowel)

          WHEN PNEUMOPERITONEUM IS SEEN, AN ERECT X-RAY SHOULD BE REQUESTED. This will demonstrate air under the diaphragm

    • Calcification:

      1. Can be normal in costal cartilage, mesenteric nodes and prostate gland. Also, phlebiliths (calcified veins in pelvis), which have no pathological significance

        Abnormal in pancreas (chronic pancreatitis), renal parenchyma (medullary sponge syndrome, RTA), vessels (atheromatous process), fibroids in females, biliary tree or gallbladder (cholecystitis), appendix (appendicitis), bladder (large masses) and abdominal aortic aneurysms

        In renal system track down the transverse processes up to vesicoureteric junction for calculi. Staghorn calculi are the largest

        Calcification in the bladder is seen in Schistosomiasis

    • Soft Tissue & bone:

      1. Look for osteoporosis as reduced bone mass, fractures and kypho-scoliosis

        Lytic lesions can indicated metastasis

        Loss of psoas outline can indicate generalised peritoneal disease

    • Iatrogenic/Other:

      1. Clips associated with recent surgery

        NG tubes and PEGs in the abdominal region

        Presence of stents in biliary tree to relieve jaundice or in cancer

        Coils in females as well as sterilisation clips


Author: Mr Adnan Darr MBCHB, BSc, MSc, MRCS  | Speciality: Radiology  | Date Added: 13/10/2011


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