of 69
7/28/2019 Plain Abdomen Pp t
1/69
Plain Films
Of the AbdomenAn Approach
In Slide Show mode, to advance slides, press spacebar
William Herring, M.D. 2002
7/28/2019 Plain Abdomen Pp t
2/69
What to Examine
Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
GESC
7/28/2019 Plain Abdomen Pp t
3/69
Normal Gas Pattern
Stomach
Always Small Bowel
Two or three loops of non-distended bowel
Normal diameter = 2.5 cm = 1 US quarter
Large Bowel
In rectum or sigmoid almost always
7/28/2019 Plain Abdomen Pp t
4/69
Gas in
stomach
Gas in a few
loops of
small bowel
Gas in
rectum or
sigmoid
Normal Gas Pattern
7/28/2019 Plain Abdomen Pp t
5/69
Normal Fluid Levels
Stomach
Always (except supine film)
Small Bowel
Two or three levels possible
Large Bowel
None normally
7/28/2019 Plain Abdomen Pp t
6/69
Erect Abdomen
Always
air/fluid level
in stomach
A fewair/fluid
levels in
small bowel
7/28/2019 Plain Abdomen Pp t
7/69
Large vs. Small Bowel
Large Bowel
Peripheral
Haustral markings don't extend
from wall to wall
Small Bowel
Central Valvulae extend across lumen
Maximum diameter of 2"
7/28/2019 Plain Abdomen Pp t
8/69
Complete AbdomenObstruction Series
Supine Prone or lateral rectum
Erect or left decubitus
Chest - erect or supine
7/28/2019 Plain Abdomen Pp t
9/69
Complete AbdomenSupine
Looking for
Scout film for gaspattern
Calcifications
Soft tissue masses
Substitute none
7/28/2019 Plain Abdomen Pp t
10/69
Complete AbdomenProne
Looking for
Gas in rectum/sigmoid
Gas in ascending and
descending colon
Substitute lateral
rectum
7/28/2019 Plain Abdomen Pp t
11/69
Complete AbdomenErect
Looking for
Free air
Air-fluid levels
Substitute left
lateral decubitus
7/28/2019 Plain Abdomen Pp t
12/69
Complete AbdomenErect Chest
Looking for
Free air
Pneumonia at bases
Pleural effusions
Substitute supine
chest
7/28/2019 Plain Abdomen Pp t
13/69
Abnormal Gas Patterns
Functional Ileus
Localized (Sentinel Loops)
Generalized adynamic ileus
Mechanical Obstruction
SBO
LBO
7/28/2019 Plain Abdomen Pp t
14/69
Air in Rectumor sigmoid
Air in SmallBowel
Air in LargeBowel
LocalizedIleus
Yes2-3 distended
loopsAir in rectum or
sigmoid
GeneralizedIleus
YesMultiple
distended loopsYes-
Distended
SBO NoMultiple dilated
loopsNo
LBO NoNone-unless
ileocecal valveincompetent
Yes-Dilated
7/28/2019 Plain Abdomen Pp t
15/69
One or two persistently dilated loops of
large or small bowel
Gas in rectum or sigmoid
Localized IleusKey Features
7/28/2019 Plain Abdomen Pp t
16/69
Sentinel Loops
Supine Prone
7/28/2019 Plain Abdomen Pp t
17/69
PancreatitisUlcer
Diverticulitis
Cholecystitis
Appendicitis
Ulcer
Ureteral calculus
Sentinel Loops
7/28/2019 Plain Abdomen Pp t
18/69
Localized IleusPitfalls
May resemble earlymechanical SBO
Clinical course
Get follow-up
7/28/2019 Plain Abdomen Pp t
19/69
Gas in dilated small bowel and largebowel to rectum
Long air-fluid levels
Only post-op patients havegeneralized ileus
Generalized IleusKey Features
7/28/2019 Plain Abdomen Pp t
20/69
Generalized Adynamic Ileus
Supine Erect
7/28/2019 Plain Abdomen Pp t
21/69
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!
7/28/2019 Plain Abdomen Pp t
22/69
Mechanical SBOKey Features
Dilated small bowel
Fighting loops
Little gas in colon, especially rectum
Key: disproportionate dilatation of SB
7/28/2019 Plain Abdomen Pp t
23/69
SBO
7/28/2019 Plain Abdomen Pp t
24/69
Mechanical SBOCauses
Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception
*Cause may be visible on plain film
7/28/2019 Plain Abdomen Pp t
25/69
Mechanical SBOPitfalls
Early SBO mayresemble
localized ileus -
get F/O
7/28/2019 Plain Abdomen Pp t
26/69
Mechanical LBOKey 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
7/28/2019 Plain Abdomen Pp t
27/69
LBO
Supine Prone
7/28/2019 Plain Abdomen Pp t
28/69
Mechanical LBOCauses
Tumor
Volvulus
Hernia
Diverticulitis
Intussusception
7/28/2019 Plain Abdomen Pp t
29/69
Mechanical LBOPitfalls
Incompetent ileocecal valve Large bowel decompresses into small
bowel
May look like SBO
Get BE or follow-up
7/28/2019 Plain Abdomen Pp t
30/69
Carcinoma of Sigmoid LBO
Decompressed into SB
ProneSupine
7/28/2019 Plain Abdomen Pp t
31/69
Air in Rectumor sigmoid
Air in SmallBowel
Air in LargeBowel
LocalizedIleus
Yes2-3 distended
loopsAir in rectum or
sigmoid
GeneralizedIleus
YesMultiple
distended loopsYes-
Distended
SBO NoMultiple dilated
loopsNo
LBO NoNone-unless
ileocecal valveincompetent
Yes-Dilated
7/28/2019 Plain Abdomen Pp t
32/69
Aunt Minnie Diagnoses
7/28/2019 Plain Abdomen Pp t
33/69
7/28/2019 Plain Abdomen Pp t
34/69
Air in
biliary
treeSBO
Gallstone Gallstone Ileus
7/28/2019 Plain Abdomen Pp t
35/69
Post-op C-section
Adynamic Ileus
7/28/2019 Plain Abdomen Pp t
36/69
Sigmoid Volvulus
7/28/2019 Plain Abdomen Pp t
37/69
Cecal Volvulus
7/28/2019 Plain Abdomen Pp t
38/69
Mesenteric Occlusion
7/28/2019 Plain Abdomen Pp t
39/69
Abnormal Gas PatternsIleus and Obstruction
Localized ileus Generalized ileus
Mechanical SBO
Mechanical LBO
7/28/2019 Plain Abdomen Pp t
40/69
Extraluminal AirFree Intraperitoneal Air
7/28/2019 Plain Abdomen Pp t
41/69
Signs of Free Air
Air beneath diaphragm
Both sides of bowel wall
Falciform ligament sign
7/28/2019 Plain Abdomen Pp t
42/69
Crescent
sign
Free Intraperitoneal Air
7/28/2019 Plain Abdomen Pp t
43/69
Free Intraperitoneal Air
Air on both sides of
bowel wallRiglers
Sign
7/28/2019 Plain Abdomen Pp t
44/69
Free Intraperitoneal Air
Falciform
LigamentSign
Football sign
7/28/2019 Plain Abdomen Pp t
45/69
Free AirCauses
Rupture of a hollow viscus
Perforated ulcer
Perforated diverticulitis
Perforated carcinoma
Trauma or instrumentation
Post-op 57 days
NOT perforated appendix
7/28/2019 Plain Abdomen Pp t
46/69
Air in Lesser Sac
7/28/2019 Plain Abdomen Pp t
47/69
Extraperitoneal Air
7/28/2019 Plain Abdomen Pp t
48/69
Soft Tissue Masses
7/28/2019 Plain Abdomen Pp t
49/69
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
7/28/2019 Plain Abdomen Pp t
50/69
Splenomegaly
7/28/2019 Plain Abdomen Pp t
51/69
Myomatous Uterus
7/28/2019 Plain Abdomen Pp t
52/69
Bladder Outlet Obstruction pre- and post- cath
Hours
later
7/28/2019 Plain Abdomen Pp t
53/69
Mass in Cologastric Space - Pancreatic Pseudocyst
7/28/2019 Plain Abdomen Pp t
54/69
Right Renal Cyst
7/28/2019 Plain Abdomen Pp t
55/69
7/28/2019 Plain Abdomen Pp t
56/69
RLQ Abscess
7/28/2019 Plain Abdomen Pp t
57/69
Free Peritoneal Fluid- Bladder Ears
7/28/2019 Plain Abdomen Pp t
58/69
AbdominalCalcifications
7/28/2019 Plain Abdomen Pp t
59/69
Abdominal CalcificationsPatterns
Rimlike Linear or track-like
Lamellar
Cloudlike
7/28/2019 Plain Abdomen Pp t
60/69
Rimlike Calcification
Wall of a hollow viscus
Cysts
Renal cyst
Aneurysms
Aortic aneurysm
Saccular organs e.g. GB
Porcelain Gallbladder
7/28/2019 Plain Abdomen Pp t
61/69
Renal Cyst Gallbladder Wall
7/28/2019 Plain Abdomen Pp t
62/69
Linear or Track-like
Walls of a tube
Ureters
Arterial walls
7/28/2019 Plain Abdomen Pp t
63/69
Atherosclerosis Calcification Vas Deferens
7/28/2019 Plain Abdomen Pp t
64/69
Lamellar or Laminar
Formed in lumen of a hollow viscus Renal stones
Gallstones
Bladder stones
7/28/2019 Plain Abdomen Pp t
65/69
Stone in Ureterocoele Staghorn Calculi
7/28/2019 Plain Abdomen Pp t
66/69
Cloudlike, Amorphous, Popcorn
Formed in a solid organ or tumor Leiomyomas of uterus
Ovarian cystadenomas
7/28/2019 Plain Abdomen Pp t
67/69
Nephrocalcinosis Myomatous Uterus
7/28/2019 Plain Abdomen Pp t
68/69
What to Examine
Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
7/28/2019 Plain Abdomen Pp t
69/69
The End