abdomen xray
TRANSCRIPT
-
7/25/2019 Abdomen Xray
1/82
Abdominal X-rayRadiological Signs
Suzanne OHagan
-
7/25/2019 Abdomen Xray
2/82
Lightbulb momenta moment of sudden inspiration, revelation, or recognition
-
7/25/2019 Abdomen Xray
3/82
Approach to AXR
Bowel gas pattern
Extraluminal air
Sot tissue masses
!alci"cations
-
7/25/2019 Abdomen Xray
4/82
Normal AXR
11th
rib
Hepatic flexure
Gas in
stomach
T12
Gas in caecum
Iliac crest
Femoral head
SI oint
Gas in sigmoid
Transverse colon
Splenic flexure
!soas margin
Sacrum
"eft #idne$
"iver
%ladder
-
7/25/2019 Abdomen Xray
5/82
#as pattern
Stomach& Almost always air in stomach
Small bowel& Usually small amount of air in
2 or 3 loops
Large bowel& Almost always air in rectum
and sigmoid
& Varying amount of gas in rest of large bowel
'hat is normal(
-
7/25/2019 Abdomen Xray
6/82
Normal uid le!els Stomach
& Always "upright# decub$
Small bowel
&%wo or three le!elsacceptable "upright# decub$
Large bowel
& None normally"functions to remo!e uid$
-
7/25/2019 Abdomen Xray
7/82
Large !s small bowel
Large bowel
& &eripheral "e'cept RU( occupied by li!er$
& )austral mar*ings don+t e'tend from wall
to wall
Small bowel
& ,entral
& Val!ulae conni!entes e'tend across lumenand are spaced closer together
-
7/25/2019 Abdomen Xray
8/82
Radiographic principles
Series of -lms for acute abdomen
.bstruction series/ Acute abdominal
series/ ,omplete abdominal series
& Supine "almost always$
&Upright or left decubitus "almost always$
& &rone or lateral rectum "!ariable$
& ,hest# upright or supine "!ariable$
-
7/25/2019 Abdomen Xray
9/82
$%E& 'OO( )OR
SU&0N1 A.41N owel gas pattern,alci-cations4asses
&R.N1 A.41N 5as in rectosigmoid5as in ascending anddescending colon
U&R05)% A.41N 6ree air# air7uid le!els
U&R05)% ,)1S% 6ree air# lung pathologysecondary tointraabdominal process
Acute abdominal series8hat to loo* for
Substitutes9 &rone Lateral rectumUpright Left lateral decub
Upright chest Supine chest
-
7/25/2019 Abdomen Xray
10/82
.btaining !iews Supine
& &atient on bac*# ' ray beam directed
!ertically downward# casetteposterior# '7ray tube anterior "A&$
&rone
& &atient on abdomen# '7ray beamdirected !ertically downward#cassette anterior# '7ray tubeposterior "&A$
Upright
& &atient stands or sits# '7ray beamdirected hori:ontally# cassetteposterior# '7ray tube anterior "A&$
Upright chest& &atient stands or sits# hori:ontal '7
ray beam# cassette anterior# '7raytube posterior "&A$
1900s X-Ray-based fluoroscopy machine
in which radiation is shot directly through
the patient and into the doctors face.
-
7/25/2019 Abdomen Xray
11/82
Abnormal 5as &atterns
6unctional ileus& .ne or more bowel loops become aperistaltic
usually due to local irritation or inammation
Localised ;sentinel loops< "one or two loops$ 5eneralised "all loops of large and small bowel$
4echanical obstruction
& 0ntraluminal or e'traluminal Small bowel obstruction
Large bowel obstruction
-
7/25/2019 Abdomen Xray
12/82
*+ ,+ R.'E
/aximum 0ormal 1iameter o
bowel
Small bowel 3cm
Large bowel =cm
,aecum >cm
-
7/25/2019 Abdomen Xray
13/82
Localised ileus?ey features
.ne or twopersistentlydilated loops of small orlarge bowel "multiple !iews$
.ften air7uid le!els insentinel loops
Local irritation# ileus insame anatomical region as
pathology 5as in rectum or sigmoid
4ay resemble early S.
-
7/25/2019 Abdomen Xray
14/82
,auses of Localised 0leusby location
S%2E O) 1%'A2E1
'OO3S
!A.SE
Right upper@uadrant
,holecystitis
Left upper @uadrant &ancreatitis
Right lower @uadrant AppendicitisLeft lower @uadrant i!erticulitis
4id7abdomen Ulcer or *idney/uretericcalculi
-
7/25/2019 Abdomen Xray
15/82
,olon cut o sign
)xplanation*
Inflammator$ exudate in acute
pancreatitis extends into the
phrenicocolic ligament via lateral
attachment of the transverse
mesocolon
Infiltration of the phrenicocolic
ligament results in functional
spasm and+or mechanicalnarroing of the splenic flexure at
the level here the colon returns
to the retroperitoneum-
.brupt cutoff of colonic gas column at the splenic flexure /arro0- The colon is
usuall$ decompressed be$ond this point-
-
7/25/2019 Abdomen Xray
16/82
5eneralised ileus?ey features
1ntire bowel aperistaltic/hypoperistaltic
ilated small bowel and large bowel torectum "with L. no gas in rectum/sigmoid$
Long air7uid le!els
!A.SE RE/AR(
B&ostoperati!e Usually abdominal surgery
1lectrolyte imbalance iabetic *etoacidosis
almost ala$s
-
7/25/2019 Abdomen Xray
17/82
5eneralised adynamic ileus
The large and
small boel are
extensivel$ airfilled
but not dilated-
The large and
small boel loo#
the same-
-
7/25/2019 Abdomen Xray
18/82
4echanical S.
ilated small bowel
6ighting loops "!isible loops# lyingtrans!ersely# with air7uid le!els atdierent le!els$
Little gas in colon# especially rectum
-
7/25/2019 Abdomen Xray
19/82
S. 1rect S. Supine
.ir fluid levels
-
7/25/2019 Abdomen Xray
20/82
,auses of 4echanical S.
B 4ay be !isible on AXR
Adhesions
)erniaB
4alignancy
5allstone ileusB
0ntussesception
0nammatory bowel
disease
-
7/25/2019 Abdomen Xray
21/82
Step ladder appearance
Loopsarrange
themsel!esfrom leftupper toright lower
@uadrant indistal S.
-
7/25/2019 Abdomen Xray
22/82
,oil spring sign
-
7/25/2019 Abdomen Xray
23/82
String of pearls sign
3onsidered diagnostic of obstruction /as opposed to ileus0
and is caused b$ small bubbles of air trapped in thevalvulae of the small boel-
-
7/25/2019 Abdomen Xray
24/82
Stretch/slit sign
Slit of air caught in a
valvulae, characteristic
of S%4
-
7/25/2019 Abdomen Xray
25/82
,losed loop obstruction
%wo points of same loop of bowelobstructed at a single location
6orms a , or a U shape
&%erm applies to small bowel# usuallycaused by adhesions
& Large bowel# called a !ol!ulus
-
7/25/2019 Abdomen Xray
26/82
,rescent Sign
3aused b$*
"56 Soft tissue mass
47
Head of intussusception
in distal transverse colon
-
7/25/2019 Abdomen Xray
27/82
ouble ubble Sign
8uodenal .tresia
-
7/25/2019 Abdomen Xray
28/82
4echanical L.
,olon dilates frompoint of obstructionbac*wards
Little/no air uidle!els "colonreabsorbs water$
Little or no air inrectum/sigmoid
-
7/25/2019 Abdomen Xray
29/82
Large bowel obstruction
%oel loops tend not to
overlap therefore
possible to identif$ site
of obstruction
"ittle or no gas in small
boel if ileocaecal valve
remains competent
If incompetent, large boel
decompresses into small boel, ma$
loo# li#e S%4
-
7/25/2019 Abdomen Xray
30/82
,auses of 4echanical L.
%U4.UR
V.LVULUS
)1RN0A
0V1R%0,UL0%0S
0N%USSUS,1&%0.N
-
7/25/2019 Abdomen Xray
31/82
Note on !ol!ulus
Sigmoid colon has its own mesentrytherefore prone to twisting
,aecum usually retroperitoneal andnot prone to twistingC 2DE peopleha!e defect in peritoneum thatco!ers the caecum resulting in amobile caecum
V l l
-
7/25/2019 Abdomen Xray
32/82
Vol!ulus. volvulus ala$s extends aa$from the area of tist-
Sigmoid volvulus can onl$ move upards and usuall$
goes to the right upper 9uadrant- 3aecal volvulus
can go almost an$here-
-
7/25/2019 Abdomen Xray
33/82
,oee ean SignSigmoid !ol!ulus
:assivel$
dilatedsigmoid loop
-
7/25/2019 Abdomen Xray
34/82
)ernia
"ateral decubitus of valueThe advantage is that there ma$ be a greater chance of air entering theherniated boel because it is the least dependent part of the boel in the
supine position-
-
7/25/2019 Abdomen Xray
35/82
Apple core sign
Radiologic manifestation ofa focal stricture of the bowelusually at contrast materialenema e'aminationF %he
stricture demonstratesshouldered margins andresembles the core of anapple that has been
partially eatenF %he mostcommon cause is anannular carcinoma of thecolonF
-
7/25/2019 Abdomen Xray
36/82
%humbprinting
The distance beteen
loops of boel is increased
due to thic#ening of the
boel all-
The haustral folds are ver$thic#, leading to a sign
#non as ;thumbprinting-;
-
7/25/2019 Abdomen Xray
37/82
Lead pipecolon
Shorteningof colonsecondary to-brosis
Loss ofhaustration
Ulcerati!ecolitis
-
7/25/2019 Abdomen Xray
38/82
Extraluminal air %G&1S
& &neumoperitoneum/free air/intraperitoneal air
&Retroperintoneal air
& Air in the bowel wall"pneumatosisintestinalis$
& Air in the biliary system "pneumobilia$
-
7/25/2019 Abdomen Xray
39/82
Upright -lm best
%he patient should be positioned sittingupright for HD72D minutes prior toac@uiring the erect chest X7ray imageF
%his allows any free intra7abdominal gasto rise up# forming a crescent beneath
the diaphragmF 0t is said that as little asHmlof gas can be detected in this wayF
-
7/25/2019 Abdomen Xray
40/82
6ree Air,auses
Rupture of a hollow !iscus& &erforated peptic ulcer
&%rauma& &erforated di!erticulitis "usually seals o$
& &erforated carcinoma
&ost7op I7J days normal# should get less withsuccessi!e studies BN.% ruptured appendi' "sealso$
-
7/25/2019 Abdomen Xray
41/82
Signs of free air
,rescent sign ,hilaiditis sign
Riglers "and 6alse Rigler+s$
6ootball sign 6alciform ligament sign
%riangle sign
,upola sign
Lesser sac sign
-
7/25/2019 Abdomen Xray
42/82
,rescent Sign 00Free air under the diaphragm
%est demonstrated on
upright chest x ra$s or
left lat decub
)asier to see underright diaphragm
-
7/25/2019 Abdomen Xray
43/82
,hilaiditis sign
4ay mimic air under
the diaphragm
Loo* for haustral folds
5et left lat decub to
con-rm
In patients ho have cirrhosis
or flattened diaphragms due to
lung h$perinflation, a void is
created ithin the upperabdomen above the liver- This
space ma$ be filled b$ boel- If
this boel is air filled then it
ma$ mimic free gas-
-
7/25/2019 Abdomen Xray
44/82
Rigler+s Sign%oel all visualised on both sides due to intra and extraluminal air
5suall$ large amounts of free air:a$ be confused ith overlapping loops of boel, confirm ith upright vie
-
7/25/2019 Abdomen Xray
45/82
6alse Rigler+s Sign
%he Rigler sign can sometimes besimulated by contiguous loops of bowel#whereby intraluminal air in one loop of
bowel may appear to outline the wall ofan adKacent loop# which results in amisdiagnosis of free airF
4easure distance of interface if unsure
-
7/25/2019 Abdomen Xray
46/82
6ootball S0gn
Seen ith massive
pneumoperitoneum
:ost often in children
ith necrotising
enterocolitis
!aediatric.dult
In supine position air
collects anterior to
abdominal viscera
l if li i
-
7/25/2019 Abdomen Xray
47/82
6alciform ligament sign
-
7/25/2019 Abdomen Xray
48/82
.ther patterns of air aroundli!er
8oge=s 3ap Sign
-
7/25/2019 Abdomen Xray
49/82
0n!erted V sign
.n the supine radiograph# an in!ertedV may be seen o!er the pel!isin apatient with pneumoperitoneumF
8hile in infants this is produced bythe umbilical arteries# in adults it
appears to be created by the inferiorepigastric !essels
,ontinuous diaphragm sign
-
7/25/2019 Abdomen Xray
50/82
,ontinuous diaphragm sign
Sufficient
free air, left
and right
hemi>diaphragms
appear
continous
L Si
-
7/25/2019 Abdomen Xray
51/82
Lesser sac Sign,upola Sign
Lessersacsign
& (blackarrows)The lesser sac ispositioned
posterior to the
stomach and is
usuall$ a potential
space- There is
free connectionbeteen the lesser
sac and the
greater sac
through the
foramen of
'inslo
Cupola
sign& (white
arrows)
.ir superior to
left lobe of
liver
8ouble %ubble Sign
, l Si
-
7/25/2019 Abdomen Xray
52/82
,upola Sign
%he term cupola comes from a dome such as
this famous dome of the uomo in 6lorenceF
.ir beneath the central tendon of the diaphragm
% i l Si
-
7/25/2019 Abdomen Xray
53/82
%riangle Sign
%he trianglesign refers tosmall triangles
of free gas thatcan typically bepositionedbetween thelarge bowel andthe an*
R t it l Ai
-
7/25/2019 Abdomen Xray
54/82
Retroperitoneal Air
Recognised by9
& Strea*y# linear appearance outliningretroperitoneal structures
& 4ottled# blotchy appearance
&Relati!ely -'ed position
4ay outline9
& &soas muscles
& ?idneys# ureters# bladder
& Aorta or 0V,& Subphrenic spaces
-
7/25/2019 Abdomen Xray
55/82
,auses of retroperitoneal air
owel perforation "appendi'# ileum#colon$
%rauma "blunt or penetrating$
0atrogenic
6oreign body
5as producing infection
& t it
-
7/25/2019 Abdomen Xray
56/82
&neumoretroperitoneum
%his patient has free air inthe retroperitoneal spaceF
%he air is seensurrounding the lateralborder of the right *idney"white arrow$F %here is
other e!idence of free gasincluding RiglerMs signF
0f you are not con-dentthat the appearance ispneumoretroperitoneum#
you can try an erect anddecubitus !iew to see ifthe gas mo!esF 0f the gasis seen to mo!e# itMs not inthe retroperitoneumF
-
7/25/2019 Abdomen Xray
57/82
Air in t4e bowel wall
Signs
& est seen in pro-le producing a linearlucency that parallels the bowel
& Air en face has a mottled appearance
resembling gas mi'ed with faeculentmaterial
-
7/25/2019 Abdomen Xray
58/82
,auses of air in bowel wall
&rimary &neumatosis cystoides intestinalis "rare$
& usually aects left colon
& &roduces cyst7li*e collections of air in the submucosa orserosa
Secondary
& iseases with bowel wall necrosis
& .bstructing lesions of the bowel that raise intraluminalpressure
,omplications
& Rupture into peritoneal ca!ity
& issection of air into portal !enous system
-
7/25/2019 Abdomen Xray
59/82
&neumatosis intestinalis
0ntramuralair# bestappreciated
in pro-le
-
7/25/2019 Abdomen Xray
60/82
Air in the biliary tree
.ne or two tube7li*e branchinglucencies in the RU(# conform tolocation of maKor bile ducts
,auses
-
7/25/2019 Abdomen Xray
61/82
,auses
;Normal< if Sphincter of .ddi incompetence &re!ious surgery including sphincterotomy
or transplantation of ,
&athology "uncommon$& 5allstone ileus9 gallstone erodes through wall of
5 into the duodenum producing a -stulabetween the bowel and the biliary systemF
& Stone impacts in small bowel mechanicalS.F ;ileus< misnomer
iliary !s &ortal Venous Air
-
7/25/2019 Abdomen Xray
62/82
iliary !s &ortal Venous Air
&ortal !enous airusuallyassociated withbowel necrosis
Air is peripheralrather thancentral
Numerousbranchingstructures
Sot tissue masses
-
7/25/2019 Abdomen Xray
63/82
Sot tissue masses .rganomegaly
& ?now normal landmar*s
2 ways to identify soft tissue
masses/organs9
& irect !isualisation of edges of structure
& 0ndirect by displacement of bowel3T, 5S and :7I have essentiall$ replaced conventional
radiograph$ in the assessment of organomegal$ and soft
tissue masses
Abdominal
-
7/25/2019 Abdomen Xray
64/82
Location &attern
Abdominal!alci"cations
6irst e'clude artefact
-
7/25/2019 Abdomen Xray
65/82
6irst e'clude artefact
?im ?ardashian=s butt & real or artefact(
Location
-
7/25/2019 Abdomen Xray
66/82
Location Vascular
Li!er 5allbladder
Spleen
&ancreas
Lymph nodes
Adrenals
?idneys
Ureters
ladder
&rostate
Ri li*
-
7/25/2019 Abdomen Xray
67/82
Rim7li*e
,alci-cation that has occurred in the wallof a hollow !iscus
& ,ysts
renal# splenic# hepatic
& Aneurysms aortic# splenic# renal artery
& Saccular organs 5allbladder
Urinary bladder
3alcified h$datid c$sts
-
7/25/2019 Abdomen Xray
68/82
Linear/%rac*
,alci-cation in walls of tubularstructures
& Arteries
& 6allopian tubes
& Vas deferens
& Ureter
.ortoiliac calcification
,hi Si
-
7/25/2019 Abdomen Xray
69/82
,hinese ragon Sign
3alcified splenic arter$
-
7/25/2019 Abdomen Xray
70/82
,alci-ed !as deferens
6loccular Amorphous
-
7/25/2019 Abdomen Xray
71/82
6loccular# Amorphous#&opcorn
6ormed in solidorgan or tumour& &ancreas "chronic pancreatitis$
& Leiomyomas of uterus
& .!arian cystadenomas& Lymph nodes
& Adenocarcinomas of stomach# o!ary# colon
& 4etastases& Soft tissue "pre!ious trauma# crystal
deposition$
,alci-ed ,alci-ed-b id
-
7/25/2019 Abdomen Xray
72/82
entericlymph nodes
-broids
,alci-edpancreas
Floccular
-
7/25/2019 Abdomen Xray
73/82
Lamellar or laminar
6ormed around a nidus inside hollowlumen
,oncentric layers due to prolongedmo!ement of stone inside hollow !iscus
& Renal stones
& 5allstones& ladder stones
ladder calculi
-
7/25/2019 Abdomen Xray
74/82
ladder calculi
"amellar
Renal calculi
-
7/25/2019 Abdomen Xray
75/82
Renal calculi!elvical$ceal calcifications
St h , l i- ti
-
7/25/2019 Abdomen Xray
76/82
Staghorn ,alci-cation
7enal stones are often small, but if large
can fill the renal pelvis or a cal$x, ta#ing on
its shape hich is li#ened to a staghorn-Tubular
Renal calculi
-
7/25/2019 Abdomen Xray
77/82
-
7/25/2019 Abdomen Xray
78/82
&utty ?idney
&utty *idney Osacs of casseous#necrotic material
"%$ Autonephrectom
y O small#shrun*en *idney
with dystrophiccalci-cation
Flocculent
,alci-ed gallstones
-
7/25/2019 Abdomen Xray
79/82
,alci-ed gallstones
"amellar
, l i
-
7/25/2019 Abdomen Xray
80/82
,onclusion
Approach to AXR should include gaspattern# e'traluminal air# soft tissueand calci-cations
Named radiological signs are a usefulway of remembering# identifying and
reporting on -lms
References
-
7/25/2019 Abdomen Xray
81/82
References
)erring# 8F Learning Radiology 2nd1d# 2DH2
egg# PF Abdominal X7rays 4ade 1asy# H>>>
http9//wwwFwi*iradiographyFcom
http9//wwwFradiopaediaForg
http9//wwwFimagingconsultFcom
Roche# , et alF Radiographics9 Selections from the buet of food signs in RadiologyF No!2DD2# R5# 22# H3=>7H3Q
Goung# LF Radiology ,ases in &aediatric 1mergency 4edicineF Vol H ,a 2F %he %arget#,rescent and Absent Li!er 1dge SignsF
Raymond# et alF Radiographics9 ,lassic signs in uroradiologyF RSN 2DD
http9//wwwFswansea7radiologyFcoFu* Radiology %eaching SiteF 0ntroduction to abdominalradiography
4ussin# RF &ostgrad 4ed P 2DHH9 QJ92J72QJF 5as patterns on plain abdominal radiographs
http9//wwwFradiologymasterclassFcoFu*/tutorials/abdo/abdo'7rayabnormalities
4ettler9 1ssentials of Radiology# 2nd1d# 2DDI
http9//wwwFlearningradiologyFcom/radsigns
4uharram 6ood signs in radiologyF 0nternational Pournal of )ealth Sciences Vol H No HF Pan2DDJF
http://www.wikiradiography.com/http://www.radiopaedia.org/http://www.imagingconsult.com/http://www.swansea-radiology.co.uk/http://www.radiologymasterclass.co.uk/tutorials/abdo/abdo_x-ray_abnormalitieshttp://www.learningradiology.com/radsignshttp://www.learningradiology.com/radsignshttp://www.radiologymasterclass.co.uk/tutorials/abdo/abdo_x-ray_abnormalitieshttp://www.swansea-radiology.co.uk/http://www.imagingconsult.com/http://www.radiopaedia.org/http://www.wikiradiography.com/ -
7/25/2019 Abdomen Xray
82/82
%)AN? G.U