Chest radiographs are phenomenal in terms of how much information they can provide given how simple and easy they are to perform. Abdominal films are also useful, but less commonly used as there are fewer indications for ordering them, and they don’t give the same wealth of information that a chest film can. Nevertheless, it’s essential that you can look at one without panicking, and get a rough idea about what’s going on inside that patient of yours.

Indications: “Gasses, masses, bones and stones”

  • Obstructed bowel
  • Perforated bowel
  • Bowel Ischaemia
  • Blunt or perforating abdominal injury
  • Intussusception
  • Foreign bodies
  • Suspected abdominal mass
  • Acute and chronic pancreatitis
  • Toxic megacolon

Views:

  • AP Supine
  • AP erect
  • Lateral decubitus
  • Supine lateral
  • KUB

Step 1: The basics

  • Patient Identity
    • right patient
      • name
      • date of birth
      • hospital number
        • always always always check all three – statistically the probability of two patients in the hospital having the same name and date of birth is scarily high…
    • right time
      • are you looking at a previous scan or the most recent
    • right view
      • is it the same as the one you ordered?
      • is it adequately exposed?
      • can you see the whole abdomen

 

Step 2: Gasses 3,6,9

  • Small bowel
    • Look for valvulae conniventes – or rings that distinguish small bowel from large
    • Small bowel shouldn’t be more than about 3 cm in diameter
  • Large bowel
    • Look for haustra – lines only go part way across the large bowel
    • The retroperitoneal parts are easier to find as they’re relatively constant in their location:
      • ascending
      • descending
      • rectum
    • Large bowel shouldn’t be more than 6 cm in diameter
    • The caecum shouldn’t exceed 9 cm
  • Walls
    • gas in the wall of bowel suggests ischaemic colitis
  • Air-Fluid levels
    • more than four or five visible fluid levels, great than 2.5 cm long is abnormal and may suggest:
      • gastroenteritis
      • ischaemia
      • obstruction
      • ileus
  • Peritoneum
    • Rigler’s sign (double wall) is a sign of intraperitoneal gas, and may reflect perforation or penetrating trauma
    • air may be seen under the diaphragm
  • Soft tissues
    • surgical emphysema may be visible especially after trauma

Step 3: Masses

  • Solid organs
    • Liver
      • Right upper quadrant
      • Grey
      • Breast tissue may overlie the upper aspect
      • May have cholescystectomy clips present
    • Spleen
      • Left upper quadrant
    • Kidneys
      • T12-L3
      • Right lower than left due to liver
    • Bladder
  • Psoas muscles
    • bulging may indicate a retroperitoneal pathology
  • Vessels
    • Calcifications may indicate an aortic aneurysm

Step 4: Bones

  • Ribs
  • Spine
  • Sacrum
  • Pelvis
    • Check all of these for:
      • fractures
      • degeneration
      • metastasis
      • cysts

 

Step 5: Stones

  • Stones should be looked for in the:
    • Kidneys
    • Ureters
      • follow the tips of the lumbar transverse processes down to the sacroiliac joint
      • The ischial spines mark where the ureters enter the bladder
    • Bladder
    • Gallbladder
    • Pancreas (calcification)

 

Remember:

  • Piercings may look like foreign bodies
  • Not all calcification of soft tissues is clinically important

 

Hope this helps!

 

 

 

References:

https://www.rcr.ac.uk/audit/indications-plain-abdominal-films-emergency-department

https://radiopaedia.org/articles/abdominal-radiography

http://lifeinthefastlane.com/investigations/axr-interpretation/

http://www.radiologymasterclass.co.uk/tutorials/abdo/abdomen_x-ray/anatomy_system_bowel_gas

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