Abdominal X-Rays for Phase 4. A Systematic Approach…
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Transcript of Abdominal X-Rays for Phase 4. A Systematic Approach…
Abdominal X-Rays for Phase 4
A Systematic Approach…
…with the clinical context always in mind…
…avoids pitfalls!
General Approach
• Date of Film• Patient Name• Patient Age• Sex• Adequate area
covered
Topics
• Intraluminal gas• Extraluminal gas• Calcification• Soft tissues• Bones• Foreign objects• Periphery of film
• Intraluminal gas
• Extraluminal gas• Calcification• Soft tissues• Bones• Foreign objects• Periphery of film
Normal Intraluminal Gas
• Stomach : Always • Small Bowel : Two or three loops of non-
distended bowel – Normal diameter < 3.5 cm (jejunum)– Normal diameter < 2.5 cm (ileum)
• Large Bowel : Almost always in rectum/sigmoid– Normal diameter < 5 cm (colon)– Normal diameter < 9 cm (caecum)
Stomach gas
Gas in a few loops of small bowel
Gas in rectum
Gas in ascending colon
Large or small bowel?
Small Bowel
• Centrally placed• Narrow angle of
curvature• Multiple loops• Mucosal folds cross
the full width of the bowel (valvulae conniventes)
Large Bowel
• Peripheral• Only a few loops• Mucosal folds
only cross part of the bowel width (haustra)
Small Bowel Obstruction
Mucosal folds go all the
way across
Peripheral loop of caecum
Mucosal folds only partly cross bowel
wall
Large Bowel Obstruction
Some reflux of air into terminal
ileum
Where is the level of obstruction?
Distal descending coloncancer proven at barium enema
32 year old patient, poorly controlled ulcerative colitis, presenting with
bloody diarrhoea and severe abdominal pain
Very dilated transverse colon(>6cm)
Oedematous mucosa descending colon (“thumbprinting”)
Toxic Megacolon
SURGICAL EMERGENCY
Very dilated large bowel
Haustral folds do not cross all the way
across
Normal gas pattern in ascending colon
and caecum
Sigmoid Volvulus
Apex of loop in left upper quadrant
Very dilated large bowel
Normal descending colon
Apex of loop centrally / left upper quadrant
Caecal Volvulus
Management of Volvulus
Sigmoid
• Trial of flatus tube / sigmoidoscopy
Caecal
• Surgical
Faecal Material
• Mottled appearance• Wide range of normal amount• Within large bowel
• Intraluminal gas• Extraluminal
gas• Calcification• Soft tissues• Bones• Foreign objects• Periphery of film
Extraluminal Gas
• Invariably abnormal
• Exceptions– Recent laparotomy / laparoscopy (<5 days)– Gas in biliary tree after biliary intervention
• Only seen if large (>1 litre) amount of gas
Can see both sides of the bowel wall
Gas outlining peritoneal
cavity
Pneumoperitoneum
Erect Chest X-ray is the best initial test for
excluding perforation
Free gas under diaphragm
Pneumoperitoneum
Pneumoperitoneum
Lateral decubitus view
Free intraperitoneal gas
• Intraluminal gas• Extraluminal gas• Calcification• Soft tissues• Bones• Foreign objects• Periphery of film
Normal structures that calcify
Abnormal structures containing calcium
Costal cartilage Pancreas
Mesenteric lymph nodes
Blood vessels/aneurysms
Pelvic vein clots (phleboliths)
Uterine fibroids
Prostate gland Calculi:• Biliary• Bladder• Renal
Gallstones
Renal Calcification
Calculi also within left ureter
Bladder stones
Calcified Aortic
Aneurysm
Pancreatic calcification
• Intraluminal gas• Extraluminal gas• Calcification• Soft tissues• Bones• Foreign objects• Periphery of film
Soft Tissues
• AXR relatively insensitive unless very large enlargement
• May see bowel displacement
Large pelvic mass
Bowel loops displaced
2 hours later
….after bladder catheterisation
• Intraluminal gas• Extraluminal gas• Calcification• Soft tissues• Bones• Foreign objects• Periphery of film
Bone pathology
Generalised problem
OsteopaeniaPaget’s diseaseAnkylosing spondylitis
Localised problem
FracturesOsteoarthritisMetastatic deposits
…abnormalities may be coincidental
Clue : 77 year old with known colon cancer and lower back pain
Sacral metastasis
Ankylosing Spondylitis
Bamboo spine
Fused sacro-iliac joints
• Intraluminal gas• Extraluminal gas• Calcification• Soft tissues• Bones• Foreign objects
lightbulbs toothbrush
Other foreign objects
• Sterilisation Clips – Should both lie in the pelvis
• Surgical Clips– Cholecystectomy
• Hip prostheses• Retained swabs / needles very
rare
• Intraluminal gas• Extraluminal gas• Calcification• Soft tissues• Bones• Foreign objects• Periphery of
Film
Periphery of Film
• Lung bases • Hernial orifices• Subcutaneous tissues
Strangulated right inguinal hernia
Small and large bowel obstruction
Summary
•Clinical context is very important
•Remember to have a systematice approach
CXR Tutor
…series of 9 self-directed learning presentations on Medi-CAL site
Includes tubes and lines, lung cancer, pneumothorax, interstitial lung disease and a quiz
The End