Critical Findings on AXR

8/8/2019 Critical Findings on AXR

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Plain abdominal radiographs are commonly

ordered in inpatient and outpatient settingsfor patients with a variety of abdominalcomplaints. In addition to the gastrointestinalsystem, a variety of critical and/or incidental

findings in the genitourinary, hepatic, biliary,and vascular systems can all be identified onabdominal radiographs. The plain abdominalradiograph shown demonstrates milk-of-

calcium bile with a stone (arrow) fromprecipitated calcium carbonate within thegallbladder lumen.


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A middle-aged patient presents with right upper

quadrant pain that radiates to the back. It isunrelated to any position or physical activity.

An abdominal radiograph is performed and

reveals what crucial finding?


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The patient is suffering from emphysematous

cholecystitis caused by an infection of thegallbladder by a gas-forming organism. The

classic radiographic findings are a curvilinear

outline of the gallbladder wall caused by air in

the right upper quadrant. It may be either

calculous or acalculous, as in this case.

Changes may be visible earlier in the disease

course on ultrasound or computedtomography (CT).


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Another example of emphysematous

cholecystitis (arrow) is shown with airpredominately in the gallbladder lumen.


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A routine abdominal radiograph is ordered by a

primary care physician for a patient with long-

standing abdominal pain. What incidental

critical finding is present on the view of the

lower abdomen and pelvis?


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The radiographs reveal calcifications within the wall

of the abdominal aorta outlining an abdominalaortic aneurysm. An outpouching is seen on thefrontal radiograph to the left of the spine (curvedline), but the right margin overlies the spine,

making it difficult to discern if it is ectasia or ananeurysm. A lateral radiograph in the samepatient reveals the full extent of the aneurysmand confirms the diagnosis (circle). Aortic

aneurysms are usually an incidental finding onplain radiographs and can best be evaluated withCT, ultrasound, or magnetic resonance imaging.


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A patient presents to his primary care physician

with chronic abdominal pain of several years'duration. He has a history of profound alcohol

abuse. An abdominal radiograph is performed

and reveals what classic finding?


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The radiograph reveals coarse calcifications in

the anatomic location of the pancreas,consistent with the diagnosis of chronic

calcifying pancreatitis. Precipitation of

proteinaceous material in the pancreatic ducts

form plugs that calcify and build up. Long-

standing alcohol abuse is invariably the most

common cause, found in more than 70% of

cases.


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On plain CT, the calcifications of chronic

pancreatitis (arrows) are easily seen within

the body and tail of the pancreas.


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A recent immigrant from Argentina presents to

his primary care provider for an initial visit. He

has worked as a farmer his whole life and lived

in a rural area. His primary complaints are a

vague abdominal pain and a feeling of

abdominal distention. A plain abdominalradiograph is ordered and reveals what critical

finding?


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The radiograph reveals multiple large curvilinearcalcifications overlying the liver. The list of

differential considerations would include cyst,abscess, or metastatic disease, but in this patientfrom a rural area of South America the most likelydiagnosis is hydatid cysts. Hydatid cysts arecaused by the larval cystic stage of a tapeworm

from the genus Echinococcus, endemic to theMediterranean, South America, Africa, andAustralia. The classic radiographic features arelarge well-defined curvilinear or ring-line

calcifications in the right lobe of the liver. In mostpatients they are asymptomatic until they eitherrupture or cause mass effect.


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A patient presents to the emergency

department with vague abdominal pain. A

plain abdominal radiograph is ordered to ruleout obstruction. No obstruction was detected

but what incidental finding is present and

what should the clinician tell the patientabout the associated risk for malignancy?


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The radiograph reveals a pyriform opaque mass

with curvilinear calcification in the right upper

quadrant from a porcelain gallbladder. The

gallbladder wall may be diffusely calcified or have

irregular stippled calcifications. This is usually an

incidental finding in asymptomatic patients.Although it was originally thought that there was

a high association between porcelain gallbladder

and adenocarcinoma, more recent research has

revealed a much weaker association and inpatients with diffuse calcification there is no

increased risk for cancer.


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with complaints of intermittent abdominal

pain, nausea, and vomiting for the previous

few days. He was finally able to get an

appointment but by now his symptoms have

resolved. His physician orders a plainradiograph of the abdomen, which reveals

what likely finding to explain his previous

symptoms? Image courtesy of Wikimedia

Commons.


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The radiograph reveals multiple calcifications

(circles) overlying the kidneys from

nephrolithiasis. The patient's symptoms were

thus likely renal colic from spontaneous passage

of a stone. Knowledge of the anatomic location of

the kidney is important to differentiate renalstones from other common, benign sources of a

calcification seen on radiographs, such as

phleboliths (arrows). Approximately 90% of renal

calculi can be detected with radiography, but uricacid stones may be missed. Image courtesy of

Wikimedia Commons.


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Stones may also be detected anywhere along

the length of the ureter especially at the

ureterovesicular junction (arrow) where the

ureter enters the bladder. This is a common

location for stones to become stuck and it may

be difficult to differentiate them fromphleboliths. Phleboliths are benign venous

calcifications commonly found in the pelvis.


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A 68-year-old woman presents to the

emergency department with acute abdominalpain. An abdominal radiograph is ordered and

reveals what predominant abnormality?

(Bonus question: what other, more subtle

critical finding is also present?)


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The radiograph reveals multiple calculi distributedin a pyriform shape in the right upper quadrant,

diagnostic of gallstones. Only 15% of gallstoneswill appear on plain radiographs, compared with85% on CT. It is important to recognize thatcholelithiasis in isolation does not meancholecystitis and must be placed in the

appropriate clinical circumstances. The secondcritical finding on this radiograph ispneumperitoneum in the left upper quadrant(arrow) which could easily be missed if one is

distracted by the gallstones. This patientunderwent a laparotomy and was found to have aperforated cecal carcinoma.


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An abdominal radiograph is ordered in a 72-

year-old woman with a history of repeated

urinary tract infections who presents with

symptoms of renal colic. What classic finding

is present and what is the most likely

composition?


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The radiograph reveals bilateral renal calculi

with a staghorn calculi on the right. Any stone

that occupies 2 or more renal calyces is

termed a staghorn calculi, but 75% of cases

are struvite stones composed of a struvite-

carbonate-apatite matrix. These typicallydevelop from urease-producing bacteria, most

commonly Ureaplasma urealyticum and

P

ro

teus

species. These stones will not passspontaneously and if they grow too large, they

need to be surgically removed.


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with complaints of vague abdominal pain. He

is currently being evaluated by an oncologist

for a suspicious thyroid mass. The clinician

orders a plain radiograph of the abdomen,

which reveals what worrisome finding?


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The radiograph reveals hepatomegaly and multiple

calcifications in the upper abdomen (arrows)

concerning for hepatic metastases. The patient

was ultimately found to have medullary

carcinoma of the thyroid with extensive

metastatic spread. The liver is a very commonlocation for metastatic spread from a variety of

malignancies. Mucin-secreting colorectal cancer

is the classic malignancy to produce metastatic

liver calcifications. Other nonmalignant processesmay produce liver calcifications, but they usually

tend to be more solid and less amorphous.

Critical Findings on AXR

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