Abdominal X-ray

Radiological Signs

Suzanne OHagan

Lightbulb moment
a moment of sudden inspiration, revelation, or recognition

Approach to AXR
Bowel gas pattern
Extraluminal air
Soft tissue masses
Calcifications

Normal AXR
Liver
11th rib

T12

Gas in
stomach

Splenic flexure

Psoas margin
Left kidney
Hepatic flexure

Transverse colon

Iliac crest
Gas in sigmoid
Sacrum

Gas in caecum
Bladder

SI joint
Femoral head

Gas pattern
What is normal?
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

Normal fluid levels

Stomach
Always (upright, decub)

Small bowel
Two or three levels
acceptable (upright, decub)

Large bowel
None normally
(functions to remove fluid)

Large vs small bowel

Large bowel
Peripheral (except RUQ occupied by liver)
Haustral markings dont extend from wall
to wall

Small bowel
Central
Valvulae conniventes extend across lumen
and are spaced closer together

Radiographic principles
Series of films for acute abdomen
Obstruction series/ Acute abdominal
series/ Complete abdominal series
Supine (almost always)
Upright or left decubitus (almost always)
Prone or lateral rectum (variable)
Chest, upright or supine (variable)

Acute abdominal series

What to look for
VIEW

LOOK FOR

SUPINE ABDOMEN

Bowel gas pattern

Calcifications
Masses

PRONE ABDOMEN

Gas in rectosigmoid
Gas in ascending and
descending colon

UPRIGHT ABDOMEN

Free air, air-fluid levels

UPRIGHT CHEST

Free air, lung pathology

secondary to
intraabdominal process

Substitutes:

Prone
Upright
Upright chest

Lateral rectum
Left lateral decub
Supine chest

Obtaining views

Supine
Patient on back, x ray beam directed
vertically downward, casette
posterior, x-ray tube anterior (AP)

Prone
Patient on abdomen, x-ray beam
directed vertically downward,
cassette anterior, x-ray tube
posterior (PA)

Upright
Patient stands or sits, x-ray beam
directed horizontally, cassette
posterior, x-ray tube anterior (AP)

Upright chest
Patient stands or sits, horizontal xray beam, cassette anterior, x-ray
tube posterior (PA)

1900s X-Ray-based fluoroscopy machine

in which radiation is shot directly through
the patient and into the doctors face.

Abnormal Gas Patterns

Functional ileus
One or more bowel loops become aperistaltic
usually due to local irritation or inflammation
Localised sentinel loops (one or two loops)
Generalised (all loops of large and small bowel)

Mechanical obstruction
Intraluminal or extraluminal
Small bowel obstruction
Large bowel obstruction

3, 6, 9

RULE

Maximum Normal Diameter of

bowel
Small bowel
3cm
Large bowel
6cm
Caecum
9cm

Localised ileus
Key features
One or two persistently
dilated loops of small or
large bowel (multiple views)
Often air-fluid levels in
sentinel loops
Local irritation, ileus in
same anatomical region as
pathology
Gas in rectum or sigmoid
May resemble early SBO

Causes of Localised Ileus

by location
SITE OF DILATED
LOOPS

CAUSE

Right upper
quadrant

Cholecystitis

Left upper quadrant

Pancreatitis

Right lower quadrant Appendicitis

Left lower quadrant

Diverticulitis

Mid-abdomen

Ulcer or kidney/ureteric
calculi

Colon cut off sign

Abrupt cutoff of colonic gas column at the splenic flexure (arrow). The colon is
usually decompressed beyond this point.
Explanation:
Inflammatory 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 mechanical
narrowing of the splenic flexure at
the level where the colon returns
to the retroperitoneum.

Generalised ileus
Key features
Entire bowel aperistaltic/hypoperistaltic
Dilated small bowel and large bowel to
rectum (with LBO no gas in rectum/sigmoid)
Long air-fluid levels
CAUSE

REMARK

*Postoperative

Usually abdominal surgery

Electrolyte imbalance

Diabetic ketoacidosis

* almost always

Generalised adynamic ileus

The large and
small bowel are
extensively airfilled
but not dilated.
The large and
small bowel "look
the same".

Mechanical SBO
Dilated small bowel
Fighting loops (visible loops, lying
transversely, with air-fluid levels at
different levels)
Little gas in colon, especially rectum

SBO Erect

Air fluid levels

SBO Supine

Causes of Mechanical SBO

Adhesions
Hernia*
Malignancy
Gallstone ileus*
Intussesception
Inflammatory bowel
disease

* May be visible on AXR

Step ladder appearance

Loops
arrange
themselves
from left
upper to
right lower
quadrant in
distal SBO

Coil spring sign

String of pearls sign

Considered diagnostic of obstruction (as opposed to ileus)

and is caused by small bubbles of air trapped in the
valvulae of the small bowel.

Stretch/slit sign

Slit of air caught in a

valvulae, characteristic
of SBO

Closed loop obstruction

Two points of same loop of bowel
obstructed at a single location
Forms a C or a U shape
Term applies to small bowel, usually
caused by adhesions
Large bowel, called a volvulus

Crescent Sign
Caused by:
LUQ Soft tissue mass
OR
Head of intussusception
in distal transverse colon

Double Bubble Sign

Duodenal Atresia

Mechanical LBO
Colon dilates from
point of obstruction
backwards
Little/no air fluid
levels (colon
reabsorbs water)
Little or no air in
rectum/sigmoid

Large bowel obstruction

Bowel loops tend not to
overlap therefore
possible to identify site
of obstruction
Little or no gas in small
bowel if ileocaecal valve
remains competent*
* If incompetent, large bowel
decompresses into small bowel, may
look like SBO

Causes of Mechanical LBO

TUMOUR
VOLVULUS
HERNIA
DIVERTICULITIS
INTUSSUSCEPTION

Note on volvulus
Sigmoid colon has its own mesentry
therefore prone to twisting
Caecum usually retroperitoneal and
not prone to twisting; 20% people
have defect in peritoneum that
covers the caecum resulting in a
mobile caecum

Volvulus
A volvulus always extends away from the area of twist.
Sigmoid volvulus can only move upwards and usually
goes to the right upper quadrant. Caecal volvulus
can go almost anywhere.

Coffee Bean Sign

Sigmoid volvulus

Massively
dilated
sigmoid loop

Hernia

Lateral decubitus of value

The advantage is that there may be a greater chance of air entering the
herniated bowel because it is the least dependent part of the bowel in the
supine position.

Apple core sign

Radiologic manifestation of
a focal stricture of the bowel
usually at contrast material
enema examination. The
stricture demonstrates
shouldered margins and
resembles the core of an
apple that has been
partially eaten. The most
common cause is an
annular carcinoma of the
colon.

Thumbprinting
The distance between
loops of bowel is increased
due to thickening of the
bowel wall.
The haustral folds are very
thick, leading to a sign
known as 'thumbprinting.'

Lead pipe
colon
Shortening
of colon
secondary to
fibrosis
Loss of
haustration
Ulcerative
colitis

Extraluminal air
TYPES
Pneumoperitoneum/free air/intraperitoneal air
Retroperintoneal air
Air in the bowel wall (pneumatosis
intestinalis)
Air in the biliary system (pneumobilia)

Upright film best

The patient should be positioned sitting
upright for 10-20 minutes prior to
acquiring the erect chest X-ray image.
This allows any free intra-abdominal gas
to rise up, forming a crescent beneath
the diaphragm. It is said that as little as
1ml of gas can be detected in this way.

Free Air
Causes
Rupture of a hollow viscus

Perforated peptic ulcer

Trauma
Perforated diverticulitis (usually seals off)
Perforated carcinoma

Post-op 5-7 days normal, should get less with

successive studies *NOT ruptured appendix (seals
off)

Signs of free air

Crescent sign
Chilaiditis sign
Riglers (and False Riglers)
Football sign
Falciform ligament sign
Triangle sign
Cupola sign
Lesser sac sign

Crescent Sign II
Free air under the diaphragm

Best demonstrated on
upright chest x rays or
left lat decub
Easier to see under
right diaphragm

Chilaiditis sign
May mimic air under
the diaphragm
Look for haustral folds
Get left lat decub to
confirm
In patients who have cirrhosis
or flattened diaphragms due to
lung hyperinflation, a void is
created within the upper
abdomen above the liver. This
space may be filled by bowel. If
this bowel is air filled then it
may mimic free gas.

Riglers Sign
Bowel wall visualised on both sides due to intra and extraluminal air
Usually large amounts of free air
May be confused with overlapping loops of bowel, confirm with upright view

False Riglers Sign

The Rigler sign can sometimes be
simulated by contiguous loops of bowel,
whereby intraluminal air in one loop of
bowel may appear to outline the wall of
an adjacent loop, which results in a
misdiagnosis of free air.
Measure distance of interface if unsure

Football SIgn
Seen with massive
pneumoperitoneum
Most often in children
with necrotising
enterocolitis
In supine position air
collects anterior to
abdominal viscera

Paediatric

Adult

Falciform ligament sign

Normally
invisible.
Supine film, free
air rises over
anterior surface
of liver

Other patterns of air around

liver

Doges Cap Sign

Inverted V sign
On the supine radiograph, an inverted
"V" may be seen over the pelvis in a
patient with pneumoperitoneum.
While in infants this is produced by
the umbilical arteries, in adults it
appears to be created by the inferior
epigastric vessels

Continuous diaphragm sign

Sufficient
free air, left
and right
hemidiaphragms
appear
continous

Lesser sac Sign

Cupola Sign
Cupola
sign

Lesser
sac
sign

(white
arrows)

(black
arrows)
The lesser
sac is
positioned
posterior to the
stomach and is
usually a potential
space. There is
free connection
between the lesser
sac and the
greater sac
through the
foramen of
Winslow

Air superior to
left lobe of
liver

Double Bubble Sign

Cupola Sign

Air beneath the central tendon of the diaphragm

The term cupola comes from a dome such as

this famous dome of the Duomo in Florence.

Triangle Sign
The triangle
sign refers to
small triangles
of free gas that
can typically be
positioned
between the
large bowel and
the flank

Retroperitoneal Air
Recognised by:
Streaky, linear appearance outlining
retroperitoneal structures
Mottled, blotchy appearance
Relatively fixed position

May outline:
Psoas muscles
Kidneys, ureters, bladder
Aorta or IVC
Subphrenic spaces

Causes of retroperitoneal air

Bowel perforation (appendix, ileum,
colon)
Trauma (blunt or penetrating)
Iatrogenic
Foreign body
Gas producing infection

Pneumoretroperitoneum

This patient has free air in

the retroperitoneal space.
The air is seen
surrounding the lateral
border of the right kidney
(white arrow). There is
other evidence of free gas
including Rigler's sign.

If you are not confident

that the appearance is
pneumoretroperitoneum,
you can try an erect and
decubitus view to see if
the gas moves. If the gas
is seen to move, it's not in
the retroperitoneum.

Air in the bowel wall

Signs
Best seen in profile producing a linear
lucency that parallels the bowel
Air en face has a mottled appearance
resembling gas mixed with faeculent
material

Causes of air in bowel wall

Primary Pneumatosis cystoides intestinalis (rare)
usually affects left colon
Produces cyst-like collections of air in the submucosa or
serosa
Secondary
Diseases with bowel wall necrosis
Obstructing lesions of the bowel that raise intraluminal
pressure
Complications
Rupture into peritoneal cavity
Dissection of air into portal venous system

Pneumatosis intestinalis
Intramural
air, best
appreciated
in profile

Air in the biliary tree

One or two tube-like branching
lucencies in the RUQ, conform to
location of major bile ducts

Causes
Normal if Sphincter of Oddi incompetence
Previous surgery including sphincterotomy
or transplantation of CBD
Pathology (uncommon)
Gallstone ileus: gallstone erodes through wall of
GB into the duodenum producing a fistula
between the bowel and the biliary system.
Stone impacts in small bowel = mechanical
SBO. ileus misnomer

Biliary vs Portal Venous Air

Portal venous air
usually
associated with
bowel necrosis
Air is peripheral
rather than
central
Numerous
branching
structures

Soft tissue masses

Organomegaly
Know normal landmarks
2 ways to identify soft tissue
masses/organs:
Direct visualisation of edges of structure
Indirect by displacement of bowel
CT, US and MRI have essentially replaced conventional
radiography in the assessment of organomegaly and soft
tissue masses

Abdominal
Calcifications
Location

Pattern

First exclude artefact

Kim Kardashians butt real or artefact?

Location

Vascular
Liver
Gallbladder
Spleen
Pancreas
Lymph nodes
Adrenals
Kidneys
Ureters
Bladder
Prostate

Rim-like
Calcification that has occurred in the wall
of a hollow viscus
Cysts
renal, splenic, hepatic

Aneurysms
aortic, splenic, renal artery

Saccular organs
Gallbladder
Urinary bladder
Calcified hydatid cysts

Linear/Track
Calcification in walls of tubular
structures
Aortoiliac calcification
Arteries
Fallopian tubes
Vas deferens
Ureter

Chinese Dragon Sign

Calcified splenic artery

Calcified vas deferens

Floccular, Amorphous,
Popcorn
Formed in solid organ or tumour
Pancreas (chronic pancreatitis)
Leiomyomas of uterus
Ovarian cystadenomas
Lymph nodes
Adenocarcinomas of stomach, ovary, colon
Metastases
Soft tissue (previous trauma, crystal
deposition)

Calcified
enteric
lymph nodes

Calcified
fibroids

Calcified
pancreas

Floccular

Lamellar or laminar
Formed around a nidus inside hollow
lumen
Concentric layers due to prolonged
movement of stone inside hollow viscus
Renal stones
Gallstones
Bladder stones

Bladder calculi

Lamellar

Renal calculi
Pelvicalyceal calcifications

Staghorn Calcification

Tubular

Renal stones are often small, but if large

can fill the renal pelvis or a calyx, taking on
its shape which is likened to a staghorn.

Renal calculi
Parenchymal calcification

Nephrocalcinosis
Uncommonly the renal
parenchyma can become
calcified.
This is known as
nephrocalcinosis, a condition
found in disease entities such
as medullary sponge kidney
or hyperparathyroidism.

Flocculent

Putty Kidney
"Putty kidney"
sacs of casseous,
necrotic material
(TB)
Autonephrectom
y small,
shrunken kidney
with dystrophic
calcification
Flocculent

Calcified gallstones

Lamellar

Conclusion
Approach to AXR should include gas
pattern, extraluminal air, soft tissue
and calcifications
Named radiological signs are a useful
way of remembering, identifying and
reporting on films

References

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http://www.swansea-radiology.co.uk Radiology Teaching Site. Introduction to abdominal
radiography
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2007.

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