RADIOGRAPHIC

TECHNIQUE
FOR ABDOMEN, KUB
BY PUJA ADHIKARI
BSC.MIT 1ST YEAR
NAMS, BIR HOSPITAL
Contents
 Introduction
 Planes and regions
 Surface landmarks
 General anatomy
 Equipment
 Patient preparation
 Technique
 Radiation protection
 References
Introduction
The abdominal radiograph is a vital first-line investigation in a range of acute
abdominal pathologies. Interpretation can be very difficult and is often
performed initially by a relatively inexperienced doctor. High-quality
examination is important but may be difficult to achieve as these patients are
often in pain and may be very distended with gas.
 Planes and regions
 Divided either into four quadrants or nine regions.
 Divided into four quadrants by a transverse and a
mid sagittal plane that intersect at the umbilicus.
• Right Upper Quadrant (RUQ),
• Right Lower Quadrant (RLQ),
• Left Upper Quadrant (LUQ), and
• Left Lower Quadrant (LLQ)
Cont…
 The two parasagittal (vertical) planes
lie at right-angles to the two
transverse planes.
 They run vertically, passing through a
point midway between the anterior
superior iliac spine and the symphysis
pubis on each side.
 Called right mid clavicular line and
left mid clavicular line
Cont…
 The upper transverse plane
 The Transpyloric Plane lies midway between suprasternal notch and symphysis pubis,
approximately midway between the upper border of xiphisternum and umbilicus.
 Posteriorly, passes through the body of the first lumbar vertebra; tips of the right and
left ninth spinous process
 Anteriorly, passes through the 10th costal cartilage.
.
 The lower transverse plane
 The Trans-tubercular Plane, lies at the level of tubercles of iliac crest anteriorly, and near
the upper border of 5th lumbar vertebra posteriorly.
 Cont….
These planes divide the abdomen into nine regions:
• centrally we have epigastric followed by umbilical and hypogastric regions and
• laterally we have right and left hypochondriac region followed by lumbar and iliac
regions.
• the nine quadrants of the abdomen are usually used by anatomists for anatomical
studies.
Body habitus:
 Cont..

Hypersthenic
 Massively built resulting in widest part of abdomen being at upper part
 Dome of diaphragm high and lower costal margin at high level
 Gall bladder is away from the midline.

Asthenic
 Thin and slender resulting widest part of abdomen at lower region
 Elongated narrow thorax with narrow costal angle at low position of dome of
diaphragm
Cont..

Sthenic
 Tending towards hypersthenic
 But not as broad in proportion to height

Hyposthenic
 Tending towards sthenic
Surface landmarks

1. Xiphoid process: T9/T10

2. Costal margin: L2/L3
3. Iliac crest: L4/L5
4. Anterior superior iliac spine: 2nd sacral segment
5. Greater trochanter
6. Symphysis pubis
7. Ischial tuberosity
 General anatomy

-The largest cavity of the body,

-Bounded
Anteriorly - by abdominal wall muscles
Posteriorly - by the vertebral column and posterior wall muscles
Laterally- by lower ribs and parts of muscles of abdominal wall
Superiorly - by the diaphragm
 Membranes
• Peritoneum - serous membrane in abdominal cavity
• Mesenteries - double sheets of peritoneum, surrounding and suspending
portion of the digestive organs.
• Greater omentum - "fatty apron", hangs anteriorly from stomach, double
layer encloses fat
• Lesser omentum - between stomach and liver
• Mesentery proper - suspends and wrap small intestine
• Mesocolon - suspends and wrap colon parts
Abdominal viscera
 contains the greater part of the
alimentary tract, some of the accessory
organs pancreas, spleen, liver
 some of the urinary organs i.e. the
kidneys, upper part of the ureters and
the suprarenal glands. Most of these
structures, as well as the wall of the
cavity are more or less covered by an
extensive and complicated serous
membrane, the peritoneum
Fig: organs of posterior parts of abdomen
Peritoneum
The serous membrane related to the viscera of the abdominal
cavity.
 Divided into two layers:
 Parietal Layer : Lines the body wall and covers the retroperitoneal organs.
 Visceral Layer : Composed of two parts; Covering of the surface of the peritoneal organs.
Cont…
 Mesentery-a double layer of peritoneum that suspends part of the GI tract
from the body wall.
 Peritoneal cavity : The potential space located between the parietal and
visceral layers.
Abdominal viscera

 Viscera are classified as:

 Peritoneal organs - have a mesentery and are almost completely enclosed in
peritoneum. These organs are mobile. Eg: spleen, stomach, liver, ileum, etc.
 Retroperitoneal organs - are partially covered with peritoneum and are immobile
or fixed organs. Eg: pancreas, kidneys, esophagus, ureters, adrenal glands, etc.
 Liver
 Lies mostly in the right hypochondrium, and
protected by rib cage.
 The liver consists of four lobes: the larger right lobe,
left lobe the smaller caudate lobe and quadrate lobe.
The left and right lobe are divided by falciform(sickle
shaped) ligament which connects the liver to the
abdominal wall.
Cont….
 Has a central hilus, or porta hepatis, which receives venous blood from the
portal vein and arterial blood from the hepatic artery.
 The central hilus also transmits the common bile duct, which collects bile
produced by the liver.
 These structures, known collectively as the portal triad
 The hepatic veins drain the liver by collecting blood from the liver sinusoids
and returning it to the inferior vena cava
 Pancreas
 about 12–15 cm(5–6 in.) long and 2.5 cm (1 in.) thick, lies posterior to the
greater curvature of the stomach
v Most of the pancreas is secondarily retroperitoneal, but the distal part of the tail
of the pancreas remains peritoneal . The tip of the tail of the pancreas
reaches the hilus of the spleen.
v Both the pancreatic duct open into the second portion of duodenum

Spleen
v a peritoneal organ in the upper left quadrant that is related to the left 9th, 10th
and 11th ribs. Fracture of these ribs may lacerate the spleen.
 situated in the left hypochondriac region of the abdominal cavity
 Gall bladder
 lies in a fossa on the visceral surface of the liver to the right
of quadrate lobe.
 It stores and concentrates bile, which enters and leaves
through the cystic duct. The cystic duct joins the common
hepatic duct to form the common bile duct.
 The parts of the gallbladder are fundus, body and neck and
the fundus projects inferiorly beyond the inferior border of
liver.
 Stomach
 has a lesser curvature. which is connected to the porta hepatis of the liver by
the lesser omentum, and a greater curvature from which the greater
omentum is suspended.
 The cardiac region receives the esophagus.
 The dome-shaped upper portion of the stomach, which is normally filled
with air, is the fundus.
 The main center portion of the stomach is the body.
 The pyloric portion of the stomach has a thick muscular wall
and narrow lumen that leads to the duodenum.
Kidney
lies retroperitoneal at the level of T12-L3 .
Each kidney is composed of three million
uriniferous tubules . Each tubules has two
parts (a) secretory part (b) collecting tube
The right kidney is positioned slightly
lower than the left because of the mass of the
liver

Ureter
Ø it's narrow thick muscular tube which conveys
urine from kidney to bladder; 25 cm long
 Urinary Bladder:
 The urinary bladder is covered superiorly by peritoneum
 The body is a hollow muscular cavity
 The neck is continuous with the urethra.
 The trigone is a smooth triangular area of mucosa located internally at the base
of the bladder.
 The base of the triangle is superior and bounded by the two openings of the
ureters
 The apex of the trigone points inferiorly and is the opening for the urethra.
Equipment
• X- ray tube
• X- ray table with bucky
• HF generator
• Vertical bucky
• Cassettes
• Grid
 Indications
 Obstruction of bowel
 Perforation
 Acute abdomen
 Foreign body localization
 Toxic mega colon
 Aortic aneurysm
 Intravenous urography
 Detection of calcifications and abnormal gas collection
 Alimentary studies using barium preparation
Patient preparation
Careful preliminary patient preparation of the intestinal and gastric contents is
important for a clear view of all the abdominal structures.
For non-acute conditions, patient preparation is as follows:
(l) Patient placed on a low-residue diet for (2 days) prior to xray examination to
prevent formation of gas due to excessive fermentation of the intestinal contents
(2) Patient should be instructed to take some laxative the night before the
examination.
 Exposure technique
 In examinations of the abdomen without a contrast medium, it is necessary to obtain
maximum soft tissue differentiation throughout its different regions.
 Because of the wide range in thickness of the abdomen and the delicate differences in
physical density between the contained viscera, it is necessary to use a more critical
exposure technique than is required to demonstrate the difference in density between
an opacified organ and the structures adjacent to it.
 The exposure factors should thus be adjusted to produce a radiograph with moderate
gray tones and less black and white contrast
Cont….
 High mA and Shorter exposure time must be used to freeze voluntary and
involuntary organ movements (breathing and bowel peristalsis).
 Exposure is taken on second full arrested expiration (to displace diaphragm
upward ) to give a better view of the abdominal structures.
Immobilization
• One of the prime requisite in abdominal examinations is the prevention of
movement, both voluntary and involuntary.
• To prevent muscle contraction, the patient must be adjusted in a
comfortable position so that he /she can relax.
• A compression band may be applied across the abdomen for immobilization
but not compression.
• The exposure should be made 1-2 sec after suspension of respiration to
allow involuntary movement of viscera to subside.
Radiographic projections
Basic : Antero-posterior — supine (KUB)
 (so named because it includes the kidneys, ureters and bladder).
Alternative: Postero-anterior supine
Supplementary: Antero-posterior —erect
Lateral
Left lateral decubitus
Dorsal decubitus
AP-supine
Patient position:
 Patient is supine with the median sagittal plane at
right angles
 Pelvis adjusted so that the anterior superior iliac
spines are equidistant from the table
 Cassette placed Longitudinally and positioned so that
the symphysis pubis is included
 Arms placed alongside the trunk or above the head.
Direction and centering of the X-ray beam
The vertical central ray is directed to the center of the cassette.
Using a short exposure time, the exposure is made on arrested respiration.
Centered at l3/l4
Equipment setting:
•Collimation - laterally to the lateral abdominal wall, superior to the
diaphragm, inferior to the inferior pubic rami
•Orientation - portrait

Kv mA time mAs FFD Film size Grid Focus

65 300 0.12-0.15 30-45 100 cm 35X43 cm yes Large

 Essential image characteristics
 Coverage of the whole abdomen to include from diaphragm to inferior
symphysis pubis and lateral peritoneal fat stripe.
 Reproduction of the whole of the urinary tract (kidneys– ureters–bladder
[KUB]).
 Demonstration of the kidney outlines.
 High resolution of the bones and the adequate contrast to demonstrate the
interface between air-filled bowel and surrounding soft tissues
 PA - Prone
 When kidneys are not of primary interest, PA projection should be used. It
reduces patient's gonad dose compared to the AP projection
 Patient prone, with median sagittal plane at right angles to the table, Arms
up beside the head and both legs extended
Collimation, equipment setting, exposure
facture, picture criteria same as supine
projection.
• AP-Erect
Position of patient and cassette
• The patient stands with their back
against the vertical Bucky.
• The patient’s legs are placed well
apart so that a comfortable and
steady position is adopted.
• The median sagittal plane is adjusted
at right-angles and coincident with
the midline of the table.
• The pelvis is adjusted so that the
anterior superior iliac spines are
equidistant from the imaging tabletop
 Direction and centering of the X-ray beam
 The horizontal ray is directed so that it is coincident with the center of the
cassette in the midline.
 An exposure is taken on normal full expiration. Centered at L3/L4

Equipment setting:
Kv mA Time mAs FFD Film size Grid Focus

65 300 0.12-0.15 30-45 100 cm 35X43 cm Yes Large

Lateral
 Complement frontal views of the abdomen, often utilized in the context of
foreign bodies or to better visualize lines such as a shunt.
Patient preparation:
• Patient turned onto the side, with hands resting near the head. The hips and knees
are flexed for stability.
• With the MSP parallel to the table, the vertebral column (about 8cm anterior to
the posterior skin surface) positioned over the midline of the table, demobilization
band applied across the pelvis.
• Cassette centered at the level of iliac crests.
 Direction and centering of the X-ray beam
The vertical central ray is directed to the center of the cassette and the
exposure made on arrested expiration
Centered on iliac crest.

Equipment setting:
kV mA Time mAs FFD Film size Grid Focus

75 300 0.2-0.25 60-75 100 cm 35X43 Yes Large

 Antero-posterior – left lateral decubitus
 Lateral decubitus is done instead of abdomen erect, if the patient is unable to
stand.
 If the left side touches the cassette then it is lateral called left lateral decubitus
and vice versa.
 To confirm the presence of subdiaphragmatic gas suspected seen on the antero-
posterior supine projection. It is also used for confirming obstruction.
 With the patient lying on the left side, free gas will rise to be located between
the lateral margin of the liver and right abdominal wall. To allow time for
the gas to collect the patient should remain lying on the left side for a short
while before the exposure is made.
Position of patient and cassette
 The patient lies on the left side, with the elbows and arms flexed so that the
hands can rest near the patient’s head.
 A 35 X 43 cm cassette is positioned transversely in the vertical Bucky or
alternatively a grid cassette is placed vertically against the posterior aspect of
the trunk, with its upper border high enough to project above the right lateral
abdominal and thoracic walls.
 A small region of the lung above the diaphragm should be included on the film.
 The patient’s position is adjusted to bring the median sagittal plane at right-
angles to the cassette.
Direction and centering of the X-ray beam

The horizontal central ray is directed to the posterior aspect of the patient and
centered to L3-L4 and the center of the film

Equipment setting:
Kv mA Time mAs FFD Film size Grid Focus

65-70 300 0.12-0.15 36-45 100 35X43 Yes Large

KIDNEY , URETER AND BLADDER
 INDICATIONS
 To visualize outline of kidneys surrounded by their perirenal fat
 Opaque stones in kidney area, in the line of ureters and in the region of bladder
 Calcifications within kidney or bladder
 Presence of gas within urinary tract
 Any other acute abdominal pathology
 ANTERO-POSTERIOR
• Patient lies supine with arms rest on side or hands on chest.
• A 35x43 cm CR cassette is used to cover the region above the upper poles of kidneys to
the symphysis pubis.
• The image receptor is positioned so that the symphysis pubis is included in lower part
of images.
• The centre of image receptor is approximately 1 cm below the line joining the iliac crest
• The vertical collimated beam is directed to the centre of image receptor
• Exposure is made on arrested expiration
Note: In some of cases, it may be necessary to include collimated kidney area if superior
renal borders are missed in image
For small opacities overlying kidney, further image is taken on arrested full
inspiration which will allow differentiation of movement between opacity and
kidney which determines if the opacity is within the kidney
Antero-posterior 15 degrees caudad(KUB)
Position of patient and cassette:
 The patient lies supine on the table, with the
median sagittal plane at right-angles to cassette
and midline of the table.
 An 18X24-cm cassette is commonly used, placed
longitudinally in the tray with its lower border 5
cm below the symphysis pubis to ensure that the
symphysis is not projected off the film.
Right or left posterior oblique
Position of patient and cassette:
 From the supine position, one side is raised so that the median sagittal plane
is rotated through 35 degrees.
 To help stability, the knee in contact with the table is flexed and the raised
side supported using a non-opaque pad.
 The patient’s position is adjusted so that the midpoint between the symphysis
pubis and the anterior superior iliac spine on the raised side is over the
midline of the table.
 A 30 X 24 cm cassette is placed longitudinally in the tray with its upper
border at the level of the anterior superior iliac spines.
Direction and centering of the X-ray beam

 The vertical central ray is directed to a point 2.5 cm above the symphysis
pubis.
 Alternatively, a caudal angulation of 15 degrees can be used with a higher
centering point and the cassette displaced downwards to accommodate the
angulation.
 Note: The right posterior oblique, i.e. left side raised, will show the right
vesico-ureteric junction, a common place for small ureteric calculi to
lodge.
 Left anterior oblique
The cassette size is chosen such that a large region of the right side of the
abdomen is included.

Patient position:
 The patient lies prone on the X-ray table. The right side is raised, rotating the
median sagittal plane through an angle of 20 degrees; the coronal plane is
now at an angle of 20 degrees to the table.
 The arm on the raised side is flexed so that the right hand rests near the
patient’s head, while the left arm lies alongside and behind the trunk.
 Cont…

 The patient is moved across the table until the raised right side is over the
center of the table, and a compression band is applied.
 A 24 30-cm cassette is placed longitudinally in the Bucky tray with its
center 2.5 cm above the lower costal margin to include the top of the iliac
crest.
 Right anterior oblique:
 Patient lies supine on the table and the left side is raised rotating MSP through 20° and
trunk is supported using non opaque pad.
 Patient is moved across the table so that the right side of abdomen is over the center of
table and arms should be flexed.
 A 24x30 cassette is placed longitudinally in the tray with its center 2.5 cm above the
lower costal margin
 Collimated vertical beam is directed to a point midway between midline and the
right abdomen wall 2.5 cm above the lower costal margin
 Exposure is made on arrested respiration after Full expiration
Radiological considerations
 Not all gallstones are radio-opaque. The pattern of calcification is variable,
from an amorphous solid appearance to a concentric laminar structure.
 Calcified stones tend to gather in the most dependent part of the
gallbladder, which will usually be the fundus in the prone position.
Cholesterol stones in particular are lighter than bile and tend to float, but
they are not usually radio-opaque.
 Air in the biliary tree may be seen after instrumentation (e.g.
sphincterotomy), after passage of calculi, or in a normal elderly person with
a patulous sphincter of Oddi
 IMAGE PARAMETERS
Item Comment
Focal spot size <=1.3mm(for single focus)
Total filtration 1.3mm Al equivalent
Grid ratio 1:10
Grid frequency 40 lines/cm
Screen/flim combination Speed class 400
FFD 100 cm
Radiographic voltage 60-75 kv
mAs 30-45
Radiation protection
• Gonadal shields should often be used on males (upper edge of the shield at
the symphysis pubis). For females, shields are used only whereas they could
not obscure essential anatomical structures (the lower border of the shield
should be at the symphysis pubis).
• For potential early pregnancy, the 10-day Rule’ (the LMP) must always be
observed, unless permission has been given by the medical specialist as to
‘ignore’ it, e.g: in the case of an emergency (e.g., trauma), or in case of a
female with a removed uterus
General observation
The following is a discussion of possible indications for this
investigation'
Calculi :Acute renal colic is a severe, sharp, intermittent pain
on one side of the abdomen, often radiating to the groin or
testicle. Frequently the patient has some degree of hematuria..
Some chemical types are relatively low density, and even
when calcified are hard to see if very small, especially when
obscured by overlying gas, faeces or bone.
Solid Mass Calcification
 Solid mass calcification has wide range of radiographic appearance and
seen anywhere in the abdomen.
 These are often irregular with dense center and incomplete margin.
 They are seen along the long axis of mesentery oriented from left upper
quadrant to right lower quadrant.
 Cont…
 Calcified fibroids are the most common lower abdominal calcific masses in
women. They are often flocculent radio densities with radiolucencies within
of variable size
Intestinal obstruction
 Intestinal obstruction may have many
causes, but the commonest is adhesions
due to previous disease or surgery.
 Tumors (especially in the colon), hernias
and Crohn’s disease (especially in the small
bowel) are other common causes.
Fluid collections

 Extensive ascites may be seen as a medium

opacity band in the paracolic gutters, loss of
clarity of the liver edge, and medial
displacement of the ascending and descending
colon or small bowel loops.
 Loculated fluid collections such as abscess or
cyst will have the appearance of a soft tissue
mass, displacing bowel loops.
Perforation
 Perforation of a hollow abdominal viscus
releases free gas into the peritoneal cavity.
This can be detected sensitively by horizontal
beam radiography.
 Common causes:
• Perforated diverticular disease and
perforated peptic ulcer
Cyst Wall Calcification
 Calcium deposition can occur in the wall of fluid-filled masses such as
true epithelial cysts, pseudocysts, and aneurysms.
 On AR, it appears as, curvilinear smooth calcification with an ovoid
configuration and is often discontinuous.
 There may be mass effect on the adjacent organs or the cyst may get
distorted by the adjacent viscera or vessels. Cyst like calcification may
be seen in vascular aneurysms, hydatid cysts, perinephric hematoma,
adrenal cysts, renal carcinomas, and porcelain gallbladder.
Aortic aneurysm
 An aortic aneurysm is a balloon-like bulge in the aorta, the large artery
that carries blood from the heart through the chest and torso.
 Aortic aneurysms can dissect or rupture: The force of blood pumping can
split the layers of the artery wall, allowing blood to leak in between them.
 Abdominal aortic aneurysm may be detected by plain radiography only if
there is significant calcification in the wall of the aneurysm.
Retroperitoneal disease
Masses may be seen incidentally on plain images, displacing other
structures (especially stomach and bowel) or as lack of clarity of the psoas muscle
outline. Loss of the psoas outline may also occur in psoas abscess or hematoma.

Constipation
Constipation most commonly occurs when waste or stool moves too slowly
through the digestive tract or cannot be eliminated effectively from the
rectum, which may cause the stool to become hard and dry.
Conclusion:
Abdomen radiography is often the first radiological investigation performed in
acute abdomen. Although the role of plain radiograph is limited in the era of
cross-sectional imaging, systemic approach and vigilant search for the
radiological features on abdomen radiography maybe diagnostic and decide
further line of investigation. Various gas patterns of intraluminal and free
peritoneal air are helpful in localizing pathology. Different patterns of
calcification seen in abdomen, ingested or inserted FBs, and location of
medical devices give a clue to diagnosis.
References:

• Clark’s positioning in radiography, 13th Edition by A. S. Whitley, G.

Jefferson, K. Holmes, C. Sloane, C. Anderson, G. Hoadley.
• Merrill`s Atlas of Radiographic Positions 10th Edition by Philip W.
Ballinger, Eugene D. Frank.
• https://radiopaedia.org/
Questions for discussion

1. What projection is done if an obstruction is suspected?

2. During decubitus projection, left lateral decubitus is mainly recommended, why?
3. In foreign body detection, what kind of projections are done?
4. What is aortic aneurysm?
5. For renal pathology detection, what kind of projections can be done?
6. Why is right posterior oblique done?
7. Why is right or left anterior oblique done?
8. An additional radiograph is taken on arrested inspiration, why?
9. What are the indications for KUB radiography?
Thank you……