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Abdominal radiograph interpretation

Introduction

  • Patient: name, DOB, hospital number, age, sex
  • Previous films for comparison

Radiograph detail

  • Date
  • Type (supine, upright, lateral decubitus)
  • Adequacy
    • Area (diaphragm to pelvis)
    • Rotation
    • Penetration
Upper limits of normal bowel diameters – the 3-6-9 rule

3cm = small bowel

6cm = large bowel

9cm = caecum and sigmoid

Interpretation (BOB)

Briefly mention obvious abnormalities first.

Bowel

  • Small bowel
    • Identify by: central position; plicae circulares/valvulae conniventes (mucosal folds that cross the whole width of the bowel)
    • Should be <3cm in diameter (enlarged in small bowel obstruction)
  • Large bowel 
    • Identify by: peripheral position; faecal contents; haustra (pouches that protrude into the lumen)
    • Should be <6cm in diameter (enlarged in large bowel obstruction)
  • Faeces (mottled appearance)
  • Gas (normal in fundus and large bowel only): extra-luminal gas indicates perforation; check for gas in rectum if bowel obstruction suspected (presence makes complete obstruction less likely)
  • Fluid levels seen in perforation/infection

Other organs 

  • Soft tissue shadows (may be seen)
    • Liver
    • Spleen
    • Kidneys
    • Gallbladder
    • Psoas shadow (lost in retroperitoneal inflammation or ascites)
  • Calcification of pancreas (chronic pancreatitis), abdominal aorta (atherosclerosis) or renal stones/gallstones

Bones

  • Spine and pelvis: Paget’s disease (cotton wool lytic/sclerotic pattern); metastasis (lytic/sclerotic lesions); osteoarthritis (loss of joint space, osteophytes, subchondral sclerosis/cysts); vertebral fractures

To complete

  • ‘To complete my analysis, I would examine previous films and ascertain the clinical history.’
  • ‘If there is any suspicion of perforation, I would request an erect chest x-ray to look for air under the diaphragm.’
  • Summarise and suggest differentials

Test yourself – what are the radiographic features of these common pathologies

Small bowel obstruction

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Large bowel obstruction

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Toxic megacolon

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Volvulus

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Chronic pancreatitis

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Pneumoperitoneum

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Here’s some radiographs for you to interpret!

This patient presented with vomiting. Click the image to enlarge.

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Systematically interpret the above radiograph

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What is the diagnosis?

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How would you investigate/manage the patient?

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This patient presented with abdominal pain. Click the image to enlarge.

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Systematically interpret the above radiograph

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What is the diagnosis?

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How would you investigate/manage the patient?

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