Abdominal x ray axr radiology training resource nchanji nkeh keneth

RADIOLOGY TRAINING RESOURCE FOR MEDICAL
IMAGING TECHNOLOGISTS/SONOGRAPHERS,
NURSES, MIDWIVES AND RELATED MEDICS
Module 5b: Abdominal X-Ray (AXR)
Course lecturer
Nchanji Nkeh Keneth
Radiologic Technologist/Sonographer
CSMRR: 001012016
+237 671459765
B.TECH/HPD in MDIRT
(St. LOUIS UNIHEBS, Univ Buea)
excellence660@gmail.com
MedicalImagingTrainingResourceForMedicalImag
Tech,Nurses,MidwivesandMedics,NchanjiNkehKeneth
1
10/23/2020

Presentation outline
 Review of Abdominal Radiographic
Anatomy
 Basic Terminologies used in AXR
 Plain Radiography (KUB Film) of the
Abdomen Abnormal Findings
 Basics on How to Read an AXR
 Radiation Protection and Safety in AXR
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Medical Imaging Training Resource
For Medical Imag Tech, Nurses,
Midwives and Medics , Nchanji Nkeh

Outcome
 At the end of this presentation, students
would have:
Learned about AXR, Basic radiographic
projections and their uses
Be able to recognize abnormal
radiographic findings and correlate with
clinical presentations
Radiation protection
10/23/2020
Medical Imaging Training Resource For Medical Imag
Tech, Nurses, Midwives and Medics , Nchanji Nkeh
Keneth
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Requirements for applicable comprehension of this
module:
All Students are Urged to review their anatomy and
physiology lectures on:
• Digestive System
• Urinary System
• Musculoskeletal System
And Pathological conditions
associated with these body systems
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Requirements for applicable comprehension of this
module:
All Students are Urged to review their anatomy and
physiology lectures on:
• Digestive System
• Urinary System
• Musculoskeletal System
And Pathological conditions
associated with these body systems
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Introduction to Abdominal X-ray
(AXR)
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Facts
 AXRs are efficient in detecting bowel perforations
and obstruction
 An AXR can show calcifications
 AXR reveals the Liver, Kidneys, Psaos muscles,
spleen, vertebrae and the bony pelvis
 AXR can detect the urinary bladder if filled
with urine at the time of the exam
 Stomach can be seen
 False positive findings are also common with
AXR
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AXR facts con’t
 Calcifications on the pancreas, gall bladder,
liver and renal stones besides the aorta are
seen on AXR
 Non-calcified normal GB, pancreas and
Blood vessels are not detected on AXR
 Foreign objects are also detected on the AXR
 Reading the Abdominal radiograph requires a
good knowledge of Gross and Radiographic
anatomy of the Abdomen
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The Abdominal X-Ray:
The abdominal x-ray (AXR) has a much more limited
value in diagnosis than a chest x-ray.
The radiation exposure of an AXR compared to a
CXR is also considerably higher. Radiation dose in One
AXR is equivalent to that gotten from 35 CXRs!!!!!!
The AXR is of mostly used in the patient with an
acute abdomen . It may guide further imaging with
other imaging modalities.
As with a CXR , an appreciation of normal structures
is vital.
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AXR Radiographic
And Gross Anatomy
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AXR aka KUB (Kidney, Ureter and Bladder )
Film
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Atlas of Human Anatomy
Third edition (260)
Review This
Four quadrants intersect umbilicus
(RUQ, LUQ, RLQ, LLQ)
Nine regions
Right hypochondriac
Right lumbar
Right inguinal (iliac)
Epigastric
Umbilical
Pubic (hypogastric)
+ Left hypochondriac
Left lumbar
Left inguinal (iliac)
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Atlas of Human Anatomy
Third edition (260)
Note
Seven landmarks
Iliac crest
Anterior superior iliac spine (ASIS}
Pubic symphysis
Greater trochanter
Xiphoid tip (T9-T10)
Inferior costal margin
Ischial tuberosity
+
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Radiographic Anatomy
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Why (in two words or less,) is
it difficult to differentiate
abdominal organs, and not
possible to visualize others
at all?
Radiographic Anatomy of
the plain film abdomen
A radiograph of the kidneys,
ureters, and bladder (KUB)
demonstrates the:
1. Size
2. Shape
3. & Position
of some, but not all the
organs in the abdominal &
pelvic cavities.
Subject Contrast
An old term was
“flat plate of the abdomen”10/23/2020
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What is normally visible
1. Liver
2. Spleen
3. psoas muscles
4. kidneys
5. flank stripes
6. bone (like crazy)
7. Calcifications
What is sometimes visible
1. Stomach and colon (gas)
2. Bladder (urine filled)
3. Arteries (calcified aorta)
What is not visible
1. Gallbladder
2. Pancreas
3. Small bowel (unless
pathological, with gas)
4. Ureters
5. Adrenal glands
6. Veins
7. Everything else
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Liver (homogeneous
shadow in RUQ)
Spleen
Stomach (c gas)
Parts of colon (c gas)
hepatic flexure
transverse colon
cecum & ascending colon
Gas, though natural,
is a negative contrast
media. In the history
of radiography, gas (air)
was injected in the bladder
and ventricles of the brain.
Carbonated soda is given
to children to create a
“window” to the kidneys
Radiographic Anatomy of the plain film abdomen
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Gas filled transverse
colon demonstrating
haustrations.
Entire colon, from
cecum to sigmoid,
filled with gas.
Unless obstructed,
distention of this
degree should be
relieved by
flautulence
More Gas
Patterns
A child’s stomach
and colon filled with
gas and feces, (speckled
appearance).
Note how the hepatic
flexure and transverse
colon define the liver
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Detail of liver in RUQ Detail of spleen in LUQRadiographic Anatomy of
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The bladder is
often seen, if
contrasted by
urine.
Gas in the
sigmoid colon
may obscure it
Detail of flank stripe Detail of urine filled bladder Radiographic Anatomy
of the plain film
abdomen
Flank stripes are not
always seen due to
lack of contrast or
clipping on larger
persons.
When visible, bowing
of the stripes may
be a sign of a mass.
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Subject contrast of the
kidneys is enhanced by the
perirenal fat capsule. They
are best seen in the asthenic
body habitus
Kidneys
Radiographic Anatomy of the plain
film abdomen
Placement of Rt marker is less than desirable
= Psoas muscles
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Calcifications can form
in various tissues, and
especially fluid filled
organs where minerals
consolidate. In the
plain film abdomen
those seen are:
* gallstones (calcium
not cholesterol)
* kidneystones
* bladderstones
* arteriosclerosis
(mostly of abdominal
aorta)
Calcifications
Radiographic Anatomy of the plain
film abdomen
Large gallstone in RUQ
If not in the RUQ, where else could it be?
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Anatomy Review: Where is it, or, at least, where should it be?
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Indications for AXR and
AXR Projections
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An AXR may be done for the
Following Reasons
1. Rule out the cause of Acute Abdomen
2. Assessment of the integrity of abdominal organs
post traumatic incident
3. Assessment of suspected calculi in the gall
bladder, pancreas, kidneys
4. Assessment of intestinal obstruction and
Perforation
5. Paralytic ileus evaluation
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Note!!
An Acute Abdomen is the
main indication for an
AXR
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Abdominal X-Ray Projections:
• Supine 99%, most preferred
• AP Erect +- PA CXR
• Lateral decubitus.
Knowledge of the anatomy of the
abdomen allows localization of the
abnormalities observed on the AXR.
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Definitions
 AP: Anterior Posterior: This projection is
done with the patient in Supine Position; It is
the Standard Examination of the Abdomen
on Plain x-rays
 PA/AP- erect: Posterior or Anterior
Projection with Patient in erect Position;
useful in assessing bowel obstruction
 Lateral decubitus Position. Indicated for
assessment of the Abdominal Aorta and
bowels
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Radiographic Positioning of the Abdomen
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Routine Upright Positioning
1. Same as KUB,
but center top
of film to axilla.
Positioning
4.
Setup and Preparation
Same as supine, expect upright.
And, patient must be in position
for at least 5 minutes prior to
exposure. Bring by WC if possible
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Standard Upright Abdomen Positioning
What (else) does the upright
demonstrate?
1. Air-fluid levels in the
bowel
2. Free air in the abdomen
(peritoneal cavity) under the
diaphragm
3. Ptosis (Change in position)
Might a change in technique be
called for on the upright?
Residual barium x 3 weeks
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Pathological Findings
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Abdominal X-Rays:
AXR-3 AXR-410/23/2020
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Small Bowel
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 Colon with barium contrast
Large bowel
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Ascites
Fluid accumulation in the
abdominal cavity, secondary
to serious disease.
Ascites creates a gray, low
contrast effect, and as in this
film, may make gas in the
bowel look trapped, or encased
by the extrinsic pressures from
the fluid.
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Small bowel
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Large bowel
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Small bowel
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Large bowel
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Small bowel
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Barium meal, stomach, duodenum and jejunum
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Small Bowel
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Assess the Film in Detail:
 Intra-luminal Gas:
 Low Small Bowel Obstruction
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Renal Stones
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Renal Stones
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HYDRONEPHROSIS AND
HYDROURETER
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STAGES OF
HYDRONEPHROSIS
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Kidneys ureters and stones
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NORMAL IVU
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HYDRONEPHROSIS
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HYDRONEPHROSIS
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 RENAL STONES
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Pancreatic Calcification
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GREY SHADOWS:
‘GREY SHADOWS’ = Soft Tissues
Soft tissues represent most of the contents of the
abdomen and feature heavily in the AXR. However,
these tissues are poorly seen when compared to
other imaging techniques such as ultrasound or CT.
The kidneys, spleen, liver and bladder (if filled) can
be seen in addition to psoas muscle shadows and
abdominal fat. Rarely would action be taken on the
basis of this imaging alone.
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Splenomegaly
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Psoas muscle
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Psoas muscle
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Psoas Abscess
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BRIGHT WHITE SHADOWS:
‘BRIGHT WHITE BITS’ = Foreign Bodies
Foreign Bodies represent an interesting final
observation . Objects that may be seen include
ingested foreign bodies , items in the path of the
x-ray beam such as belt buckles, dress buttons and
jewelry . Other objects may have been deliberately
placed for example an aortic stent, an inferior vena
cava filter or a suprapubic urinary catheter.
Sterilization clips and an intra-uterine device are
common findings in women.
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Assess the Film in Detail:
Sterilisation and Surgical Clips Intra-abdominal foreign bodies
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Hernia
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Finals Radiology Cases:
Abdominal X-Ray
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Case 1:
This 67 year-old women
presented to the surgical
ward with a distended
abdomen and vomiting.
Present this x-ray
Give a diagnosis and
potential causes
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Case 1: Answer
Radiology Report:
Plain abdominal radiograph.
Multiple dilated loops of small bowel
within the central abdomen. Gas is not
seen in the large bowel. No evidence
of hernia or gallstone to suggest
potential cause of the dilated loops.
These findings are in keep with a low
small bowel obstruction.
I would like to know if the patient has
a history of abdominal surgery as the
commonest cause is surgical
admissions.
The three commonest causes of small bowel obstruction are:
• Surgical adhesions
• Herniae
• Intraluminal mass eg, small bowel lymphoma or gallstone (in gallstone
ileus)
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Case 2:
This 71 year-old gentleman
visits his GP complaining of
in his urine. He has had a
number of UTI’s in recent
years.
Present this x-ray
potential causes
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Case 2: Answer
Radiology Report:
Plain abdominal radiograph.
Two rounded radio-opacities
measuring 4cm within the pelvis.
Both opacities are smooth in
outline, laminated in nature, have
the same density as bone and
project over the bladder . No
other renal tract calcification.
Does the patient have a history of
neurogenic bladder?
Given the size of these stones
and history of UTI’s these are
bladder calculi.
Bladder calculi are more common in those with a history of:
•UTI’s
•A neurogenic bladder
•Bladder diverticulum10/23/2020
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Case 3:
This patient was
admitted with poor renal
function.
Present this x-ray
potential causes
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Case 3: Answer
Radiology Report:
Plain abdominal radiograph
Multiple areas of punctuate
calcification project over the renal
outlines bilaterally.
The calcification is within the medulla
of the renal parenchyma. The bones
are normal in appearance.
These findings are consistent with
nephrocalcinosis
Causes of Nephrocalcinosis include:
• Hyperparathyroidism
•Medullary sponge kidney
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Systematic approach to viewing
an abdominal film:
1. Start by identifying the name on the film
and the date.
2. What is the projection of the film? Is if PA
or AP? Most are PA.
3. Is the view Supine, Erect or Lateral
Decubitus? Are there erect and supine
films? If so decide which is which.
4. Confirm that an adequate area has been
covered.
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5. Check exposure. If the spine is visible
most structures to be seen will be visible.
6. Artefacts may be immediately obvious.
Piercing of the umbilicus is very popular,
especially in young women but genital
piercing is not infrequent. Metallic objects
are obvious. There may be clips or
materials from previous surgery.
Occasionally a retained surgical
instrument is seen. Swabs contain a radio-
opaque band.
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Solid organs, hollow organs
and bones can be classified as:
 Visible or not visible
 Normal in size, enlarged, or too small
 Distorted or displaced
 Abnormally calcified
 Containing abnormal gas, fluid, or
discrete calculi
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Bones Look in a specific order
and keep to your regime:
 Lower Rib Cage
 Lumbar Spine
 Sacrum
 Pelvis
 Hip Joints
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Check bones for:
 Cortical Outline
 Joint and Disc Space
 Trabecular Pattern
 General Bone Density
 Lysis, Fracture, Sclerosis
 Epiphyseal Lines
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Solid organs
 Liver – There is soft tissue density in the
right upper quadrant that displaces any
bowel from this area.
 Spleen - Soft tissue mass in the left upper
quadrant about the size of a fist. It may
be clear or obscured but usually is not
seen at all.
 Kidneys – A shadow may be visible. The
left kidney is higher than the right. The
upper poles tilt medially. They should be
about 3 vertebrae in size.10/23/2020
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 Psoas Muscles - Form straight lines
extending infero-laterally from the
lumbar spine to the lesser trochanter of
the femur.
 Bladder - If the bladder is full, it will
appear as a soft tissue density in the
pelvis.
 Uterus - Sits on top of and may indent the
bladder. It is often not seen on plain
films.
 Prostate - Sits deep in the pelvis. Usually
only seen if calcified10/23/2020
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Hollow organs
 Stomach - When supine, air in stomach
will rise anteriorly and fluid will pool
posteriorly.
 Small Bowel - Gas will be seen in
polygonal shapes due to perstalsis.
Normal small bowel is 2.5 to 3.0 cm in
diameter. Valvulae may be seen crossing
the entire lumen. Often little small bowel
is seen on a plain film.10/23/2020
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 Appendix - Occasionally an appendicolith
is seen. Less commonly barium from an
old study, or ingested foreign bodies
appear in the appendix.
 Colon - Start in the right iliac fossa with
the caecum that may show fluid levels.
Follow it up to the hepatic flexure, over to
the splenic flexure, and down into the
pelvis. It may be filled with air or faeces.
Shape may altered by redundant bowel.
The colon is in the periphery of the
abdomen.10/23/2020
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Normal Calcification
* Costal cartilage
* Mesenteric lymph nodes
* Pelvic vein phleboliths
* Prostate gland
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Abnormal calcification Calcium
indicates pathology in
* Pancreas
* Renal parenchymal tissue
* Blood vessels and vascular aneurysms
* Gallbladder fibroids (leiomyoma)
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Calcium is the pathology in
* Biliary calculi
* Renal calculi
* Appendicolith
* Bladder calculi
* Teratoma
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 Mesenteric lymph nodes may calcify and
be confused with ureteric calculi. They are
usually oval in shape . The line of the
ureter is along the transverse processes of
the lumbar vertebrae . Phleboliths from
calcified pelvic veins may appear like
bladder stones. Calcification may appear in
the ageing prostate , low down in the
pelvic brim. Prostate calcification may also
occur in malignancy but it is not
diagnostic.
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 The pancreas lies at the level of the T9 to T
12 vertebrae . Calcification occurs in
chronic pancreatitis and may show the
whole outline of the gland.
 Between the levels of T12 and L2,
nephrocalcinosis may be seen. Calcification
of the renal parenchyma indicates
pathology including hyperparathyroidism,
renal tubular acidosis, and medullary
sponge kidney.
 Renal calculi tend to obstruct at certain
sites, especially the pelviureteric junction,
brim of the pelvis, and vesicoureteric
junctions.
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 Calcification of blood vessels usually affects the
arteries and can be quite striking. The whole
vessel may be outlined by calcium. Extensive
calcification may indicate widespread atheroma,
especially in diabetes.
 Abdominal aortic aneurysms are usually
below the 2nd lumbar vertebra. Calcification
may make them obvious and can give a rough
indication of the internal diameter.
 Abdominal ultrasound is required for
accurate assessment , and to determine the
need for surgery or follow up.
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 Gallstones are visible in only 10 to 20%
of cases. Ultrasound is vastly superior
but plain abdominal x-ray is often the
initial investigation in patients with
abdominal pain . The gallbladder may
become calcified after repeated
episodes of cholecystitis . This is called
a porcelain gallbladder and 11% will
become malignant11.
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 In the pelvic region bladder calculi
may occasionally be seen. Bladder
stones are usually quite large and often
multiple. Calcification of a bladder tumor
may also occur . Schistosomiasis may
produce calcification of the bladder wall.
 Uterine fibroids can become calcified
 Sometimes ovarian teratoma may show a
tooth. This is of passing interest although
such an ovarian tumour can
undergo torsion
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Systematic approach to
viewing an abdominal film with
contrast:
 When we examine x.ray abdomen
with contrast the following steps should
followed:
1. Which organ is examined?
2. Which type of contrast?
3. Is there a pathology or not?
4. The position and view of examiantion?
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Paralytic ileus
 Causes of paralytic ileus
– Peritoneal irritation (peritonitis, pancreatitis, hemoperitoneum,)
– Recent abdominal surgery
– Hypokalemia
– Acute bowel ischemia
– ? Neurologic mechanism (spinal fracture, passing ureteral stone, baby
delivery)
 Causes of mechanical small bowel obstruction
– Adhesions from prior abdominal surgery
– Incarcerated hernia
– Tumor
 Primary (carcinoid, lymphoma, adenocarcinoma)
 Metastatic (e.g., ovarian CA)
– Stricture (chronic ischemia, Crohn dis., radiation, endometriosis)
– Secondary involvement in adjacent inflammation (appendicitis,
diverticulitis)
– Gallstone ileus
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Paralytic Ileus on AXR
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Types of contrast
examinations
1. Esophagus
2. Stomach
3. Small intestine
4. Large intestine
5. Kidney, ureters and urinary bladder
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Contrast examination of the
esophagus
 Barium
swallow We see if there is
narrowing or
dilatation .
 if there is filling
defect in the lumen
of esophagus.
 We see if contrast reached the stomach
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Contrast examination of stomach
 We see if contrast reached the stomach
and fill it completely.
 We check contrast and air in the stomach
to detect the position of the patient
during examination.
 We see the wall of the stomach if the
is ulcer or tumor.
 There are two types of contrast positive
and negative we identify them. We see
whether the exam is with double or single
contrast.10/23/2020
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Ba meal with double contrast
Patient is in supine position
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Ba meal with single contrast
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Gass in the fandus
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Gass in the fandus
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Narrowing in the stomach
Patient is standing
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Ulcer in the wall of the
stomach
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Barium meal with single and double contrast in
prone position
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Barium meal and follow through
 The patient drinks a contrast
medium containing barium sulfate.
 X-ray images are taken as the
contrast moves through the intestine,
commonly at 0 minutes, 20 minutes, 40
minutes and 90 minutes.
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 Crohn 's disease of distal ileum with stricturing and
sacculation on the antimesenteric aspect ( curved
arrows), and fissure ulcers ( small arrows ). Open arrow
points to ileo-caecal valve.10/23/2020
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 Aphthoid ulceration of terminal ileum (small arrows)-
Note also "cobblestoning" (larger arrows).10/23/2020
123

 Chronic ileocaecal tuberculosis. The caecum and ascending
colon are retracted craniad and are fibrotic . scarred and
saccilated (curved arrows). The terminal ileum in this patient is
relatively patulous (straight arrows) and probably nodular.
v=ileocaecal valve.10/23/2020
124

Small Bowel Enema
 Enteroclysis examination demonstrates a segment of
ileum in the right iliac fossa with wall
thickening, destruction of the normal fold pattern and
aneurysmal ulceration (arrowed) and mass effect
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Small Bowel Enema
 Multiple moderate-sized and large
diverticula present.10/23/2020
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Barium Enema
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Barium enema
 To confirm colonic obstruction, a limited
barium enema is a quick, simple, cheap,
definitive exam, not requiring bowel prep
 Following are images of barium enema on
same patient who had preceding 2-way of
abdomen
 BE shows a short-segment obstructing lesion
with a polypoid intraluminal component,
indicating a sigmoid colon cancer
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Plain x-ray abdomen (erect film) showing multiple air
fluid levels in the loops of jejunum due to small gut
obstruction.10/23/2020
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Plain x-ray abdomen showing marked dilatation
of the large gut from caecum to splenic flexure
due to large gut obstruction.10/23/2020
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Plain x-ray abdomen showing dilatation of
large gut due to twisted and obstructed
caecum and ascending colon due to
volvulus
of caecum
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Plain x-ray abdomen showing air fluid level
under the right dome of diaphragm due to
presence of gas in the right subphrenic abscess
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Surgical Clips10/23/2020
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Sigmoid colon obstruction
 Causes of sigmoid colon obstruction
– Adenocarcinoma of colon
– Diverticulitis
– Sigmoid volvulus
 Following is KUB on patient with sigmoid volvulus
– Two-part obstruction (closed loop obstruction of
twisted sigmoid and upstream colon obstruction)
– Note massively dilated sigmoid, because acute
obstruction typically occurs on background of chronic
constipation and chronic colonic dilatation)
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Gas out of place
 Gas “out of place” may be seen on abdominal
X-rays
– Bowel wall
– Portal vein
– GB and biliary tree
– Urinary tract
 Following shows gas in wall of small bowel,
usually indicating dead bowel, particularly if
patient looks sick
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Case
 On following KUB most remarkable finding is
easy visibility of outside wall of some of the
bowel loops, indicating that outside wall is
outlined by air (pneumoperitoneum)
 The upright CXR confirms a large amount of
free intraperitoneal air (secondary to perforated
diverticulitis)
 Note the widened superior mediastinum on the
CXR, an incidental old finding on this elderly
female, due to intrathoracic goiter.
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Extra-luminal gas seen on erect CXR. This
indicates a Perforated Viscous
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Adult AXR Radiologic Signs
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Pediatric AXRs radiological
Signs and meaning
 Insert the radiographs
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Crazy X-ray Findings
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What? Identifying ingested or inserted
foreign bodies are another
use for the KUB film
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What in the World?
A Sprinter champion presents
with abdominal pain.
This Greenfield caval filter is in
the inferior vena cava for the
purpose of catching clots from
leg veins. If the filter were not
present, clots would travel to the
right heart, pulmonary artery, and
the arterioles of the lungs,
causing pulmonary embolism.
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There is something odd
about the gas pattern
In the area of the sigmoid
colon
And it’s shaped like a tooth
brush holder
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Perhaps from your village?
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Night watch man??
Illustration from “The Compete
Idiot’s Guide to Home Medical
Treatment,” or what?
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https://rpop.iaea.org/SAFRON/
https://rpop.iaea.org/safrad/
https://nucleus.iaea.org/isemir/
http://nucleus.iaea.org/HHW/MedicalPhysics/index.html
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Identify abnormalities with the AXRs
Below?
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ANY QUESTIONS ?
Medical Imaging Training Resource For Medical Imag Tech, Nurses, Midwives and Medics ,
Nchanji Nkeh Keneth
161
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References
1.RDSC 233 Unit 1.Plain Film
Radiography of the Abdomen.
Bontrager pp. 98-116
2.Abdominal X-ray (n.d)
3. Clark’s Positioning in Radiography;
13th edition
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https://rpop.iaea.org/SAFRON/
https://rpop.iaea.org/safrad/
https://nucleus.iaea.org/isemir/
http://nucleus.iaea.org/HHW/MedicalPhysics/index.html
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I am a proud Polyvalent Medical Imaging
Technologist
I love my Professional Field
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Nchanji Nkeh Keneth

16710/23/2020

Abdominal x ray axr radiology training resource nchanji nkeh keneth

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