This document provides information on interpreting normal and abnormal abdominal radiography findings. It begins by showing a normal abdominal x-ray with labeled anatomy like the stomach, colon, feces, kidney and psoas margins. It then discusses abnormalities like pneumoperitoneum where free gas is seen under the diaphragm. Other techniques for detecting free gas are described, and findings that can mimic gas are presented. Specific conditions like gastric ulcer, small bowel obstruction, ileus and sigmoid volvulus are shown. The document concludes with emphasizing that a normal abdominal x-ray will show normal bowel gas pattern and soft tissues with no air fluid levels.

1. ABDOMINAL
RADIOGRAPHY
INTERPRETATIO
N
DR MALEYA

2. NORMAL
ABDOMINAL
RADIOGRAPHY

4. Normal bowel gas pattern.
4
Gas is in the stomach (St) and colon (C). There is practically no gas in
small bowel. Feces (F) in the colon has a stippled gas appearance. The
kidney (K) and psoas margins (Ps) are visible because they are outlined
by fat (arrowheads).

9. ABNORMAL
ABDOMINAL
RADIOGRAPHY

10. : Pneumoperitoneum
10
Free gas under diaphragm’ – indicates free peritoneal
gas between the dome of the hemidiaphragm and
superior surface of liver.
Pneumoperitoneum

12. Other Radiographic Techniques That Can Detect Free
Intraperitoneal Air 12
1. Rigler sign=
doublebbowel wall
sign
2. Triangular sign- gas
collecting between
adjacent bowel loops.
B. supine AXR
3. Football sign- gas in peritoneum within a distended abdomen
outlining intraabdominal Viscera

13. Other Radiographic Techniques That Can
Detect Free Intraperitoneal Air
13
On the upright abdominal radiograph, free air is visible under
the middle dome of the diaphragm—the cupola sign (arrow).
Normal cupola sign

14. Large pneumoperitoneum (CXR)
 A very large amount
of free air within the
peritoneal cavity lying
beneath both
diaphragms
 The liver and spleen
are pushed
downwards and the
diaphragms upwards.

15. Pneumoperitoneum (supine plain
abd film)
 Large collection of
air in the L flank
 There is a ‘double
wall sign’ the outer
wall of the bowel
can be well seen.
 The small bowel is
dilated due to ileus

16. If clinical suspicion remains high despite a negative CXR
16
1. A CT scan is better at demonstrating the extent of intraperitoneal
free gas and detecting small amounts of gas collects anterior to the
liver
2. A watersoluble contrast examination of the bowel may help to
confirm/rule out the diagnosis (by demonstrating contrast leakage from
the site of perforation

17. Other Radiographic Techniques That Can Detect Free
Intraperitoneal Air
17
Demonstrates a crescent of free intraperitoneal air between the liver edge
and lateral abdominal wall.
A.left lateral decubitus view
(for patient too ill to stand or sit upright)

18. Chest Radiographic Findings That Can Mimic Free Intraperitoneal Air

19. Chest Radiographic Findings That Can Mimic Free Intraperitoneal Air
19
The hepatic flexure of the colon has migrated superior to the liver.
This can mimic free air under the right hemidiaphragm on a chest radiograph.
A. Hepatodiaphragmantic interposition of the colon

20. Chest Radiographic Findings That Can Mimic Free Intraperitoneal Air

21. Chest Radiographic Findings That Can Mimic Free Intraperitoneal Air
21
Subdiaphragmatic air mimicked by
the inferior margin of a rib (arrow).
By following the inferior margin of
the rib to the lateral chest wall
(arrowhead), it can be determined
that this is not free air but a rib.
B . Rib margin that parallels diaphragm

22. Free air under the diaphragm is seen better on an
upright chest radiograph than an upright
abdominal radiograph.
22
Second, abdominal radiographs are exposed for soft tissues and
subdiaphragmatic air is therefore overpenetrated (too dark) and not visible).

24. Free air under the diaphragm is seen better on an upright
chest radiograph than an upright abdominal radiograph.
24
The chest radiograph clearly
shows free air on the right
(arrowhead
Volumes as small as 1–2 ml of free
air may be detected (Miller et al.
1971 and 1980).

25. 25
First, on an upright chest radiograph,
the x-ray beam is centered near the
diaphragm rather than the
midabdomen, and is therefore parallel
to the intra-abdominal air/fluid level
x-ray beam is obliquely
oriented at this level.

26. Are we together?
Yes, we are together!
26

27. Gastric ulcer 27
Gastric ulcer on the lesser curve. Note how the gastric folds are pulled
towards it instead of passing longitudinally down the body of the stomach
Normal mucosal pattern

28. Small bowel obstruction supine
position
 Dilated loops of
small bowel
recognized by:
 valvulae conniventes
in the jejunum.
 The bowel is lying
centrally

29. Small bowel obstruction upright position
 Dilated loops of
small bowel showing
multiple short air-
fluid levels

30. Ileus supine position
 Dilated loops of
small bowel

31. Ileus upright position
 Few and long air-
fluid levels

32. Sigmoid volvulus supine
position
 Greater diameter
and irregular folds
showing the
appearance of
haustrations
 The bowel shows
central loop due to a
dilated sigmoid loop

33. Carcinoma of esophagus
 A long stricture and
irregularity of the
lumen due to
mucosal destruction.

34. NORMAL ABDOMINAL X-RAY
 NORMAL BOWEL GAS PARTEN
 NORMAL SOFT TISUES
 THERE IS GAS IN THE RECTUM
 NO AIR FLUID LEVELS
 CONCLUSION:
1. NORMAL ABDOMINAL X-RAY

35. 35
QUESTIONS