PLAIN X-RAY ABDOMEN 63

PLAIN X-RAY ABDOMEN INV-08

Shuja Tahir, FRCSEd

It is the radiological examination of abdomen and The plain film is exposed with or without
its contents. preparation. The abdominal x-ray is exposed in
appropriate position. The x-ray pictures are
It is used as a screening investigation in various exposed in erect or standing position and supine
abdominal problems such as; or lying position. Occasionally the films are
exposed in lateral position as well.
1. Gastro-intestinal problems
2. Inflammations of abdominal viscera Sometimes the patient is unfit to stand, then
3. Abdominal trauma lateral decubitus film is exposed. It is a relatively
4. Urinary tract problems poor alternate and does not provide enough
5. Gynaecological problems. information. The areas of lower chest and pelvis
6. Vascular problems are also exposed to have complete visualization
7. Retroperitoneal problems. of the abdomen.

Plain x-ray abdomen (normal film) without preparation

Plain x-ray abdomen (normal film) after preparation

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The clinical data is always critically examined large intestine in small quantities. The gas is
before performing the radiological investigations. present as individual bubbles of gas scattered in
It is inspected and interpreted in an organized and the bowel.
structured manner.
Peritoneal and extra-peritoneal contents of
OVER VIEW abdomen and pelvis are examined. Pancreas
cannot be seen on plain film of abdomen.
Whole of the exposed film is seen over an
illuminater and never against sunlight or electric If a loop of bowel is seen filled with gas, it should
light to avoid wrong conclusions. Possible not be longer than 5-8 cm and should not be
provisional diagnosis is made and objective distended under normal circumstances. The gas
interpretation is done. does not form a loop pattern in healthy persons.

Large amount of gas is seen in stomach and Gas shadows outside the intestine always
colon. Stomach is identified because of its indicate intra-abdominal pathology.
anatomical position and contents. An air-fluid level
is seen under the left hemidiaphragm normally.
The presence of gas in the bowel is seen on plain
film.

Plain x-ray abdomen (normal) KUB film

Multiple gas-fluid levels in the dilated loops of

Plain x-ray abdomen showing diverging psoas shadows small or large gut indicate obstruction to the
Gas is normally present in the stomach, small and gastrointestinal flow. The level of obstruction is

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usually looked for. 3. Psoas shadow obliteration

4. Sentinel loops
The psoas shadows are visible as diverging lines
on both sides of spine starting from first lumbar Trauma may be;
vertebra towards pelvis.
a. Penetrating
The psoas shadows may be obliterated by b. Blunt
inflammatory, neoplastic and hemorrhagic
(traumatic) lesions of the organ in front and in the The penetrating injuries are usually visible on
vicinity (pancreas, spleen, liver etc.) clinical examination. But the extent of injury may
not be evaluated specifically on clinical
Ascities or presence of pus in the peritoneal cavity examination. It presents with pneumoperitoneum
is identified by typical ground glass appearance. on radiological examination in the earlier part.
It offers valuable diagnostic information.
Similarly blunt injuries of abdomen are diagnosed
Radio-opaque shadows and calcifications in the from clinical history and examination but extent
film are seen and their anatomical correlation is of injury can only be assessed by various
interpreted. investigations and sometimes even laparoscopy
or laparotomy may be required.
Soft tissue shadows of liver, spleen, kidneys, and
psoas muscle are visible normaly. Outline of PNEUMOPERITONEUM
urinary bladder, if filled with urine may be seen
on plain film. Normally no air is present in peritoneal cavity.

The plain x-ray film of the abdomen showing

complete urinary system is called KUB film
(Kidney, Ureter, Bladder film).

ABDOMINAL TRAUMA

The injuries of abdomen show various radiological

features depending upon the type, time and site
of injury.

The common features seen on plain x-ray

abdomen after various type of trauma are:

1. Pneumoperitoneum
X-ray chest showing air under the diaphragm
2. Ground glass appearance (pneumoperitoneum)

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Pneumoperitoneum is the presence of free air in GROUND GLASS APPEARANCE

the peritoneal cavity. The most common site is
usually under the right dome of diaphragm. This is a typical feature seen on x-ray abdomen.
It is visible due to presence of fluid, pus or blood
The penetrating injuries of abdomen present with in the peritoneal cavity. The presence of fluid
free air in the peritoneal cavity. gives this appearance on plain x-ray abdomen.
(Pneumoperitoneum) This is seen within few hours after penetrating
injuries of abdomen when the peritonitis has
The free air may be either due to perforation of already set in.
the hollow viscus or the air entering from the
exterior. The blunt injury of abdomen may lead to injury to
the hollow viscera leading to leakage of gastro-
The free gas appears about 1-2 hours after the intestinal contents into the peritoneal cavity and
perforation of bowel. similar radiological features.

Absence of free gas in the peritoneal cavity does

not necessarily exclude presence of perforation
as it is absent in approximately 25 % cases of
perforated duodenal ulcer. It is very rare in acute
appendicitis even if it is perforated. It is seen in
following conditions;

1. Perforated duodenal ulcer

2. Perforated gastric ulcer
3. Perforated gastric carcinoma
4. Perforated colonic carcinoma
5. Perforated colonic diverticulum
6. Traumatic gastric rupture
7. Traumatic small gut rupture
8. Traumatic colonic rupture
9. Typhoid perforation
10. Diagnostic pneumoperitoneum
11. Post laparotomy pneumoperitoneum
12. Post laparoscopy pneumoperitoneum.
Plain x-ray abdomen showing ground glass
13. Penetrating intraperitoneal injuries appearance due to presence of fluid or pus in
14. Diagnostic fallopian tube insufflation the peritoneal cavity
15. Gas gangrene of intra peritoneal viscera. PSOAS SHADOW OBLITERATION
16. Septic peritonitis with gas forming organisms
The hematomas are formed which may obliterate

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the psoas shadow in case of injury to the solid Indo-Pak subcontinent the incidence of typhoid
organs. This feature is seen in hepatic, splenic perforation is higher.
and renal trauma. It is also seen in pancreatic
injuries or infections. These conditions can be diagnosed reasonably
well by looking at the plain x-ray of the abdomen.
SENTINEL LOOPS It shows free gas under the diaphragm specially
on right side in most of the cases. Ileal perforation
An isolated distended loop of bowel is seen near due to typhoid presents in this manner.
the site of injured viscus or inflamed organ. This
loop is called a "sentinel loop". It is a feature due
to body's efforts to localize traumatic or
inflammatory lesions. The local distention of
intestinal loop is due to local paralysis and
accumulation of gas in the intestinal loop.

In acute pancreatitis, the sentinel loop is usually

seen in left hypochondrium while in acute
appendicitis, the sentinel loop is seen in right iliac
fossa. The sentinel loop is seen in right
hypochondrium in acute cholecystitis.

Other radiological features of peritonitis are also

seen in late cases of blunt injuries of abdomen,
when peritonitis has developed (Ground glass
appearance and pneumoperitoneum).

INFLAMMATORY & MISCELLANEOUS

LESIONS OF ABDOMEN

There are many inflammatory lesions of peritoneal Plain x-ray abdomen (supine film) showing
viscera. The history of illness is present for some dilated jejunal loops due to small gut
obstruction
period. The acute symptoms of intestinal
perforation and resulting peritonitis are seen as Perforations of other intra peritoneal hollow
pneumoperitoneum, ground glass appearance viscera also present similarly. Perforation of
and Psoas shadow obliteration. appendix is rarely associated with
pneumoperitoneum.
The duodenal ulcer and gastric ulcer perforations
used to be one of the most common surgical INTESTINAL OBSTRUCTION
emergencies during previous decades. Now in our
The obstruction to the flow of contents of

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68 PLAIN X-RAY ABDOMEN

gastrointestinal tract can be; distension of intestinal loops and gas fluid levels
inside the intestine.
MECHANICAL
C Acute The gas shadows are better seen in supine or
C Subacute lying position film. More than two fluid levels seen
C Chronic in small gut are abnormal and pathological.

PARALYTIC The gas filled loops of gut show increase in their

C Adynamic ileus diameter due to distension.

The fluid levels are seen in erect or standing films

or lateral decubitus films.

SMALL INTESTINAL OBSTRUCTION

The small gut distended loops are recognized by

the following features;

1. The caecum is not distended in cases of

small intestinal obstruction.
2. The location of distended loops or air fluid
level is central.
3. Fine serrations along the margins formed by
mucosal folds are complete along the
transverse axis in case of jejunum.
4. These fine serrations are very close to each
other.
5 Featureless gut (with serrations) is seen in
ileal obstruction.
Plain x-ray abdomen (erect film) showing 6 Step ladder pattern of air fluid shadows is
multiple air fluid levels in the loops of jejunum also seen some times.
due to small gut obstruction.
COLONIC OBSTRUCTION
The causes of intestinal obstruction may be
external or internal hernias, adhesions, neoplasia, The colon is distended from caecum to the
volvulous, stenotic lesions, inflammatory lesions, obstructive lesion where the distension ends
meconeum and gallstones. abruptly.

After 3-5 hours of acute intestinal obstruction, Haustrations are deeper and these are not
enough gas and fluid accumulates to show

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PLAIN X-RAY ABDOMEN 69

continuous along the transverse axis of colon. 4. The serrations are partial and incomplete.
These are in fact alternating type. These look like indentations into the
transverse diameter of the colon. These are
If caecum gets distended more than 9-10 cm it is not opposite each other but are alternating.
likely to perforate.
VOLVULUS OF COLON
Colonic obstruction presents with following
features on x-ray abdomen; In cases of volvulus of sigmoid colon, an inverted
U shaped distended loop of colon is seen in the
1. The caecum and colon are distended pelvis and abdomen. Double fluid levels may be
seen.
2. The distended colonic loops are present at
the periphery in the abdomen.

Plain x-ray abdomen showing dilatation of

Plain x-ray abdomen showing marked dilatation large gut due to twisted and obstructed
of the large gut from caecum to splenic flexure caecum and ascending colon due to volvulus
due to large gut obstruction. of caecum
3. The gas fluid levels are seen and these are
more than those normally seen in a single In cases of peritonitis, the signs of free fluid
x-ray view. present in the peritoneal cavity, sentinel loop or
a localized distended loop of bowel is seen
adjacent to the lesion.

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70 PLAIN X-RAY ABDOMEN

COLONIC CARCINOMA Presence of air fluid level under the diaphragm

is highly suspicious of subphrenic collection.
Most often these are not diagnosed from presence Ultrasound examination helps to confirm the
of soft tissue shadows. When these lesions are diagnosis.
causing partial or complete obstruction or
perforation, these can be detected indirectly from; GALL STONE ILEUS

1. Radiological features of intestinal obstruction In cases of gall stone ileus when the gall stone
2. features of intestinal perforation has ulcerated into the duodenum and descended
3. features of generalized peritonitis along the small intestine, it causes small gut
obstruction. It presents with following features;
ACUTE MESENTERIC OCCLUSION
1. All the features of small intestinal obstruction
It shows the features of peritonitis and may be are present.
detected by plain x-ray abdomen. 2. It is diagnosed by presence of stone which
is usually radio-opaque.
INTRA ABDOMINAL ABSCESSES 3. Gas shadow is seen in the biliary tree
(common bile duct, common hepatic duct and
These can not be seen on plain x-ray film directly. hepatic ducts).

Plain x-ray abdomen showing air fluid level

under the right dome of diaphragm due to
Plain x-ray abdomen showing gas in the biliary
presence of gas in the right subphrenic
passages and gall bladder due to gall stone
abscess
ileus
Various features such as presence of sentinel
loops, abnormal diaphragmatic shadows and
ground glass appearance may help in suspecting
the lesion.

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4. The gall bladder may also be filled by the gas.

Gas shadow is seen in biliary tree in following

conditions;

1. Colo-biliary fistula due to gall stone erosion.

2. Duodeno-biliary fistula due to gall stone

erosion or duodenal ulcer penetration.

3. Sphinterotomy or sphinteroplasty of sphinter

of oddi
Plain x-ray abdomen showing calcification in
the large uterine fibroid
4. Choledocho-duodenal anastomosis
CYSTS
5. Acute cholecystitis with gas forming
organisms. Soft tissue shadows of larger cysts may

GYNECOLOGICAL PROBLEMS
FIBROID UTERUS

In women, uterine shadow may also be seen

specially if the patient is not fat or the fibroid is
calcified. It is easily seen on plain film x-ray of the
pelvic area.

OVARIAN TUMOURS

Normally these are not picked up on plain film at

an early stage. Teratomas may be detected
because of radiopaque structures present in these
tumours (cartilage, teeth etc)

RENAL TUMOURS

Soft tissue renal shadow is usually seen in

properly prepared patients and occasionally renal
lesion may be detected on plain x-ray abdomen. Plain x-ray abdomen showing multiple radio-
opaque shadows in the upper part (multiple
biliary and bilateral renal stones)

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occasionally be out lined on plain film. But most Foreign bodies may be ingested accidently. These
often these are undetected and require ultrasound usually pass through the gastro intestinal tract
examination or urography for proper detection. easily if small and not pointed. Even needles
may pass without causing perforation.
CALCULUS DISEASE
The plain x-ray of abdomen helps in finding the
Stones in the gall bladder and stones in the site and type of foreign body if it is radio-opaque.
urinary system are seen as radio-opaque If the foreign body is obstructed at some place,
shadows in the relevant area. it may be removed surgically.

These cases are diagnosed if the stones are REFERENCES

radio-opaque otherwise ultrasonography,
1. Peter Armstrong. Martin L. Wastie. Plain
cholecystography or urography is required. Abdomen: In Diagnostic Imaging. 4th Edition
Blackwell Scientific publications London. pp
FOREIGN BODIES 133-143, 1998

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