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Abdominal Radiography – Radiology | Lecturio

Abdominal Radiography – Radiology | Lecturio

[Music] so before we delve into the many abnormalities that can be found within the abdomen on an x-ray let’s review first some of the normal findings on an abdominal film and a normal approach so most abdominal imaging and diagnosis involves the use of ultrasound CT or MRI however radiographs are often used as a quick first step to help you decide what further imaging is needed next if any so what can be evaluated on abdominal plain films the bowel gas pattern is a very important thing you could always evaluate for free air which is something that you really don’t want to miss abnormal calcifications can be seen on abdominal radiographs or abnormal masses so these are the four major points that you want to keep in mind when you’re taking a look at an abdominal radiograph so let’s come up with a general approach as with Olive radiology it’s important to have a standard approach so that you make sure that you look at every aspect of the film so what I do is I start off with the lung bases even though we’re performing an abdominal film oftentimes a patient may have an abnormality at the lung base that you don’t want to miss I then look for free air because this is a finding that you really don’t want to miss on an abdominal plane film next I look at the bell gas pattern and then I evaluate the solid organs I then look for any abnormal soft tissue masses any abnormal calcifications and lastly I take a look at all of the bony structures so before we look at the abdominal normal Anatomy on a radiograph let’s just review what normal abdominal Anatomy looks like on a diagram so a large part of the upper abdomen is encompassed by the liver it’s essentially seen in the right upper abdomen but also extends over to the left upper abdomen adjacent to it is the spleen and oftentimes on a radiograph you can see the outline of both the spleen and the liver the gallbladder is usually not well seen on an abdominal plane film however it if it has calcifications in it such as gall stones that may be visualized and then the majority of the rest of the abdomen is encompassed by large bowel which is seen peripherally and then small bowel which is usually seen centrally so let’s review some radiographic anatomy so again start off by taking a look at the lung bases and you can see them on every abdominal radiograph so you can see the diaphragm here on the right and then you can see the left hemidiaphragm here and just above it are the lung bases and a small portion of the heart in the left upper abdomen you can see the stomach bubble it usually has a little bit of air and then it has an air fluid level which is again normal you can see the outline of the liver primarily encompassing the right upper abdomen and then you can see air within the large and small bowel in terms of bony structures you can take a look at the iliac crests which really should be included on every abdominal radiograph and you can see the thoracic and lumbar spines so how can you differentiate between small and large bowel on a radiograph when there’s a bowel abnormality it’s important to try and see which bowel it’s involving so the small bowel is located centrally and it has valvular markings called valve you leak on event days they cross the entire width of the small bowel and they’re spaced very close together they have the classic stacked coin appearance so if you take a look at these stacks of coins the small barrel actually looks very similar to that and that’s a very classic appearance of small bowel large bowel on the other hand is usually located peripherally and it contains house draw so the house tray either do not connect from one wall to the other or they’re spaced a lot wider apart than the valve you leak on event azar so if you take a look at this image here the house tour do actually go all the way from one end of the wall to the other however they’re not the typical stacked coin appearance that you would expect from a small bowel they’re much wider apart this is another example of the large bowel again seen predominantly in the periphery periphery of the abdomen and you can see air within small pieces of small bowel seen more centrally so how do you assess bowel gas pattern but normal bowel gas pattern in the small bowel usually has about two or three air fluid levels it’s normal to see air within the small bowel and usually the bowel is not more than about three centimeters in diameter large bow on the other hand usually doesn’t have air fluid levels because a lot of the fluid is absorbed within the large bowel it does contain air and that’s normal and it can have a very variable diameter so it’s hard to rely on large bowel diameter to tell whether or not it’s abnormal so let’s take a look at this this is a cone down view of the right upper abdomen you can see a somewhat mottled appearance here so what do you think that represents it doesn’t follow the typical features of small or large bowel so this is an example of normal stool within the colon it appears as very small bubbles of gas that are partially solid and they appear within the expected location of the colon so abdominal films can be performed in three different projections and each one has different uses so typically it’s performed as an upright film air is gravity dependent so it’s very useful to evaluate for free air so the air will rise up to the top and can often be seen just underneath the diaphragm it’s also used to evaluate for air fluid levels which could indicate stasis and ileus or bowel obstruction so when the patient is standing upright again the air will rise to the top of the bowel and you can see the air fluid level because the fluid will be at the bottom of the bowel usually these are obtained with the patient sitting or ideally in the standing position a left lateral decubitus is usually used in patients that aren’t able to stand upright so this is performed really as just a substitute for an upright film it also allows for evaluation of air fluid levels and it allows for evaluation of free air so the patient lies on their left side down the right side is up and again air will rise to the top part of the of the body and so you can see it adjacent to the liver on the right here ideally again is performed on the left side down because the liver forms a solid organ on the right which allows you to see the difference between the air and the density of the liver if you perform it the other way you have a lot of bow on the left side and you may not see the difference between air within the bowel and air outside of the bowel so supine film is also very commonly perform and it’s usually performed in addition to an upright or a decubitus this provides a general overview of the abdomen and it’s the one that’s used to look for calcifications or abnormal soft tissue masses this is obtained with the patient lying on their back and it’s really best when it’s used again in conjunction with another examination either the upright or the decubitus so incidentally this patient has a finding in their pelvis so what do you think this is this is actually an intrauterine device or an IUD it’s used as a contraceptive device and this is very commonly seen and in women this is a t-shaped metallic structure which is why it appears so dense it’s actually a little bit more dense than the surrounding bony structures so the takeaway points from this lecture I think are that you really need to look for air fluid levels and free air within the abdomen those are the two most important findings and these are really best seen on an upright or a decubitus view free air is most easily seen on these views as well and it’s a finding that you really don’t want to miss so hopefully now that you have the background knowledge of the abdominal anatomy we can move on to discussing some pathology and the appearance of pathology on an abdominal plane film [Music] you

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