MRCS

Abdominal X-ray (AXR)

Overview

Limited use and often over requested.

Useful in certain presentations of the acute abdomen i.e. bowel obstruction, volvulus,
malrotation, renal stones.

Equivalent of 35 chest X-rays.

Technical details:

Predominantly supine view. Note also: lateral, decubitus, erect.

Includes - diaphragm to pubic symphysis.

Anatomy of the AXR
Liver
Kidney
Colon
Bowel loops
Bladder
Sacroiliac
joint
Spleen
Ureteric stent -
shows course of
ureter
L5
L4
L3
L2
L1
MRCS
Abdominal X-ray (AXR)
Landmarks

Bones on AXR can be used as landmarks for soft tissue not easily visible on x-ray.

Liver: lies in RUQ, superior edge forms right hemidiaphragm.

Gallbladder: rarely visible but clips post cholecystectomy may be visible.

Kidneys: lie lateral to the psoas at level the T12 -L3. Right lower due to liver.

Ureter: the transverse processes of the lumbar vertebrae delineate the course of the
ureters.

Spleen: lies superior to the left kidney.

Bladder: within the pelvis, variable appearance depending on how full.

Pathology
Sigmoid volvulus
Most common type of volvulus.
Clinical features:

Abdominal pain

Distension

Absolute constipation
Predisposing factors:

Elderly

Constipation

Excessively mobile colon

Chronic immobility
Radiological appearance:

Bent inner tube

Co!ee bean

Limbs of loop directed toward LIF -

if towards RIF could be a caecal
volvulus.

Loss of haustra

Oedematous bowel wall

Image from: www.radrounds.com/prole/saeedrad
MRCS
Abdominal X-ray (AXR)
Small bowel obstruction
Clinical features:

Colicky abdominal pain

Vomiting

Fever

Tachycardia

Distension

Hyperactive to hypoactive bowel

sounds
Causes include:

Adhesions

Malignancy

Crohns strictures

Hernias

Foreign bodies

Atresia
Radiological appearance:

Dilated loops of small bowel >3cm,

note presence of valvulae
conniventes.

Generally central loops

Multiple gas/uid levels

Absence of gas in rectum

Image from: www.ganfyd.org/index.php?title=Image:Gallstone_ileus.jpg
Image from: www.ganfyd.org/index.php?title=Image: AXR_ large_ bowel_
obstruction.jpg
Large bowel obstruction
Clinical features:

Constant abdominal pain

Vomiting

Absolute constipation

Distension

Hyperactive bowel sounds

Causes include:

Malignancy

Strictures

Hernias
Radiological appearance:

Dilated loops of large bowel, note

presence of haustra.

Diameter >8cm = signicant risk of

perforation.
MRCS
Abdominal X-ray (AXR)
Image from: www.ganfyd.org/index.php?title=Image:Axr_rigler.jpg
Extra-luminal gas
Causes include:

Recent abdominal surgery

Perforation of a viscus

Gas forming infections - abscesses,

cholangitis.

Trauma
Radiological appearance:

Best diagnosed on erect chest x-ray - free gas

below the diaphragm, most apparent on right
side as appears between solid liver and
diaphragm = Crescent sign.

Riglers sign - gas either side of the bowel

wall causes a clear outline of the bowel. Easily
confused with overlapping loops of bowel.

Falciform sign - visualisation of the falciform

ligament - long vertical line to the right of the
midline extending from liver.

Area of hyperlucency over liver.

Image from: http://www.ganfyd.org/index.php?title= Image:
Pneumoperitoneum.jpg
Hyperlucent liver
Falciform sign
Riglers sign
Louis Rigler
16/10/86 - 25/10/79
American radiologist
MRCS
Abdominal X-ray (AXR)
Image from: en.wikipedia.org/wiki/File:StonesXray.PNG
Image from: www.ganfyd.org/index.php?
title=Image:Aerobilia.jpg
Gall bladder pathology

Plain AXR should not be used as a

primary investigation for gall bladder
disease.

See biliary revision sheet for further

information.
Gall stones

Only 10-20% of biliary calculi are

radio-opaque.

Ultrasound = gold standard

investigation.
Porcelain gall bladder

Calcication of gall bladder wall.

Rare.

Associated with chronic inammation

and brosis.

Increased risk of carcinoma of the gall

bladder.
Aerobilia

Recent instrumentation: ERCP.

Biliary-enteric stula - usually

secondary to abnormal passage of
gall stone/cholecystitis.

Perforated gall bladder.

Emphysematous cholangitis.
Gallstone ileus

Gallstone enters the bowel via a

biliary-enteric stula then causes
mechanical obstruction within the
intestinal tract.

Riglers triad:
1. Aerobilia
2. Small bowel obstruction
3. Impacted gallstone - usually in
the terminal ileum

See earlier small bowel obstruction

image - aetiology gall stone ileus.
Image from: commons.wikimedia.org/wiki/File:Porcelain.JPG