Abnormal bowel gas pattern

Introduction

In certain clinical settings, such as suspected bowel obstruction or perforation, assessing the bowel gas pattern on an abdominal X-ray can be very informative. Occasionally abnormalities of the bowel gas pattern relate to other abnormalities, such as inflammatory bowel disease.

Key points

Suspected bowel obstruction or perforation are the main indications for abdominal X-ray An ERECT chest X-ray should be requested if perforation is suspected The pattern of bowel dilatation may help determine a level of obstruction Occasionally features of inflammatory bowel disease are demonstrated on abdominal x-rays

Free gas/pneumoperitoneum

Free gas, or pneumoperitoneum, is gas or air trapped within the peritoneal cavity, but outside the lumen of the bowel. Pneumoperitoneum can be due to bowel perforation, or due to insufflation of gas (CO 2 or air) during laparoscopy. Both these causes have identical X-ray appearances, but very different clinical significance.

Bowel perforation

Bowel perforation is a surgical emergency. All medical students and junior doctors must therefore be familiar with the X-ray appearances of pneumoperitoneum in the clinical context of an acute surgical abdomen.

Erect chest X-ray

Patients presenting with an acute surgical abdomen should be investigated with an ERECT chest X-ray, as well as the standard supine abdominal X-ray. The patient should be positioned sitting upright for 10-20 minutes prior to acquiring the erect chest X-ray image. This allows any free intra-abdominal gas to rise up, forming a crescent beneath the diaphragm. It is said that as little as 1ml of gas can be detected in this way.

Air/gas under the diaphragm - erect chest X-ray

This patient has a large volume of free gas under the diaphragm. Dark crescents have formed separating the thin diaphragm from the liver on the right, and bowel on the left. This patient had a perforated duodenal ulcer.

Air/gas under the diaphragm - close up

If perforation is suspected you must look very closely. In this patient, only a very thin crescent has formed under only the right hemidiaphragm.

Abdominal X-ray

Although the erect chest X-ray is a much more sensitive investigation for pneumoperitoneum, there are several signs that may be useful in detecting free gas on an abdominal X-ray. Rigler's/double wall sign Rigler's sign (also known as the double wall sign) is the appearance of lucency (gas) on both sides of the bowel wall.

Rigler's/double wall sign - diagram

Normally only the inner wall of the bowel is visible If there is pneumoperitoneum both sides of the bowel wall may be visible

Football sign - example

A large volume of free gas has risen to the front of the peritoneal cavity resulting in a large round black area 'football sign' The double wall sign (Rigler's) is also visible (arrowhead)

Liver edge - example (close up) Gas may be seen outlining soft tissues structures such as the falciform ligament, or the liver edge

Free gas mimics

Stomach bubble

The normal stomach bubble should not be confused with free intra-abdominal gas. The stomach bubble forms a round/ovoid shape under the left hemidiaphragm. As the stomach has a thick wall, there is a thick line separating gas in the stomach from air in the lungs. In contrast to this, free intra-abdominal gas forms a crescent under the diaphragm, and is separated from the lungs only by the thin membrane of the diaphragm.

Key points Certain normal structures can mimic pneumoperitoneum

Normal stomach bubble - erect chest X-ray

Normal stomach bubble may be identified Round/ovoid - 'bubble' shape Thick upper wall Fluid level or food contents

Chilaiditi's phenomenon

Gas forms a near crescent shape under the right hemidiaphragm There is however a thick hemidiaphragm (partly consisting of bowel wall) Gas can be seen to lie within bowel Importantly, this patient with hyperexpanded lungs, due to emphysema, did not have acute abdominal pain

False Rigler's/double wall sign

Gas seen on both sides of the bowel wall is contained within adjacent bowel There are no black triangles or sharp angles on the outside of the bowel wall

False football sign - example

1 - Perirenal fat (retroperitoneal) 2 - Peritoneal fat (next to the liver)

3 - Abdominal wall fat (separating muscles of the abdominal wall)

Small bowel obstruction/ileus

If a patient presents with clinical features of obstruction then radiological assessment can be very helpful in determining the level of obstruction, and occasionally the cause. There are features visible on a plain abdominal X-ray that may help locate the level of obstruction. These are partly determined by a knowledge of small and large bowel anatomy Dilatation >3cm of the small bowel is considered abnormal, however the longer the segment of bowel that is dilated, the more likely bowel dilatation represents an obstruction.

Key points

Dilated small bowel >3cm is considered abnormal

Small bowel obstruction and ileus can have similar appearances

Small bowel obstruction - features

Centrally located multiple dilated loops of gas filled bowel (arrowheads)

Valvulae conniventes (arrow) are visible - confirming this is small bowel

Evidence of previous surgery - note the anastomosis site (red ring) - this suggests adhesions is the likely cause of obstruction (confirmed at surgery)

Small bowel obstruction - causes

The most common causes of obstruction are adhesions secondary to intra-abdominal surgery, hernias, tumours and Crohn's disease. Ileus is a term used for aperistaltic bowel not caused by a mechanical obstruction. This phenomenon is common after abdominal surgery. The radiological features can be similar to those of obstruction.

Post operative ileus

Appearances are similar to those of mechanical obstruction There are multiple loops of gas filled bowel projected centrally over the abdomen This patient had prolonged noncolicky abdominal pain following a Caesarian section - recovery was spontaneous

Sentinel loop

Intra-abdominal inflammation, such as with pancreatitis, can lead to a localized ileus. This may appear as a single loop of dilated bowel known as a 'sentinel loop.' A localized loop of small bowel is dilated in this patient with acute pancreatitis This appearance is not diagnostic of intra-abdominal inflammation, but rather an occasional associated feature

Sentinel loop

Large bowel obstruction

The most common causes > colo-rectal carcinoma > diverticular strictures. > hernias or volvulus (twisting of the bowel on its mesentery). > Adhesions Radiological appearances of large bowel obstruction differ from those of small bowel obstruction, however, with large bowel obstruction there is often co-existing small bowel dilatation proximally.

Dilatation of the caecum >9cm, and >6cm for the rest of the colon is considered abnormal.

Key points

Dilatation of the caecum >9cm is abnormal Dilatation of any other part of the colon >6cm is abnormal Abdominal X-ray may demonstrate the level of obstruction Abdominal X-ray cannot reliably differentiate mechanical obstruction from pseudo-obstruction

Large bowel obstruction

Here the colon is dilated down to the level of the distal descending colon. There is the impression of soft tissue density at the level of obstruction (X). No gas is seen within the sigmoid colon. Obstruction is not absolute in this patient as a small volume of gas has reached the rectum (arrow).

An obstructing colon carcinoma was confirmed on CT and at surgery.

Pseudo-obstruction

Pseudo-obstruction is a poorly understood functional abnormality of bowel, most often occurring in the elderly population, in those with underlying systemic medical conditions, or due to certain drugs. The clinical features can be similar to true obstruction, but no mechanical cause is found. An abdominal X-ray cannot reliably differentiate true mechanical obstruction from pseudo-obstruction.

Volvulus

Twisting of the bowel, or volvulus, is a specific cause of bowel obstruction which can have characteristic appearances on an abdominal X-ray.

The two commonest types of bowel twisting are sigmoid volvulus and caecal volvulus.

Sigmoid volvulus

Unlike the majority of the large bowel, the sigmoid colon has its own mesentery. It is therefore more prone to twisting at the root of its mesentery, which is located in the left iliac fossa. The result is the formation of an enclosed bowel loop which becomes dilated. If untreated this can lead either to perforation due to excessive dilatation, or to ischaemia due to compromise of the blood supply.

Sigmoid volvulus - coffee bean sign

Sigmoid volvulus classically results in the formation of a loop of sigmoid colon, which is twisted at the root of the sigmoid mesentery, which lies in the left iliac fossa (LIF). The loop of dilated bowel usually points upwards towards the diaphragm. This image demonstrates dilatation of the twisted sigmoid loop 'coffee bean' and of the proximal large bowel (*). This patient is at high risk of perforation and/or bowel ischaemia.

Caecal volvulus

The caecum is most frequently a retroperitoneal structure, and therefore not susceptible to twisting. However, in up to 20% of individuals there is congenital incomplete peritoneal covering of the caecum with formation of a 'mobile' caecum on a mesentery, such that it no longer lies in the right iliac fossa. This is a normal variant but is associated with increased incidence of folding or twisting of the caecum (caecal volvulus), which may be complicated by obstruction, vascular compromise, or perforation.

Caecal volvulus

The massively dilated caecum no longer lies in the right iliac fossa (RIF). Rather this is occupied by small bowel (red outline). The small bowel is identified by the valvulae conniventes - mucosal folds that cross the full width of the bowel (arrowheads). Caecal volvulus was confirmed at laparotomy.

Bowel wall inflammation

Occasionally, abdominal X-rays show signs of inflammation in patients with inflammatory bowel disease. Abnormalities may relate to either acute or chronic stages of disease.

Key points

Abdominal X-rays sometimes demonstrate signs of bowel inflammation such as mucosal thickening 'thumb-printing' or a featureless colon 'lead pipe' colon.

Mucosal thickening - 'thumbprinting'

This patient presented with an exacerbation of symptoms of ulcerative colitis . The distance between loops of bowel is increased (arrows) due to thickening of the bowel wall. The haustral folds are very thick (arrowheads), leading to a sign known as 'thumbprinting.'

Lead pipe colon

This patient with ulcerative colitis has a featureless segment of transverse colon with shows loss of the normal haustral markings. This 'lead pipe' appearance is associated with longstanding ulcerative colitis. The distal bowel is always involved in this disease but, as there is no air in the descending colon, this segment of colon is not evidently abnormal.

Toxic megacolon

Toxic megacolon is a potentially lifethreatening condition characterized by dilatation of the large bowel without obstruction, in the context of acute bowel inflammation. This may be due to inflammatory bowel disease, especially ulcerative colitis, or other causes of colitis such as infection.

Toxic megacolon

The colon is very dilated in this patient with acute abdominal pain, sepsis, and a known history of ulcerative colitis. The clinical features and X-ray appearances are consistent with toxic megacolon. There is evidence of bowel wall oedema with 'thumbprinting', and pseudopolyps or 'mucosal islands' (red-patches).

Abnormal soft tissues/bones

Introduction

The bones and soft tissues of the abdomen are primarily imaged by means other than the abdominal X-ray. Ultrasound is usually the initial investigation for suspected soft tissue abnormalities of the abdomen. Dedicated X-rays are usually required to investigate suspected bone and joint disease. Occasionally you will come across an unexpected abnormality of bone or soft tissue on an abdominal X-ray.

Lung bases

There is often a good view of the lung bases on a good quality abdominal X-ray. Occasionally patients with chest disease present with abdominal pain, particularly if the lung bases are involved. Check for pathology of the lung bases

Key points

Lung bases

This patient had pseudo-obstruction (note the dilated bowel) secondary to a left basal pneumonia The image shows consolidation and a loculated pleural effusion at the left lung base

Solid organs

Although ultrasound and CT are more informative means of imaging the solid organs of the abdomen, occasionally you will see evidence of enlarged organs on an abdominal Xray.

Key points

If enlarged the solid organs of the abdomen may displace bowel

Hepatomegaly

There is diffuse soft tissue density shadowing in the right upper quadrant due to hepatomegaly (liver enlargement) The enlarged liver has displaced the normal bowel downwards and to the left The spleen is also mildly enlarged

Massive splenomegaly

This patient with a myeloproliferative disorder has both hepatomegaly and massive splenomegaly There is generalised increase in soft tissue density but the bowel appears pushed away by the edge of the spleen

Enlarged kidneys

Both kidneys are very enlarged The bowel is not displaced because the kidneys are retroperitoneal structures This patient had a family history of polycystic kidneys This diagnosis was confirmed with ultrasound

Ascites

Abdominal X-rays should not be used to check for ascites. If this diagnosis is suspected then again ultrasound is the best initial investigation, and can also be used to assist drainage. Fluid and soft tissues have similar densities, and so ascites may be mistaken for organomegaly. The bowel does not appear pushed to the side as in organomegaly, but rather gas filled bowel rises in a central position, in the supine patient.

Key points

Free fluid and solid organs have similar densities

In the presence of ascites gas within bowel is located centrally

Ascites

There is generalised hazy density of the entire abdomen

A loop of gas filled bowel lies centrally in the abdomen

Abdominal and pelvic masses

Occasionally masses of the pelvis are visible on an abdominal X-ray. If large, masses of the pelvis may extend into the abdomen and displace bowel. Investigation with ultrasound and/or CT is required for assessment of a suspected abdominal mass. Pelvic masses can displace bowel upwards

Key points

Pelvic mass - large

A very large soft tissue density mass extends upwards from the pelvis

Bowel is displaces superiorly in the abdomen

Pelvic mass - small

A right pelvic wall mass is easily missed

If you see a mass on an abdominal Xray - re-examine the patient before planning further imaging

Fractures and osteoarthritis

It is not uncommon for patients with bone disease to present complaining of abdominal pain. Doctors often ascribe abdominal symptoms to gastrointestinal disorders without considering other causes. Tenderness on palpation of the abdomen may be due to radiated bone pain. If you suspect bone disease then request dedicated X-rays(s) of the bone or joint in question, rather than an abdominal X-ray.

Key points

Abdominal pain or tenderness may be caused by bone or joint disease

Pelvic fracture and osteoarthritis

This elderly patient presented with abdominal pain with no clear history of trauma Tenderness in the suprapubic regions was thought to be due to intra-abdominal pathology The pubic ramus fractures was the cause of symptoms

Note the osteoarthritic appearances of the hips and lumbar spine

Bone disease

Localised or widespread bone disease may give rise to abdominal symptoms. If you suspect bone or joint disease then dedicated images of the area in question are required. Occasionally there will be unexpected bone disease seen on an abdominal X-ray which may be incidental only, or pivotal to diagnosis Bone metastases may be seen on abdominal X -rays. These can be lytic (low density - black) or sclerotic (higher density - white). The most frequently encountered bone metastases are prostate cancer in men which is sclerotic, and breast cancer in women which can be sclerotic or lytic.

Bone tumours

Key points

Assess bones and joints on an abdominal X-ray

Bone metastases

There are numerous sclerotic densities (white) of the vertebrae, sacrum, pelvis and proximal femora This patient had a known history of breast cancer Abdominal pain was actually due to high serum calcium

Paget's disease

This patient has Paget's disease which affects his lumbar spine and right hemipelvis

This was an incidental finding when looking for a cause of abdominal pain
The typical features of Paget's are bone expansion and coarsening of the trabecular pattern involving the whole of the bone(s) affected

key points

Bone and soft tissue disease are encountered incidentally on abdominal X-rays Ultrasound or dedicated X-rays are required for initial investigation of suspected abdominal soft tissues or bone disease

Abnormal calcification
Renal calcification

Abnormal renal calcification may affect either the renal parenchyma (nephrocalcinosis) or more commonly the collecting system (renal calculi).

Pelvicalyceal calcification

Renal stones/calculi are concretions of inorganic material within the renal collecting system. 90% of renal calculi contain enough calcium to be visible on abdominal X-rays. Urate and matrix stones are not visible.
Renal stones are often small, but if large can fill the renal pelvis or a calyx, taking on its shape which is likened to a staghorn.

Key points

Renal calcification can affect the renal collecting systems (calculi/stones) or the kidney parenchyma (nephrocalcinosis) Renal calculi may be visible on the 'control' study of an intravenous urogram (IVU) Renal calculi may also be visible with ultrasound, or CT of the abdomen and pelvis (CT-KUB)

Other investigations

Staghorn calculus

The irregularly shaped calcific density has filled and taken on the form of the right kidney lower pole calyx

Nephrocalcinosis Uncommonly the renal parenchyma can become calcified. This is known as nephrocalcinosis, a condition found in disease entities such as medullary sponge kidney or hyperparathyroidism.

Nephrocalcinosis

The renal parenchyma contains clusters of small calcific densities

Conclusion

abnormalities of bowel gas which may be demonstrated on an abdominal X-ray. If bowel perforation is suspected don't forget to request an erect chest X-ray. In the context of obstruction, the level may be determined on an abdominal X-ray. There is also a role for abdominal X-rays in the assessment of an acute exacerbation of inflammatory bowel disease.

key points

Suspected bowel obstruction or perforation are the main indications for abdominal X-ray An ERECT chest X-ray should be requested if perforation is suspected The pattern of bowel dilatation may help determine a level of obstruction Occasionally features of inflammatory bowel disease are demonstrated on abdominal x-rays

Ureteric calcification

Ureteric stones (calculi) are often seen on an abdominal X-ray performed as a 'control' study for an IVU. This control image is known as a Kidneys-Ureters-Bladder image (KUB). As with renal stones approximately 90% are visible. Ureteric stones originate as renal stones. If a renal stone migrates into a ureter it may cause renal outflow tract obstruction, which manifests clinically with severe ipsilateral flank/loin/groin pain, usually with haematuria.

Key points

If clinically suspected look very carefully for a ureteric stone

Other investigations

IVU or CT-KUB can be used to determine the position of a stone and the degree of obstruction
If these are contraindicated then ultrasound can be used to determine the presence of renal outflow tract obstruction

Ureteric stone/calculus

Look carefully for ureteric stones which can be very subtle

Don't mistake a transverse process for a stone

Bladder stones

Bladder stones generally form in the bladder itself. They arise as a result of urinary stasis such as in bladder outflow obstruction (enlarged prostate) or in patients with a neurogenic bladder (loss of bladder function due to spinal cord injury/disease). Those with bladder wall abnormalities (ureterocele, diverticulum) or those with recurrent urinary infections are also at higher risk of forming bladder stones. When seen on an abdominal/pelvic X-ray they are often multiple and rounded.

Key points

Bladder stones form in the bladder as a result of urinary stasis Although ultrasound only occasionally shows renal or ureteric stones it is a much more reliable examination for bladder stones

Other investigations

Bladder stones

Multiple well defined calcific densities are seen within the bladder

Vascular calcification

Calcification of arteries seen on xrays is a sign of more generalised atherosclerosis. Occasionally vascular calcification seen on an abdominal X-ray reveals an unexpected aneurysm. Remember that abdominal pain is not only caused by gastrointestinal disease.

Key points

Don't forget non-gastrointestinal causes of abdominal pain An abdominal aortic aneurysm can often be seen with ultrasound but is more definitively assessed prior to treatment with CT

Other investigations

Vascular calcification

There is striking calcification of the aorta and iliac vessels

This is a sign of generalised atherosclerosis elsewhere in the body

Abdominal aortic aneurysm - AAA

There is calcification of the dilated aortic wall

As in this case often only one side of the aneurysm is visible - the other projected over the spine

Retroperitoneal calcification

Occasionally you may see calcification of retroperitoneal organs such as the pancreas or adrenals, which only become visible when calcified. Pancreatic calcification is a feature of chronic pancreatitis. Adrenal (suprarenal) calcification is an uncommon finding and is usually incidental. Most often it is considered a result of previous haemorrhage or tuberculosis.

Key points

Pancreatic calcification is a sign of chronic pancreatitis

Adrenal calcification is usually an incidental finding

Retroperitoneal calcification can also be seen incidentally with CT

Other investigations

Chronic pancreatitis

This X-ray shows soft tissue calcification which follows the anatomical position of the pancreas Also note calcification of the abdominal aorta which is of normal calibre

Adrenal calcification

The adrenal (suprarenal) glands form a triangle shape lying directly above the kidneys

Viscus calcification

Abnormal calcification also occurs in the hepatobiliary tree, and the gastrointestinal tract such as in the appendix (appendicolith).

Gallstones

Gallstones are very common. Approximately 20% of the adult population in western countries have gallstones. They can become pathological if they fall out of the gallbladder into the biliary tree.

Only 10-15% of gallstones contain enough calcium to be visible on an abdominal X-ray. If they are visible don't assume they are the cause of abdominal pain as most are asymptomatic.

Key points

The gallbladder and hence gallstones have a variable position Most gallstones are asymptomatic Appendicolith is an occasional but important X-ray feature of appendicitis

Other investigations

Ultrasound is the initial investigation of choice for suspected gallstones Ultrasound or CT can be used to investigate appendicitis but the diagnosis is usually made clinically

Gallstones and mesenteric lymph node

Gallstones have a variable position depending on the position of the gallbladder and may be mistaken for renal stones Unlike renal stones they are often rounded and cluster together This X-ray also shows an incidental calcified mesenteric node which may also mimic renal stones

Appendicolith

In appendicitis the abdominal X-ray is usually normal, and is not a required investigation unless a complication such as perforation is suspected. Occasionally an appendicolith is seen. This is a small calcified stone within the appendix, and is seen in the right iliac fossa. Although an uncommon feature of appendicitis an appendicolith is highly predictive of the diagnosis in patients presenting with abdominal pain, and is also thought to be associated with a higher risk of gangrene or perforation.

Appendicolith

Appendicoliths are highly predictive of appendicitis in patients presenting with right iliac fossa pain

Artifact and foreign body

Artifact can be medical or due to abnormally internalised objects. This page demonstrates a selection of the many medical artifacts you may come across, or objects that are ingested by patients. When presenting your findings of an abdominal X-ray note the presence of artifact - internal or external

Key points

Naso-jejunal tube

Placed for the purpose of enteral feeding

The tube passes through the stomach and forms a C-shape as it navigates the 4 parts of the duodenum (D1-4)
The tube tip lies beyond the duodenojejunal flexure which lies on the left

Pig-tail (DJ) stent

A ureteric stent has been placed to relieve ureteric obstruction

Colonic stent

Large bowel obstruction can be treated with placement of a metallic colonic stent This is often used as a temporary measure allowing a patient to recover from the effects of obstruction prior to definitive colonic resection

inferior vena cava (IVC) filter

An IVC filter may be used to reduce the risk of large pulmonary emboli Most commonly used in patients who have had pulmonary embolism but for whom anticoagulation is contraindicated IVC filters are self-expanding wire structures shaped like an umbrella Small clots may pass between the wires of the filter but large clots are prevented from reaching the pulmonary arteries

Foreign body - ingested

This psychiatric patient has ingested numerous radio-opaque objects

key points

Knowledge of the X-ray appearances of abnormal abdominal calcification is necessary to avoid confusion Other imaging investigations are often more informative for assessing abdominal calcification