Radiographic Technique

Abdomen Radiography
Image Analysis

Medical Diagnostic Imaging Department

College of Health Sciences Dr. Mohamed Abuzaid
University of Sharjah Associate Professor

1
The Abdominal Cavity
The Stomach is located predominately in the
left upper quadrant of the abdomen. The
main job of the stomach is to break down,
or denature, large fat molecules into smaller
ones, so that they can be absorbed into the
intestines more easily.

The Small Intestine’s primary function is the

absorption of nutrients from digested food.
The Large Intestine is responsible for
absorbing water and excretion of solid waste
material.
The upper margin of the symphysis pubis
can be palpated and is an important
landmark for locating the urinary bladder.

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Image Analysis Presentation- Abdomen
 Projection, Position & Methods

Essential Anatomy Projection Position

Yes Abdomen AP Recumbent; upright

Yes AP L lateral decubetus
Yes Lateral R or L
Yes Lateral R or L dorsal decubetus
Yes PA Upright

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 Standard Projections
Standard protocols for the abdomen are Anteroposterior (AP)
supine, and AP upright projections (often called flat and
upright). At other facilities, and depending on patient
pathology and ability to cooperate, a posteroanterior (PA)
KUB is standard.
A 3-way or acute abdomen series may be requested to rule
out free air and infections. These projections include AP
supine, AP upright, and a PA chest.
If a patient is unable to stand for the upright AP projection,
the exposure is taken using the left lateral decubitus position.
In this presentation only the standard AP supine projection
will be discussed.

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 EVALUATION CRITERIA
 Objective 1: Students are expected to be able to
state the following for each routine projection:
• Position of the part
• Direction of the CR & CP
• What should be included on the radiograph
• What the radiograph best demonstrates
• Phase of respiration
• Immobilization necessary
• Shielding necessary.

All the above can be found in Merrill’s Atlas and the

Radiographic Manual

6
 Imaging Criteria Abdomen-General

A R or L marker identifying the correct side of the patient is present and is

not superimposed over the anatomy of interest.
Facility’s identification requirements are visible on the image.
Radiation protection practices have been followed.
No evidence of preventable artifacts, such as undergarments, buttons,
zippers, body jewelry or pins are present.
The cortical outlines of the posterior ribs, lumbar vertebrae and pelvis and
the gases within the stomach and intestines are sharply defined.
Contrast and density, and penetration are adequate to demonstrate the
collections of fat that outline the psoas major muscles and kidneys as well as
the bony structures of the inferior ribs and transverse processes of the
lumbar vertebrae.

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 Evaluation Criteria - Abdomen

The Area from the pubic symphysis to the upper abdomen should be
clearly demonstrated. Two (2) radiographs may be needed if the
patient is tall.
The vertebral column is centered to the film.
The ribs, pelvis and hips are equidistant to the edge of the radiograph
on both sides, assuring proper alignment.
No rotation: Spinous processes in the center of the lumbar vertebrae.
The Alae or wings of the Ilia are symmetric.

The psoas muscles, lower border of the liver and kidneys should be
demonstrated.
The transverse processes of the lumbar vertebrae should be clearly
seen.

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 Diagnosis
Bilateral Renal Calcifications. (See notes for definition)

There are multiple bilateral clusters of calcifications. The

largest overlies the right lower pole measuring 5-6 mm.

BOWEL: The small and large bowel is normal in appearance

with no evidence of obstruction or inflammation.

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 Film Specifics and Technical Factors:

Film Specifics:
•Name of Patient
•Age & Date of Birth
•Location of Patient
•Date Taken
•Film Number (if applicable)

Film Technical factors:

•Type of projection (Supine is standard)
•Markings of any special techniques used
 Assess the Film in Detail:

A simple guide to interpretation is shown

below. Working through these headings
•‘dark bits’,
•‘white bits’,
•‘grey bits’ and
•‘bright white bits’ in turn.
BLACK BITS’
•Intra-luminal gas
•Extra-luminal gas
•However, intra-luminal gas can be abnormal if it is in the wrong place or if
too much is seen.
Intra-luminal gas:
•The maximum normal diameter of the large bowel is 55mm.
•Small bowel should be no more than 35mm in diameter.
•The natural presence of gas within the bowel allows assessment of caliber -
although the amount varies between individuals.
•Large and small bowel may be distinguished by looking at bowel wall
markings.
 Assess the Film in Detail

Intra-luminal gas (continued):

It is usual to see small volumes of gas throughout the GI tract and the
absence in one region may in itself represent pathology.
For example, if gas is seen to the level of the splenic flexure and nothing
is seen beyond this, a site of the obstruction at this site
If bowel obstruction is observed try
to look for the cause. For example
a hernia as the cause of
obstruction.
Extra-luminal Gas:
When an bowel is
obstructed, or any other gas
containing structure
perforates, its contained gas
becomes extra-luminal.
Extra-luminal gas is never
normal, but may be seen
following intra-abdominal
surgery or endoscopic
retrograde cholangio-
pancreatography (ERCP).

Extra-luminal gas seen on erect

CXR.
Causes of Extra-luminal gas:
•Post Abdominal Surgery/ERCP
•Perforation of viscus (eg. bowel, stomach)
•Gallstone ileus
•Cholangitis (infection with gas forming organisms)
•Abscess

An erect CXR (not AXR) is the best projection to

diagnose a pneumoperitoneum (gas in the
peritoneal cavity).
 ‘WHITE BITS’ = Calcification
Calcified structures (‘WHITE BITS’) are often seen on AXR.
The main question is – does its presence have any important
implications. Calcification can be broadly divided into 3 types:
(1) Calcium that is an abnormal structure - eg. gallstones and renal
calculi
(2) Calcium that is within a normal structure, but represents pathology -
eg. nephrocalcinosis,
(3) Calcium that is within a normal structure, but is harmless - eg. lymph
node calcification.

Bones are normal ‘white’ structures. On the AXR they

comprise mainly those of the thoraco-lumbar spine and pelvis.
Findings are largely incidental as direct bone pathology would
be investigated with specific views.
Pancreatic Calcification Gallstones
 ‘GREY BITS’ = Soft Tissues

Soft tissues represent most of the contents of the abdomen and

feature heavily in the AXR. However, these tissues are poorly
seen when compared to other imaging techniques such as
ultrasound or CT.

The kidneys, spleen, liver and bladder (if filled) can be seen in
addition to psoas muscle shadows and abdominal fat. Rarely
would action be taken on the basis of this imaging alone.
Splenomegaly
 ‘BRIGHT WHITE BITS’ = Foreign Bodies

Foreign Bodies represent an interesting final observation.

Objects that may be seen include ingested and rectal foreign
bodies, items in the path of the x-ray beam such as belt
buckles, dress buttons and jewelry. Other objects may have
been deliberately placed for example an aortic stent, an inferior
vena cava filter or a suprapubic urinary catheter. Sterilization
clips and an intra-uterine device are common findings in
women.
Sterilisation and Surgical Clips Foreign body per rectum
 Objective no. 2

Explain why all radiographs of

the abdomen are done on
expiration?

The diaphragm is elevated

during expiration more of the
abdominal content are
visualized

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 Objective no. 3

State the criteria for evaluating a good supine abdomen

radiograph:

•Includes from the symphysis

pubis upwards.
•Can see outline of psoas
muscle, lower border of
liver, ribs, & Spinous
processes.
•No abdominal organ
movement.

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Objective no 4

State why the diaphragm must be included on the erect

& decubetus radiographs.

• To demonstrate the
presence of air under the
diaphragm.
Note - Important to:
1. Place “ERECT” marker –
differentiate between
supine & erect abdomen
radiographs.
2. Place ID at bottom of
abdomen image – avoid
superimposition over Air under both diaphragms
spleen / liver.
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 Objective 5a

State two reasons why PA projections may be preferred

over AP projections.
• Reduces gonad dose.
• Compresses the abdomen & therefore lower exposure
factors can be used. Lower patient dose
Objective 5b

State one reason why the AP erect projection may be

preferred over PA projection.

•When the kidneys are focus of interest.

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 Objective 6

Explain why high kVp techniques (100kV++) are NOT used

for abdomen radiographs.

• To maximize the low

inherent contrast in the
abdomen.

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 Objective 7

Explain why a left lateral decubetus is used rather than a

right lateral decubetus.

• Any free air will rise to an area under the right hemi
diaphragm.

• The air will not be superimposed by the gastric bubble

normally present.
Objective 7

Explain why the patient must lie on the side for 5-15
minutes before doing a decubetus film.

• To allow time for any free air to rise under the right hemi
diaphragm.

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 Objective 9

•State two reasons for including a PA chest radiograph as

part of the acute abdomen series.

1. To show air under 2. Because lower lobe pneumonia

the diaphragms. can cause abdominal pain.

2
1 1 2

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 Objective 10

State the sequence for exposing the films for an acute

abdomen series.

1st - PA chest (& upper abdomen) using a chest exposure.

2nd - AP or PA abdomen– erect.

3rd - AP or PA abdomen supine

Why is this sequence used?

If perforation is present, it takes time for air to collect under
diaphragm (on CXR) & form fluid levels (on erect abdomen)

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Objective 11

State three major reasons for performing an acute

abdomen series:
1. Obstruction
2. Perforation
3. Visceral rupture

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 1. Intestinal Obstruction

Common causes: constipation / mass / congenital abnormality / intussuception

Erect radiograph of
Supine - Many loops of (small) bowel dilated abdomen showing proximal
with air as a consequence of bowel dilated jejunal
obstruction from cecal volvulus. loops & fluid levels. 32
Intestinal obstruction due to:
(a) constipation
(b) abdominal mass

(a) Supine & Erect: (b) Abdominal mass anterior

Note: fluid levels on erect to L4-L5 33
 Intestinal obstruction due to intussuception
• Definition - the invagination of one segment of the
bowel into another.
• Results in obstruction
• More common in infants than adults.
Which image is ‘supine’ , which is ‘erect’ & why?

Erect Supine 34
 2. Perforation of the GI Tract

Common causes: ulcer / mass /trauma / surgery

Radiograph of the abdomen

obtained 1 month after stent
placement shows a well-shaped
rectal stent (long arrow) and sub
diaphragmatic free gas (short
arrow) due to rectal perforation.

stent

35
 2. Perforation

CXR – erect showing Supine abdomen showing

perforation – air in abdomen perforation (gas filled
peritoneum)
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 3. Visceral Rupture
Definition: A tear in an organ:
Common causes:
a. Caesarean section
b. Gall bladder rupture
c. Appendix rupture
d. Trauma, (car accident,
physical attack)

What can you see in this image?

Paperclip marks bullet entrance

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 Other indications for E & S abdomen radiograph

Gall stones - large

Acute pancreatitis & numerous

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Other indications for E & S abdomen radiograph (cont’d)

Faecolith (a mass of
faeces – may be calicified)

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 Other indications –cont’d
• Megacolon- dilation of the colon & loss of haustration.
Which image is ‘supine’ , which is ‘erect’ & why?
Supine Erect

Fluid levels

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 Additional Information:

• For the patient who needs extra immobilisation - a

compression (bucky) band can be used but do not
compress or reduce the abdomen thickness.
• Frequent abdomen x-ray request for _______
“KUB” : kidneys,
ureters & bladder.
• use same tech as a ______
supine abdomen radiograph.

Preliminary bowel
preparation may be required
for non-acute cases. i.e.
dietary control or ________
laxative
or enema prior to x-ray.
(Too much gas overlying kidneys)

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 KUB
• Renal colic ?cause”:
Request usually states “_______
• Frequently due to renal _______
calculi .

Renal (kidney) stones Bilateral stag horn kidney

stones. 42
 Objective 12

Define Imperforate Anus & explain the procedure for

obtaining radiographs to demonstrate this condition.
a. Congenital - Where the distal portion of the GI tract does not open
to the outside. Suspected if the baby fails to pass meconium.
b. U/S preferred
c. Baby min of ___18 hrs old.
d. Method – invert the baby
for _____
2-10 minutes before
exp. (p. 100 Hardwick & Gyll)
c. Lateral radiograph in the
inverted position.

gas in the
NOTE: no ____
rectum
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44
Anatomy on the
Abdominal
X-Ray:
 AXR-2
AXR-1
Finals Radiology Cases:
Abdominal X-Ray
Case 1:

A 53 Year old Female presents with a history of renal

calycles.

Patient has been experiencing pain in the kidney area and

radiating to the bladder.

No prior comparison exams available at this facility.

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Case 1
KUB- Kidneys, Ureters and Bladder

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Case 1
Positioning Critique: Superior Aspect
Lower border of liver is
demonstrated. (yellow)

Kidney shadows are seen.

(black oval)
Psoas muscles are clearly
visualized. (red lines)
Vertebral column is centered to
the film. (See comments in notes
section)

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Case 1
2 radiographs were taken to include Pubic
Symphysis.

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Case 1
Inverted Images

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Case 1
Positioning Critique: Inferior Aspect
The Alae or wings of the Ilia are
symmetric.

The ribs, pelvis and hips are

equidistant to the edge of the
radiograph on both sides.

The transverse processes of the

lumbar vertebrae are seen.

Because the patient was tall, 2

radiographs were taken to include
the pubic symphysis. (see previous
slide #8)
Images were overlapped to
visualize complete anatomy
53
Case 1

Positioning Critique- Rotation

The blue Plumb line

demonstrates the spine was
straight and centered to the
film.
A very slight marginal
difference exists between the
right iliac crest and the left.
(red line) The right side is about
1 cm higher, the pelvis was
rotated only slightly, not
enough to make any
corrections.

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Case 1
Positioning Critique- Rotation cont’d
Examining the inferior area more
closely, the R femoral head is
slightly higher than the left (red).
The bladder is seen more on the
right side. Patient’s legs may
have been slightly rotated
causing this.
The blue plumb line indicates
that the sacralcoccygeal area
could have been adjusted
slightly. But this is not a pelvic
exam, therefore no major
correction is needed.

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Case 1
Image Identification and Medicolegal
Requirements
A right marker is positioned properly, not superimposing the
anatomy of interest.
Date and time stamps, along with the patient info and facility
identification is visible in the PACS database. This data is being
withheld from this presentation to respect patient
confidentiality.
Collimination is tight. Due to patients height, 2 radiographs had
to be taken to include symphysis.
Because the anatomy of interest would be covered by a lead
gonadal shield, radiation protection was instead placed below
the pubic symphysis*, and a thyroid shield was given as
requested by the patient. Male patients would receive a flat
contact shield covering the testes.
Patient could have held her breasts as far upward and laterally
as possible for this projection to avoid unnecessary radiation to
this area.

* In my opinion, placing a shield on the upper thigh area

makes the patient more at ease and it shows that I am
doing everything possible to minimize exposure.

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Case 1
Exposure Factors
A kVp between 70-80 is used to enhance the subject
contrast, demonstrate soft tissue, and penetrate the
abdomen. (very muscular patients may require 80+
kVp).
A grid is used to improve contrast and quality.
The mAs are adjusted according to patient size and
equipment. (Film-screen speed is not discussed here
because of the digital technology used). Fast exposure
times are used to minimize breathing and peristaltic
motion.

Technique: This projection was made using AEC and

provided optimal density, contrast, and recorded
detail for diagnostic interpretation. Technique for this
projection was 75 kVp @12.5 mAs.

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Case 1
Exposure Factors cont’d
• Contrast and density, and penetration are adequate
to demonstrate the collections of fat that outline the
psoas major muscles (green arrow) and kidneys as
well as the bony structures of the inferior ribs
(yellow arrow) and transverse processes of the
lumbar vertebrae (red arrows).

• Detail: Sharply defined recorded detail is seen in this

image. The cortical outlines of the posterior ribs,
lumbar vertebrae and pelvis and the gases within the
stomach and intestines are sharply defined.

• Respiration was suspended on expiration for the

exposure. A 48” SID was used and a grid was also
inserted in the bucky prior to the exam
• Artifacts: Patient was wearing underpants with an
elastic waistband. This waistband shows up as a
dark horizontal line. Small calcifications can be seen
Windowed Image in both kidneys.
14 x 17 lengthwise • Distortion: None
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Case 1
AP- Flat KUB
Normal Inverted

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 Case 2:
This 67 year-old women
presented to the
surgical ward with a
distended abdomen and
vomiting.

Present this x-ray

Give a diagnosis and

potential causes
 Case 2: Answer
Radiology Report:
Plain abdominal radiograph.
Multiple dilated loops of small bowel
within the central abdomen. Gas is not
seen in the large bowel. No evidence of
hernia or gallstone to suggest potential
cause of the dilated loops.
These findings are in keep with a low
small bowel obstruction.
I would like to know if the patient has a
history of abdominal surgery as the
commonest cause is surgical admissions.

The three commonest causes of small bowel obstruction are:

•Surgical adhesions
•Herniae
•Intraluminal mass eg, small bowel lymphoma or gallstone (in gallstone ileus)
 Case 3:
This 71 year-old
gentleman visits his GP
complaining of blood in
his urine. He has had a
number of UTI’s in
recent years.

Present this x-ray

Give a diagnosis and

potential causes
 Case 3: Answer
Radiology Report:
Plain abdominal radiograph.
Two rounded radio-opacities measuring
4cm within the pelvis. Both opacities are
smooth in outline, laminated in nature,
have the same density as bone and
project over the bladder. No other renal
tract calcification.
Does the patient have a history of
neurogenic bladder?
Given the size of these stones and history
of UTI’s these are bladder calculi.

Bladder calculi are more common in those with a history of:

•UTI’s
•A neurogenic bladder
•Bladder diverticulum
 Case 4:
This patient was
admitted with poor renal
function.

Present this x-ray

Give a diagnosis and

potential causes
 Case 4: Answer
Radiology Report:
Plain abdominal radiograph
Multiple areas of punctuate calcification
project over the renal outlines bilaterally.
The calcification is within the medulla of
the renal parenchyma. The bones are
normal in appearance.
These findings are consistent with
nephrocalcinosis

Causes of Nephrocalcinosis include:

•Hyperparathyroidism
•Medullary sponge kidney
 13-year-old boy with 2 days of fever, abdominal pain,
Case 5: nausea, and vomiting

Appendicitis

A supine abdominal film from the

day of admission demonstrates a
1.5 cm rounded calcific density
overlying the right mid sacrum
with a second 0.5 cm oval calcific
density just inferior to it.

Appendicolith- seen in only 10-

15% of cases
 Intussusception
► Prolapse of a segment of bowel and its mesentery into the distal bowel segment
► Structurally, an intussusception is composed of three concentric layers of bowel
wall: the outer layer, or intussuscipiens, and two inner layers of intussusceptum
(the bowel folded back on itself).
► Ileocolic intussusception-ileum prolapsed into colon-comprises about 90% of all
cases
► 6 months and 2 years
► Less than 50% of patients present with all classic symptoms
Intussusception

Radiographic signs of intussusception

include:

► *Soft tissue mass in the right upper or

lower quadrant

► * Gas in cecum

► Lateralization of the ileum

Intussusception
 AXR-4
AXR-3