ABD 1

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Questions and Answers

In the absence of CT availability, which of the following is an appropriate indication for an emergent abdominal X-ray?

  • Screening for renal calculi
  • Assessing for cholecystitis
  • Evaluating appendicitis
  • Emergent evaluation of bowel gas (correct)

A patient presents to the emergency department with acute abdominal pain. An abdominal X-ray series is ordered. Which radiographic view is MOST sensitive for detecting free air in the abdomen?

  • Upright AP abdomen view
  • Supine AP view (KUB)
  • Upright PA chest view (correct)
  • Left lateral decubitus abdomen view

The supine AP view of the abdomen, commonly known as KUB, is primarily utilized to assess which of the following?

  • Air-fluid levels
  • Most abdominal pathologies (correct)
  • Pneumoperitoneum
  • Small bowel obstruction

Which of the following anatomical structures is primarily located in the Right Upper Quadrant (RUQ) of the abdomen?

<p>Liver (D)</p> Signup and view all the answers

The splenic flexure of the colon is typically located in which abdominal quadrant?

<p>Left Upper Quadrant (LUQ) (D)</p> Signup and view all the answers

Which of the following organs is NOT primarily located in the Left Lower Quadrant (LLQ)?

<p>Appendix (D)</p> Signup and view all the answers

In abdominal radiography, what is the upper limit of normal diameter for the small bowel, according to the '3-6-9 rule'?

<p>3 cm (A)</p> Signup and view all the answers

Valvulae conniventes, also known as Kerckring folds, are characteristic mucosal folds found in the:

<p>Small bowel (A)</p> Signup and view all the answers

Haustra are mucosal folds characteristic of which part of the gastrointestinal tract on abdominal radiographs?

<p>Large bowel (C)</p> Signup and view all the answers

When interpreting abdominal X-rays, which mnemonic is commonly used as a systematic approach to ensure all key aspects are evaluated?

<p>Free ABDO (C)</p> Signup and view all the answers

In the 'Free ABDO' approach to reading abdominal X-rays, what does 'Air' primarily refer to?

<p>Pneumoperitoneum or free air outside the bowel (D)</p> Signup and view all the answers

When reading abdominal CT scans, a systematic approach is recommended. Which of the following is a component of this approach?

<p>Tracking organs through the entire sequence (B)</p> Signup and view all the answers

Which anatomical landmark is crucial to identify when systematically reviewing abdominal CT scans?

<p>Anatomical landmarks in each transverse plane (A)</p> Signup and view all the answers

Ascites is best defined as the pathologic accumulation of fluid in which anatomical space?

<p>Peritoneal cavity (C)</p> Signup and view all the answers

Morison's pouch, a common location for fluid accumulation in ascites, is located between which two organs?

<p>Liver and right kidney (C)</p> Signup and view all the answers

On an abdominal X-ray of a patient with ascites, what radiographic finding is associated with the lateral fat stripes?

<p>Increased distance between lateral fat stripes and adjacent colon (A)</p> Signup and view all the answers

In ascites, the bowel loops tend to appear:

<p>Pooled centrally (A)</p> Signup and view all the answers

Pneumoperitoneum is defined as the presence of air:

<p>Outside the bowel lumen within the peritoneal cavity (B)</p> Signup and view all the answers

Which of the following is the MOST sensitive imaging modality for detecting pneumoperitoneum?

<p>Erect chest X-ray (D)</p> Signup and view all the answers

Rigler's sign, also known as the double wall sign, is associated with:

<p>Pneumoperitoneum (C)</p> Signup and view all the answers

In a left lateral decubitus abdominal X-ray, where would free air typically collect in a patient with pneumoperitoneum?

<p>Under the patient's right flank (C)</p> Signup and view all the answers

Pseudopneumoperitoneum refers to the radiographic appearance of pneumoperitoneum:

<p>Without true free air (C)</p> Signup and view all the answers

Chilaiditi sign, a cause of pseudopneumoperitoneum, involves the interposition of which organ between the liver and diaphragm?

<p>Large bowel (A)</p> Signup and view all the answers

Retroperitoneal air is defined as air located in:

<p>The retroperitoneal space (A)</p> Signup and view all the answers

Which imaging modality is considered the gold standard for diagnosing retroperitoneal air?

<p>Computed Tomography (CT) (C)</p> Signup and view all the answers

In cases of retroperitoneal air, the air may outline which anatomical structures, making their margins more visible on radiographs?

<p>Kidney and psoas muscle (D)</p> Signup and view all the answers

Pneumobilia refers to the presence of air where?

<p>Biliary tree (A)</p> Signup and view all the answers

Portal venous gas, as opposed to pneumobilia, is characterized by air in which location?

<p>Peripheral portal veins (C)</p> Signup and view all the answers

Which of the following is a common cause of pneumobilia?

<p>Endoscopic Retrograde Cholangiopancreatography (ERCP) (C)</p> Signup and view all the answers

Bowel wall abnormalities, such as mesenteric ischemia and perforated ulcer, are more likely to cause:

<p>Portal venous gas (D)</p> Signup and view all the answers

What mnemonic is used to differentiate between pneumobilia and portal venous gas based on their location?

<p>Central vs Peripheral (C)</p> Signup and view all the answers

According to the 'SAD PUCKER' mnemonic, which of the following organs is retroperitoneal?

<p>Pancreas (B)</p> Signup and view all the answers

Which of the following is NOT considered a retroperitoneal organ according to the 'SAD PUCKER' mnemonic?

<p>Liver (D)</p> Signup and view all the answers

What is the primary indication for obtaining an upright (AP or PA) abdominal view in an abdominal series?

<p>Detection of small bowel obstruction (SBO) (B)</p> Signup and view all the answers

Which of the following views is part of an 'acute abdominal series'?

<p>Upright PA chest (B)</p> Signup and view all the answers

If a patient is unable to stand for upright views during an abdominal series, what alternative view can be obtained to assess for free air?

<p>Lateral decubitus abdomen (left side down) (A)</p> Signup and view all the answers

Which of the following is NOT a typical indication for abdominal imaging?

<p>Routine health checkup without specific symptoms (D)</p> Signup and view all the answers

What is the primary advantage of using CT over abdominal X-ray in evaluating abdominal pathology?

<p>Better visualization of soft tissues and organs (A)</p> Signup and view all the answers

Which of the following is a limitation of abdominal X-ray compared to CT in the assessment of abdominal pain?

<p>Limited ability to assess soft tissue structures (A)</p> Signup and view all the answers

A patient with suspected bowel perforation is undergoing abdominal radiography. Which radiographic sign is MOST suggestive of pneumoperitoneum on a supine abdominal X-ray?

<p>Football sign (C)</p> Signup and view all the answers

A 75-year-old patient presents with abdominal distention, increased girth, and shifting dullness on physical exam. Ultrasound reveals a homogenous, freely mobile anechoic collection in the abdomen. These findings are MOST consistent with:

<p>Ascites (D)</p> Signup and view all the answers

A 60-year-old male with a history of chronic alcoholism presents with worsening abdominal pain and vomiting. An upright chest X-ray demonstrates free air under the right hemidiaphragm. This finding is MOST indicative of:

<p>Pneumoperitoneum (C)</p> Signup and view all the answers

Which of the following conditions is LEAST likely to cause portal venous gas?

<p>Appendicitis (D)</p> Signup and view all the answers

A patient who recently underwent ERCP develops right upper quadrant pain and fever. An abdominal CT reveals air in the biliary tree centrally. This finding is MOST consistent with:

<p>Pneumobilia (A)</p> Signup and view all the answers

Identify the anatomical location of 'A' in the provided image.

<p>Small Bowel (C)</p> Signup and view all the answers

In the context of abdominal imaging, if Computed Tomography (CT) is unavailable, which of the following is an appropriate indication for an emergent abdominal X-ray?

<p>Emergent evaluation of suspected bowel obstruction or perforation. (D)</p> Signup and view all the answers

A patient is unable to tolerate an upright position for abdominal radiographs. Which alternative radiographic view is MOST appropriate to assess for free air in this patient?

<p>Left lateral decubitus view of the abdomen. (D)</p> Signup and view all the answers

On an abdominal radiograph, which of the following features is characteristic of small bowel, aiding in its differentiation from the large bowel?

<p>Valvulae conniventes (Kerckring folds) that span the width of the bowel. (B)</p> Signup and view all the answers

Rigler's sign, also known as the double wall sign, is a radiographic finding suggestive of pneumoperitoneum. Which of the following BEST describes the appearance of Rigler's sign on an abdominal X-ray?

<p>Air outlining both the inner and outer walls of the bowel. (B)</p> Signup and view all the answers

Retroperitoneal air can outline specific anatomical structures, making their margins more visible on radiographs. Which of the following structures are MOST likely to be clearly delineated by retroperitoneal air?

<p>The kidneys and psoas muscles. (B)</p> Signup and view all the answers

Flashcards

When to use Abdominal X-ray

X-ray used if CT is unavailable, and there is emergent need to evaluate bowel gas or pneumoperitoneum.

Other uses for Abdominal X-ray

Detecting radiopaque foreign bodies and assessing the placement of lines and tubes.

Objectives of Abdominal Imaging

Identify normal anatomy, detect free air or fluid, and diagnose bowel obstructions.

Standard Abdominal X-ray Views

Supine AP (KUB), Upright (AP or PA) Abd, Upright PA chest view.

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Left Lateral Decubitus View

Alternative to upright views when patient can't stand; includes abdomen and AP chest.

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Contents of the RUQ

Liver, duodenum, pylorus, right kidney, hepatic flexure, parts of ascending/transverse colon.

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Contents of the LUQ

Spleen, stomach, left kidney, pancreas, splenic flexure, parts of transverse/descending colons.

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Contents of the RLQ

Appendix, cecum, ascending colon, bladder, right ovary, uterus (if enlarged), right spermatic cord, right ureter.

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Contents of the LLQ

Sigmoid colon, descending colon, bladder, left ovary, uterus, left spermatic cord, and left ureter.

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Small Bowel on X-ray

ULN of 3cm diameter. Mucosal folds are thin, span width of bowel, located centrally.

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Large Bowel on X-ray

Usually located peripherally. Diameter is ULN 6cm for colon, 9cm cecum. Haustra do not span width.

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"SAD PUCKER" for Retroperitoneal Organs

Suprarenal glands, aorta, duodenum, pancreas, ureters, colon, kidneys, esophagus, rectum.

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Normal Anatomy on Abdominal CT

Liver, Portal vein, GB, Hepatic flexure, Ascending colon, Pancreas, Stomach, Mesentery, Small bowel, Bladder

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Approach to Reading Abdominal X-rays

Free ABDO: Free fluid, Air, Bowel wall, Densities, Organs

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Approach to Reading Abdominal CT

Cranial to caudal, superficial to deep, track organs. Follow major vessels, identify the landmarks.

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Ascites Definition

Pathologic accumulation of fluid within the peritoneal cavity.

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Etiologies of Ascites

Cirrhosis, peritonitis, cancer, CHF.

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Presentation of Ascites

Increasing abdominal girth, weight gain and abdominal discomfort.

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Diagnosing Ascites

Homogenous freely mobile collection inside the peritoneal cavity. First seen in the Morison pouch.

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Ascites Findings on X-ray

Increased distance between lateral fat stripes, pooling of bowel, lucencies in flanks.

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Definition of Pneumoperitoneum

Air outside the bowel lumen, requiring emergency surgery.

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Etiology of Pneumoperitoneum

Perforation or disruption of a hollow organ.

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Normal Air after Surgery

After abdominal surgery, air may resorb within a week.

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Diagnosing Pneumoperitoneum

Erect chest x-ray (most sensitive); adb left lateral decubitus and upright x-ray; U/S; CT (gold standard).

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Pneumoperitoneum X-ray findings

Air under the diaphragm on the right side, Rigler's sign, Air in the patient's flank on the left side

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Pseudopneumoperitoneum

Pneumoperitoneum look-alike without true free air.

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Causes of Pseudopneumoperitoneum

Chilaiditi sign/syndrome, lung collapse, skin fold air.

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Retroperitoneal Air X-Ray findings

Appearance of air outlines retroperitoneal structures (kidney) making margins visible.

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What is Hepatic Gas?

Air in the biliary tree, can be central or peripheral

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Study Notes

Abdominal Radiography - Indications

  • Abdominal X-rays are indicated for emergent evaluation, especially when CT is not available.
  • Assessment of bowel gas or pneumoperitoneum necessitates imaging.
  • Additionally, X-rays aid in assessing radiopaque foreign bodies, lines, and tubes.

Standard Views

  • Supine AP view (KUB) is utilized for general abdominal pathology.
  • Upright AP or PA abdominal views are used for small bowel obstruction (SBO).
  • The upright PA chest view is essential for detecting pneumoperitoneum.
  • Left lateral decubitus abdomen with AP chest should be employed if the patient cannot stand.
  • Three views make up the acute abdominal series.

Abdominal Anatomy

  • The abdomen is divided into four quadrants: Right Upper (RUQ), Left Upper (LUQ), Right Lower (RLQ), and Left Lower (LLQ).
  • It's also divided into nine regions: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right iliac, hypogastric, and left iliac.
  • Contents of the RUQ: liver, duodenum, pylorus, right kidney, hepatic flexure, portions of ascending and transverse colon.
  • Contents of the LUQ: tip of medial liver lobe, spleen, stomach, left kidney, pancreas, splenic flexure, portions of transverse and descending colon.
  • Contents of the RLQ: appendix, cecum, ascending colon, bladder, right ovary, uterus (if enlarged), right spermatic cord, and right ureter.
  • Contents of the LLQ: sigmoid colon, descending colon, bladder, left ovary, uterus, left spermatic cord, and left ureter.

Bowel Gas Anatomy

  • Small bowel is typically located centrally, while large bowel is located peripherally.
  • Small bowel mucosal folds (valvulae conniventes or Kerckring folds) are thin and span the width of the bowel.
  • Large bowel mucosal folds (haustra) are thicker and usually do not span the bowel's width.
  • Upper limits of normal bowel diameter: small bowel is 3cm, colon is 6cm, cecum is 9cm.
  • The mnemonic to remember these diameters is the "3-6-9 rule."

Retroperitoneal Viscera Mnemonic

  • SAD PUCKER is used to remember the retroperitoneal organs.
  • S = Suprarenal glands (aka the adrenal glands)
  • A = Aorta + IVC
  • D = Duodenum (except proximal part)
  • P = Pancreas (head, neck and body)
  • U = Ureters
  • C = Colon (ascending and descending portions)
  • K = Kidneys
  • E = Esophagus
  • R = Rectum (not in abdominal cavity)

Approach to Reading X-Rays

  • FREE ABDO is a useful mnemonic.
  • Free Fluid
  • RAir
  • EBowel wall
  • EDensities
  • AOrgans

Approach to Reading CTs

  • Assess images in a cranial to caudal sequence, from superficial to deep.
  • Track organs through the entire sequence and transverse plane.
  • Identify anatomical landmarks.
  • Follow major vessels.

Ascites (Free Fluid)

  • Pathologic accumulation of fluid within the peritoneal cavity
  • Etiologies include cirrhosis, peritonitis, cancer, and CHF.
  • Presents with increasing abdominal girth, weight gain, and abdominal discomfort.
  • Diagnosis: U/S shows homogenous, freely mobile anechoic collection in the peritoneal cavity.
  • The smallest amount of fluid is usually seen in Morison pouch.
  • On X-ray, you may see increased distance between lateral fat stripes and adjacent colon segment.
  • Bowel may appear pooled towards the center of the film.
  • Blurring of the psoas shadow can indicate ascites.

Pneumoperitoneum (Free Air)

  • Presence of air outside the bowel lumen.
  • Usually an emergency requiring immediate surgery.
  • Typically results from perforation or disruption of a hollow viscus' wall.
  • Pneumoperitoneum can be a normal finding post abdominal surgery and takes about 7 days for air to be resorbed.
  • The amount of air should decrease on subsequent x-rays.
  • Diagnosed via erect chest X-ray (most sensitive), left lateral decubitus abdomen and upright X-ray, U/S, or CT (gold standard).
  • On erect abdominal X-ray, air is seen under the diaphragm on right side.
  • On supine abdominal X-ray, Rigler’s sign (double wall sign) indicates a large pneumoperitoneum.
  • On left lateral decubitus X-ray, free air collects under the patient's right flank.

Pseudopneumoperitoneum

  • Appearance of pneumoperitoneum without true free air.
  • Can be caused by Chilaiditi sign or syndrome (bowel interposed between liver and diaphragm).
  • Additional causes include atelectasis, skin fold gas, and pneumobilia.
  • Patients are usually asymptomatic or have nonspecific abdominal pain.
  • Diagnosed using erect CXR, U/S, or CT (gold standard).

Retroperitoneal Air

  • Air in the retroperitoneal space, often iatrogenic.
  • Patients may present with abdominal pain post-procedure.
  • Dx: CT is the gold standard; otherwise, upright x-ray, U/S, or MRI.
  • Air outlines retroperitoneal structures, such as the kidney and iliopsoas muscle, making their margins more visible on X-rays.

Hepatic Gas: Pneumobilia vs. Portal Venous Gas

  • Pneumobilia: Air within the biliary system, often central in appearance.
  • Portal Venous Gas: Air in the portal venous system, appearing peripheral.
  • Common causes of pneumobilia include instrumentation (ERCP, IOC), incompetent sphincter, Sphincterotomy, Chronic pancreatitis, Gallstone passage, Cholangitis, Emphysematous cholecystitis and Hepatic abscess
  • Common causes of portal venous gas include Bowel wall abnormalities (Mesenteric ischemia, IBD, Perforated ulcer, CRC), Bowel distension (latrogenic insufflation), SBO, ileus, or Barotrauma, Infection such as Diverticulitis, Cholecystitis, Cholangitis, and Appendicitis.

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