Podcast
Questions and Answers
In the absence of CT availability, which of the following is an appropriate indication for an emergent abdominal X-ray?
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?
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?
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?
Which of the following anatomical structures is primarily located in the Right Upper Quadrant (RUQ) of the abdomen?
The splenic flexure of the colon is typically located in which abdominal quadrant?
The splenic flexure of the colon is typically located in which abdominal quadrant?
Which of the following organs is NOT primarily located in the Left Lower Quadrant (LLQ)?
Which of the following organs is NOT primarily located in the Left Lower Quadrant (LLQ)?
In abdominal radiography, what is the upper limit of normal diameter for the small bowel, according to the '3-6-9 rule'?
In abdominal radiography, what is the upper limit of normal diameter for the small bowel, according to the '3-6-9 rule'?
Valvulae conniventes, also known as Kerckring folds, are characteristic mucosal folds found in the:
Valvulae conniventes, also known as Kerckring folds, are characteristic mucosal folds found in the:
Haustra are mucosal folds characteristic of which part of the gastrointestinal tract on abdominal radiographs?
Haustra are mucosal folds characteristic of which part of the gastrointestinal tract on abdominal radiographs?
When interpreting abdominal X-rays, which mnemonic is commonly used as a systematic approach to ensure all key aspects are evaluated?
When interpreting abdominal X-rays, which mnemonic is commonly used as a systematic approach to ensure all key aspects are evaluated?
In the 'Free ABDO' approach to reading abdominal X-rays, what does 'Air' primarily refer to?
In the 'Free ABDO' approach to reading abdominal X-rays, what does 'Air' primarily refer to?
When reading abdominal CT scans, a systematic approach is recommended. Which of the following is a component of this approach?
When reading abdominal CT scans, a systematic approach is recommended. Which of the following is a component of this approach?
Which anatomical landmark is crucial to identify when systematically reviewing abdominal CT scans?
Which anatomical landmark is crucial to identify when systematically reviewing abdominal CT scans?
Ascites is best defined as the pathologic accumulation of fluid in which anatomical space?
Ascites is best defined as the pathologic accumulation of fluid in which anatomical space?
Morison's pouch, a common location for fluid accumulation in ascites, is located between which two organs?
Morison's pouch, a common location for fluid accumulation in ascites, is located between which two organs?
On an abdominal X-ray of a patient with ascites, what radiographic finding is associated with the lateral fat stripes?
On an abdominal X-ray of a patient with ascites, what radiographic finding is associated with the lateral fat stripes?
In ascites, the bowel loops tend to appear:
In ascites, the bowel loops tend to appear:
Pneumoperitoneum is defined as the presence of air:
Pneumoperitoneum is defined as the presence of air:
Which of the following is the MOST sensitive imaging modality for detecting pneumoperitoneum?
Which of the following is the MOST sensitive imaging modality for detecting pneumoperitoneum?
Rigler's sign, also known as the double wall sign, is associated with:
Rigler's sign, also known as the double wall sign, is associated with:
In a left lateral decubitus abdominal X-ray, where would free air typically collect in a patient with pneumoperitoneum?
In a left lateral decubitus abdominal X-ray, where would free air typically collect in a patient with pneumoperitoneum?
Pseudopneumoperitoneum refers to the radiographic appearance of pneumoperitoneum:
Pseudopneumoperitoneum refers to the radiographic appearance of pneumoperitoneum:
Chilaiditi sign, a cause of pseudopneumoperitoneum, involves the interposition of which organ between the liver and diaphragm?
Chilaiditi sign, a cause of pseudopneumoperitoneum, involves the interposition of which organ between the liver and diaphragm?
Retroperitoneal air is defined as air located in:
Retroperitoneal air is defined as air located in:
Which imaging modality is considered the gold standard for diagnosing retroperitoneal air?
Which imaging modality is considered the gold standard for diagnosing retroperitoneal air?
In cases of retroperitoneal air, the air may outline which anatomical structures, making their margins more visible on radiographs?
In cases of retroperitoneal air, the air may outline which anatomical structures, making their margins more visible on radiographs?
Pneumobilia refers to the presence of air where?
Pneumobilia refers to the presence of air where?
Portal venous gas, as opposed to pneumobilia, is characterized by air in which location?
Portal venous gas, as opposed to pneumobilia, is characterized by air in which location?
Which of the following is a common cause of pneumobilia?
Which of the following is a common cause of pneumobilia?
Bowel wall abnormalities, such as mesenteric ischemia and perforated ulcer, are more likely to cause:
Bowel wall abnormalities, such as mesenteric ischemia and perforated ulcer, are more likely to cause:
What mnemonic is used to differentiate between pneumobilia and portal venous gas based on their location?
What mnemonic is used to differentiate between pneumobilia and portal venous gas based on their location?
According to the 'SAD PUCKER' mnemonic, which of the following organs is retroperitoneal?
According to the 'SAD PUCKER' mnemonic, which of the following organs is retroperitoneal?
Which of the following is NOT considered a retroperitoneal organ according to the 'SAD PUCKER' mnemonic?
Which of the following is NOT considered a retroperitoneal organ according to the 'SAD PUCKER' mnemonic?
What is the primary indication for obtaining an upright (AP or PA) abdominal view in an abdominal series?
What is the primary indication for obtaining an upright (AP or PA) abdominal view in an abdominal series?
Which of the following views is part of an 'acute abdominal series'?
Which of the following views is part of an 'acute abdominal series'?
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?
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?
Which of the following is NOT a typical indication for abdominal imaging?
Which of the following is NOT a typical indication for abdominal imaging?
What is the primary advantage of using CT over abdominal X-ray in evaluating abdominal pathology?
What is the primary advantage of using CT over abdominal X-ray in evaluating abdominal pathology?
Which of the following is a limitation of abdominal X-ray compared to CT in the assessment of abdominal pain?
Which of the following is a limitation of abdominal X-ray compared to CT in the assessment of abdominal pain?
A patient with suspected bowel perforation is undergoing abdominal radiography. Which radiographic sign is MOST suggestive of pneumoperitoneum on a supine abdominal X-ray?
A patient with suspected bowel perforation is undergoing abdominal radiography. Which radiographic sign is MOST suggestive of pneumoperitoneum on a supine abdominal X-ray?
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:
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:
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:
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:
Which of the following conditions is LEAST likely to cause portal venous gas?
Which of the following conditions is LEAST likely to cause portal venous gas?
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:
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:
Identify the anatomical location of 'A' in the provided image.
Identify the anatomical location of 'A' in the provided image.
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?
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?
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?
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?
On an abdominal radiograph, which of the following features is characteristic of small bowel, aiding in its differentiation from the large bowel?
On an abdominal radiograph, which of the following features is characteristic of small bowel, aiding in its differentiation from the large bowel?
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?
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?
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?
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?
Flashcards
When to use Abdominal X-ray
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
Other uses for Abdominal X-ray
Detecting radiopaque foreign bodies and assessing the placement of lines and tubes.
Objectives of Abdominal Imaging
Objectives of Abdominal Imaging
Identify normal anatomy, detect free air or fluid, and diagnose bowel obstructions.
Standard Abdominal X-ray Views
Standard Abdominal X-ray Views
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Left Lateral Decubitus View
Left Lateral Decubitus View
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Contents of the RUQ
Contents of the RUQ
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Contents of the LUQ
Contents of the LUQ
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Contents of the RLQ
Contents of the RLQ
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Contents of the LLQ
Contents of the LLQ
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Small Bowel on X-ray
Small Bowel on X-ray
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Large Bowel on X-ray
Large Bowel on X-ray
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"SAD PUCKER" for Retroperitoneal Organs
"SAD PUCKER" for Retroperitoneal Organs
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Normal Anatomy on Abdominal CT
Normal Anatomy on Abdominal CT
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Approach to Reading Abdominal X-rays
Approach to Reading Abdominal X-rays
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Approach to Reading Abdominal CT
Approach to Reading Abdominal CT
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Ascites Definition
Ascites Definition
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Etiologies of Ascites
Etiologies of Ascites
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Presentation of Ascites
Presentation of Ascites
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Diagnosing Ascites
Diagnosing Ascites
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Ascites Findings on X-ray
Ascites Findings on X-ray
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Definition of Pneumoperitoneum
Definition of Pneumoperitoneum
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Etiology of Pneumoperitoneum
Etiology of Pneumoperitoneum
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Normal Air after Surgery
Normal Air after Surgery
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Diagnosing Pneumoperitoneum
Diagnosing Pneumoperitoneum
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Pneumoperitoneum X-ray findings
Pneumoperitoneum X-ray findings
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Pseudopneumoperitoneum
Pseudopneumoperitoneum
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Causes of Pseudopneumoperitoneum
Causes of Pseudopneumoperitoneum
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Retroperitoneal Air X-Ray findings
Retroperitoneal Air X-Ray findings
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What is Hepatic Gas?
What is Hepatic Gas?
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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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