Test yourself: Abdominal X-ray
Case Study 1.
A 17-year-old boy underwent laparoscopic appendectomy one week ago. Abdominal recovery is delayed. The patient has had no bowel movement over the past few days. Physical examination reveals distension and irritation in the entire abdomen. Particularly the lower right quadrant is painful on palpation. Sink-like sounds are audible on auscultation.
An abdominal X-ray is made to look for evidence of an ileus (fig. 1).
Note: after the abdominal X-ray, ultrasound is performed. It reveals an abscess in the ileocecal region.
Figure 1. Supine AP image (a) and left lateral image.
- Supine AP image: there are multiple widened (> 2.5 cm) small intestinal loops present centrally and at left in the abdomen (discernible by the Kerckring folds). The colon is not pathologically dilated (discernible by the haustra pattern). There is some fecal matter in the ascending colon.
- Left lateral image: some air-fluid levels in the pathologically dilated small intestinal loops (Note: they are invisible on AP images because they are made in supine position).
- There is evidence of intra-abdominal free air on both the AP and lateral images.
The abdominal X-ray supports the clinical diagnosis of a paralytic ileus secondary to an intra-abdominal abscess..
♦ Figure 1. Answer: paralytic ileus.
Case Study 2
A 20-year-old woman with no medical history presents to the Emergency Assistance department with colic-like bouts of pain in the right flank.
Renal ultrasound reveals a slightly dilated pyelocaliceal system of the right kidney. Also the proximal part of the right ureter is slightly dilated.
No obvious concrements are visible in the right kidney. Tracing the proximal ureter is difficult because of the overprojecting intestinal loops.
You decide to make an abdominal X ray to see if there is nephrolithiasis/urolithiasis (fig. 2).
Figure 2. Supine AP image (a) with an additional detail image of the upper abdomen (b).
The renal and psoas contours can be easily traced.
At the level of the right transverse process of L3, a sharply delineated oval/round density is visible. The structure is located in the right ureter. The detail image reveals that the structure does not originate in the transverse process (fig. 2).
There is no evidence of concrements in the kidneys or bladder.
Other findings: belly button piercing, fecal matter in the ascending colon.
Mild right-sided hydronephrosis (ultrasound!) secondary to urolithiasis.
♦ Figure 2. Supine AP image (a) with an additional detail image (b). Answer: urolithiasis.
Case Study 3
A 67-year-old man with acute abdominal pain is referred by his GP for emergency examination at the Emergency Assistance department with suspected gastric perforation.
Patient is adipous and in much pain. The entire abdomen is irritated and painful.
History: diverticulosis, hypertension, H. pylori infection, total hip prosthesis left
An abdominal X-ray is made immediately after arrival to confirm or exclude free air (fig. 3). The patient is very restless and afraid. Unfortunately, only a supine AP image could be made.
Figure 3. Supine AP image.
Technically inferior image; a large part of the abdomen has not been imaged. The diaphragmatic domes are invisible, so subdiaphragmal free air cannot be excluded.
No pathologically widened intestinal loops or direct evidence of free air have been imaged.
Multiple calcifications are visible centrally along the spine. The calcifications create a balloon-shaped form.
Aortic aneurysm. In view of the clinical situation, this must be considered an AAAA pending evidence to the contrary.
The patient was hemodynamically stable at the Emergency Assistance department and an emergency CT scan was made (fig. 4). This revealed a ruptured aneurysm. Immediately after the scan, patient was transported to the operating room where he received an aortic bifurcation graft.
General comment: suspicion of aortic aneurysm is no indication for an abdominal X-ray. This requires ultrasound or CT examination
♦ Figure 3. Answer: aortic aneurysm.