1. Plain picture in acute abdomen
Moderator-
Dr (Prof). R. K. Gogoi
Presenter:
Dr. Sarbesh Tiwari

2. INTRODUCTION
• Acute abdomen refers to presence of severe
abdominal pain developing suddenly or over
a period of several hours.
• Most frequent reasons for presentation at the
emergency department (ED).
• It requires a clinician to make an urgent
therapeutic decision.
2

3. Plain Radiography
• Plain abdominal radiography is traditionally the
first radiological investigation in acute abdomen
• Interpretation of plain films presents with
formidable challenge because though specific
diagnosis can be made, not infrequently the
appearance are non specific and misleading.
3

4. Basic radiographs
A supine Abdomen radiograph
& Basic standard
radiographs
Erect Chest x ray
 Erect abdomen
 Left lateral decubitus (right side raised) are taken to add
information
Patient to remain in given position – 10 minutes
4

5. Erect chest radiograph:
o Small pneumoperitoneum can be detected
o Various chest conditions may mimic an
acute abdomen.
o Acute abdominal conditions may be
complicated by chest pathology
o Even a normal chest radiograph acts as a
baseline and helps in detection of post
operative complication.
5

6. Chest Conditions that mimic acute abdomen
1. Pneumonia
2. Myocardial Infarction
3. Pulmonary Infarction
4. Congestive cardiac failure
5. Pericarditis
6. Leaking or dessecting thoracic aortic aneurysm
7. Pneumothorax
8. Pleurisy 6

7.  Abdominal radiographs: (kv:60-65, short
exposure time)
o Supine abdominal radiograph-
Distribution of gas
Calibre of bowel
Displacement of bowel
Obliteration of fat lines
o Erect abdominal radiograph- fluid level and free
gas
o Horizontal-ray films( erect or lateral decubitus)-
free intra- abdominal air, fluid levels
7

8. TECHNIQUE standard projection
• supine with knee
Anteroposterior supine slightly flexed.
• centered at iliac crest.
• Exposure during
expiration
• Low kV (60-75 kV)
• Short exposure time to
avoid motion
• Both the lung bases
and the pubic
symphysis included.
8

9. Supplemental projections
Abdomen AP erect • Ideally, tilting x ray
table with potter
Bucky diaphragm
used to reduce
distress to patient
• 14”- 17” film, high mA,
short exposure time,
increased 7-10 kVp
over supine.
• Centered just above
umbilicus in midline
9

10. ADDITIONAL PROJECTIONS
• Prone, Oblique, Lateral
• For better definition and localization of
• mass lesions
• calcifications
• herniations
• A prone radiograph is useful when distal colonic
obstruction is suspected.
10

11. RADIATION EXPOSURE
• One PP abdomen exposes a patient to 0.7 mSv
of radiation, equivalent to 35 chest radiograph.
• Gonadal shielding should be used if gonads lie
within 5 cm of the primary beam, if clinical
objective is not compromised
11

12. 12

13. NORMAL GAS PATTERN
• Stomach
- always
• Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 2.5 cm
• Larger bowel
- in rectum or sigmoid colon - always

15. NORMAL FLUID LEVELS
• Stomach
- always (except supine film)
• Small bowel
- 2 or 3 levels possible
• Large bowel
- none normally

17. DISEASE ENTITY
PNEUMOPERITONEUM
17

18. • Pneumoperitoneum refers
to the presence of free gas
within the peritoneal cavity
• Almost always caused by
perforation of hollow
viscus.
• Perforated duodenal ulcer
is the most frequent cause
18

19. CAUSES
1. Perforation
• Peptic ulcer disease
• Inflammation- Diverticulitis, toxic megacolon,necrotizing
enterocolitis
• Infraction
• Pneumatosis coli- The cyst may rupture
• Maliganacy.
• Mechanical perforation following trauma
2. Iatrogenic
• Abdominal surgery
• Peritoneal dialysis
3. Pneumothorax- due to congenital pleuroperitoneal
fistula.
19
4.Introduction per vaginum- e.g. douching

20. RADIOGRAPHY
• Optimal radiographic technique is important.
• At least 2 radiographs,
• a supine abdominal radiograph and
• either an erect chest image or a left lateral decubitus
image.
• The patient should remain in position for 5-10 minutes
before a horizontal-beam radiograph is acquired.
• As minimal as 1ml of free gas could be detected by
proper technique.
20

21. Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both
does of diaphragm.
21

22. Left lateral decubitus film showing gas between the liver and
abdominal wall. 22

23. Signs of pneumoperitoneum of supine radiograph
• Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrison’s pouch
• Fissure for ligament teres
• Rigler’s (double wall sign)
• Ligament visualization
Falciform
Umbilical inverted ‘V’ sign
• Triangular air
• The cupola sign
• Football or air dome
• Scrotal air in children 23

24. Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air
within the subhepatic space 24

25. Doges cap sign
• Doges Cap sign refers
to free air in Morrison's
pouch.
• Morrison's pouch is
normally a potential
space between the right
kidney and the liver
25

26. Triangular gas shadow superior to kidney and postero-
inferior to 11th rib 26

27. Rigler’s sign
Rigler's sign refers to the appearance of the bowel wall on
plain film when it is outlined by intraluminal and extraluminal
air .The extra luminal air is free peritoneal gas
27

28. Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of
28
the ligament

29. Football sign
• The football sign likens the massively air-
filled peritoneum to an American football
• In the supine position, free air collects
anterior to the abdominal viscera, producing
a sharp interface with the parietal
peritoneum and thereby creating the
football outline
29

30. 30

31. Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub
diaphragmatic free gas and the other is normal gas within the fundus of
31
the stomach

32. The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central
tendon of diaphragm. The superior border is well defined (arrows)
32
compared with the inferior extent of the collection.

33. The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically
be positioned between the large bowel and the flank(black arrow)
33

34. CONDITIONS SIMULATING PNEUMOPERITONEUM
1. Chilaiditi’s syndrome-intestine between liver and
diaphragm
2. Subphrenic abscess
3. Curvilinear supradiaphragmatic pulmonary
collapse
4. Subdiaphragmatic fat
5. Cyst in pneumatosis intestinalis
6. Sub pulmonary pneumothorax
34

35. CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditi‟s syndrome-
intestine between liver
and diaphragm
35

36. CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic
abscess
36

37. CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of
the right lung mimics a
large pneumoperitoneum
37

38. INTESTINAL OBSTRUCTION
38

39. GASTRIC DILATATION
Causes
1. Mechanical gastric outlet
obstruction.
2. Paralytic ileus
3. Gastric volvulus
4. Air swallowing.
39

40. GASTRIC VOLVULUS
o Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long
axis and becomes obstructed, with the greater curvature
being displaced superiorly and the lesser curvature
located more caudally in the abdomen
40

41. • Mesenteroaxial volvulus --less common , occurs when the
stomach rotates along its short axis, with resultant
displacement of the antrum above the gastroesophageal
junction
41

42. SMALL BOWEL OBSTRUCTION
• Small bowel obstruction refers to any condition
where the lumen of the small bowel is
obstructed
• The obstruction may be intrinsic (as with
intussusception) or extrinsic (as with abdominal
adhesions)
• A small bowel diameter on plain film greater
than 30mm is considered dilated
42

43. Clinical Presentation of SBO
 Abdominal pain
 Rapid onset of nausea and vomiting
 Belching
 Abdominal swelling
 Constipation and obstipation.
 Squealing bowel sounds (early obstruction)
 No bowel sounds (bowel wall muscular
exhaustion) 43

44. SMALL BOWEL OBSTRUCTION
• Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
• Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
• Intraluminal causes - gall stones
-foreign bodies
44

45. PLAIN RADIOGRAPH
• Plain film Signs appear after 3-5 hours
marked after 12 hours
• Supine abdominal X-rays-
dilated gas filled bowel loops (more
than 2.5 cm) with little or no gas in
colon
• Erect films shows-
multiple fluid level assuming a
„„step-ladder apperance‟‟
• „„String of pearls sign‟‟-
- Seen in decubitus or upright
film and is virtually diagnostic of
SBO
45

46. markedly distended loops of
small bowel, with effacement
Step ladder pattern
of the Valvulae in the mid produced by air fluid
abdomen levels in erect film 46

47. STRING OF PEARL SIGN
Left lateral decubitus radiograph of the abdomen
demonstrates a row of small air bubbles (arrows), which
represents air trapped between the Valvulae Conniventes.
47

48. The coiled spring appearance only occurs in the dilated air-
filled small bowel. It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced 48

49. GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled
dilated small bowel
All the air is absorbed
Difficult to differentiate
with normal bowel loops
49

50. PARALYTIC ILEUS
• lleus occurs from hypomotility of the gastrointestinal
tract in the absence of mechanical bowel obstruction.
• Causes- 1. Post operative ileus
2. Electrolyte imbalance
3. Sepsis
4. Generalised peritonoitis
5. Blunt abdominal trauma
6. Infiltration of mesentry by tumor
50

51. PARALYTIC ILEUS
• Difficult to distinguish adynamic ileus from
mechanical obstruction based on single
radiograph
• Degree of distension varies and features are not
specific
• Generalized distension- difficult to distinguish
from low large bowel obstruction
51

52. 52

53. Differentiating SBO from Paralytic Ileus
SBO Ileus
Patient with prior
Recent (hours) post-
Etiology surgery weeks to years
operative patient
prior
Pain Colicky Not a prominent feature
Abdominal
Frequently prominent May not be apparent
distension
Bowel sounds Usually increased Usually absent
Small bowel
Present Present
dilatation
Large bowel
Absent Present
dilatation
53

54. STRANGULATING OBSTRUCTION
• Occurs when two limbs of a loop are incarcerated
by a band or in a hernia, compromising the blood
supply
• Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may
resemble a large coffee bean
- if gangrene occurs, lines of gas seen in the wall of
the small bowel
54

55. Dilated small bowel
loops with an
obstructed bowel in the
right inguinal canal.
55

56. GALLSTONE ILEUS
• Mechanical intestinal obstruction due to impaction
of gall stones in the intestine
• Comprises about 2% of small bowel obstruction
• Unusual complication of chronic cholecystitis
• Impaction of gallstone in terminal ileum after
passing through a biliary-enteric fistula
• Average age of diagnosis is 70 years.
56

57. • The classic
radiographic signs,
described by Rigler
• Rigler’s traid:-
1. Incomplete or
complete SBO
2. Gas within gall
bladder/bile duct
3. Ectopic location
of gall stone
57

58. INTUSSUSCEPTION
• It is the invagination of a segment of
bowel ( intussusceptum) into the
contiguous segment ( intussuscipiens)
• Commonly seen in children below 2 years
• Ileocolic segment involved in 90% cases
• Colocolic and ileoileal intussusception
may occur
• Common in the ileum due to inflammation
of the lymphoid tissue in Peyer’s patches
58

59. INTUSSUSCEPTION
• In adults usually secondary to tumor of the bowel.
• Results in small bowel obstruction
• Crescent sign-Soft tissue mass, sometimes surrounded
by a crescent of gas, most commonly in
Rt.hypochondrium.
• Target sign- two concentric circles of fat density lying to
the rt. of spine.
• Target sign twice as common as crescent sign
59

60. There is a prominent crescent sign in the left upper quadrant with
a subtle target sign in right upper quadrant.
60

61. Intussusceptions in the left
upper quadrant on this plain
film of an infant with pain
vomiting 61

62. SMALL INTESTINAL INFARCTION
• Thrombosis or embolism of superior mesentric artery
• FEATURES
1. Gas filled dilated loops with multiple fluid levels.
2. Thickened bowel loops owing to submucosal
edema or hemorrhage.
3. Linear gas in wall streaks suggest gangrene.
4. Free gas if perforation.
5. Intra luminal gas in mesentric veins or portal
vein in advanced cases.
62

63. Intramural gas with
positive rigler sign (due
to intraperitoneal gas)
suggests possibilty of
intestinal infarction.
63

64. • LARGE BOWEL OBSTRUCTION
64

65. Large Bowel Obstruction
• Dilated colon to point of obstruction
• Little or no air in rectum/sigmoid
• Little or no gas in small bowel, if ileocecal valve
remains competent
65

66. Etiology
• Mechanical obstruction
1. Carcinoma of colon (60%)
2. Diverticulitis (second most common)
3. Volvulus
4. Extrinsic compression
• Paralytic ileus. AKA acute colonic psudo-
obstruction, was first described by Ogilvie
66

67. LARGE BOWEL OBSTRUCTION-types
• TYPE 1 A
• Large bowel distension
only-
• Owing to competent
ileocaecal valve.
• Caecum at risk of
perforation
67

68. LARGE BOWEL OBSTRUCTION-types
• TYPE 1 B
• Competent ileocaecal
valve leading to
caecal distension but
also as a mechanical
obstruction to small
bowel
• Caecum at risk of
perforation.
68

69. LARGE BOWEL OBSTRUCTION-types
• TYPE II
• Large and small
bowel distension
• Incompetent valve
69

70. Large bowel Volvulus
• Sigmoid colon and caecum - most common
sites
• If twist greater than 360 degrees, unlikely to
resolve spontaneously.
• The risk of vascular compromise more
important than mechanical effects
• Compound volvulus, involving interwining of
two loops of bowel is rare, such as
ileosigmoid knot.
70

71. CAECAL VOLVULUS
• Torsion of the bowel around its own mesentery
and often results in a closed-loop obstruction
• Occurs due to development failure of peritoneal
fixation.
• Accounts for 2-3% case of intestinal obstruction
and 11% cases of colonic volvulus.
71

72. The cecum twists in the axial plane, rotating clockwise or
counterclockwise around its long axis.
At times caecum twists and inverts and occupy left upper quadrant. 72

73. PLAIN RADIOGRAPH
• Plain film diagnostic in about 75%.
• Dilated air filled caecum in an ectopic location,
usually with the caecal apex in left upper quadrant
• Kidney or coffee bean appearence due to medially
placed ileo caecal valve producing a soft tissue
indentation.
• Little gas in distal colon, and usually collapsed.
• Refluxed gas may erroneously suggest a small bowel
obstruction.
73

74. Even though there is
considerable distension of
the caecum,one or two
haustral markings can be
usually seen,unlike sigmoid
volvulus
Identification of attached gas
filled appendix confirms
diagnosis.
74

75. SIGMOID VOLVULUS
• Accounts for 60-70% of
colonic volvulus
• Classically occur in old age,
psychiatrically disturbed,
mentally retarded or
institutionalised people.
• Twists around mesenteric
axis, rarely with axial torsion.
75

76. SIGMOID VOLVULUS-findings
• Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an
important diagnostic point
• Left flank overlap sign
• Liver overlap sign
• Apex under left hemidiaphram
• Apex above 10th thoracic vertebra
• Inferior convergence on left
76

77. 77

78. 78

79. COLONIC PSEUDO OBSTRUCTION
• Also known as OGILVIE
syndrome
• Due to autonomic
imbalance
• Acute abd distension
within10 days of
precipitating pathology
• Contrast enema/ CT
required to exclude
mechanical obstruction.
79

80. DISTINCTION BETWEEN SMALL AND LARGE
BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Present in Absent
Conniventes jejunum
Number of loops Many Few
Distribution of Central Peripheral
loops
Haustra Absent Present
Diameter 3-5 cm >5cm
Radius of small large
curvature
Solid faeces Absent Present 80

81. Acute colitis
• An assessment of the extent of colitis, state of
mucosa,depth of ulceration,presence or
absence of toxic megacolon and perforation
can be made.
• The extent of faecal residue related to the
extent of colitis.
• ‘Empty abdomen’-no faecal residue or gas s/o
active total colitis
• Intra luminal gas tend to accumulate as colitis
progress.
81

82. Acute ulcerative
colitis- descending
colon with irregular
outline, absent
haustrations, absent
faecal residue
82

83. TOXIC MEGACOLON
• Fulminating form of colitis with trans mural
inflammation.
• Perforation and peritonitis common
• Radiologically-dilatation and nodular mucosa.
• Dilatation >55mm- significant and sufficient,
• Changes most frequent in transverse colon.
• Gaseous distension of small bowel- severe colitis –
poor prognosis
83

84. TOXIC MEGACOLON
• Plain abdominal
radiograph shows
distention of the
transverse colon
associated with
mucosal edema.
• The maximum
transverse diameter of
the transverse colon is
6 cm
84

85. • ISCHAEMIC COLITIS
o Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the
proximal descending colon.
o Radiographically, difficult to identify unless some intra
luminal gas present.
o Submucosal thickening with cresentic margins (thumb-
printing).
o Involved area acts as a functional obstruction, so
proximal parts frequently distended
85

86. Ischemic colitis
86

87. PSEUDOMEMBRANOUS COLITIS
• Common cause of antibiotic associated diarrohea
• Clostridium difficile is usually involved
• 1/3 rd cases shows positive findings on plain films.
• Colonic dilatation (32 %)
• Thumb printing, thickened haustra, abnormal
mucosa (18 %)
• Untreated cases develops toxic megacolon and
subsequent perforation.
• Associated small bowel dilation(20 %), ascites
(7 %) may be seen.
87

88. extensive haustral thickening
(arrows) in a patient with
pseudomembranous colitis
88

89. INFLAMMATORY DISORDERS
89

90. ACUTE APPENDICITIS
o Commonest acute surgical condition in the
developing country
o Radiological signs-
 Appendix calculus(0.5-0.6)cm
 Right lower quadrant mass indenting the caecum
 Dilated caecum
 Sentinel loop
 Widening / blurring extraperitoneal fat line
 Scoliosis concave to the right
 Right lower quadrant haze
 Gas in the appendix
90

91. Appendicoliths are found in 10% of cases. Its presence with
pain in rt lower abdomen is highly suggestive of diagnosis.91

92. ACUTE CHOLECYSTITIS
• Gall stones- in 20% only
• Porcelein GB
• Right hypochondrial mass due to enlarged gall
bladder.
• Duodenal ileus
• Ileus of hepatic flexure of colon
• Gas within biliary system
92

93. 93

94. ACUTE PANCREATITIS
• Acute pancreatitis refers to acute inflammation of
the pancreas.
• Causes
• Gallstones (most common)
• Alcohol abuse, usually chronic
• Trauma, more often penetrating
• Drug-induced
• Anatomic abnormality
• ERCP-induced
• Infectious, especially post-viral in children
• Vasculitis
• Idiopathic
94

95. ACUTE PANCREATITIS
• Pathological changes are edema,
hemorrhege,lnfarction,fat necrosis followed
by acute suppuration
• Inflammatory processes tend into gastro
colic ligament or paraduodenal areas-
follow route of mesentry or extend out of
peritoneum into perirenal space.
• Lot of radiological signs described, but
many are of little value in diagnosing
individual cases.
95

96. Plain film changes-
 Chest x-ray-
o Left sided pleural effusion
o Splinting of left hemidiaphragm
o Basal atelactasis
 Abdominal film-
o Duodenal ileus
o Gasless abdomen
o “colon cut off” sign
o Renal “halo” sign
o Absent left psoas shadow
o Indistinct mottled shadowing
o Sentinel loop
o Intrapancreatic gas-abscess/ enteric fistula
96

97. The abrupt termination of gas within the proximal colon
at the level of the radiographic splenic flexure, usually
with decompression of the distal colon
97

98. A sentinel loop is a focal area of adynamic ileus close to an intra-
abdominal inflammatory process. The sentinel loop sign may aid in
localizing the source of inflammation
98

99. • Later stages- pancreatic pseudocyst visible on
plain film as large soft tissue mass
• Pleural effusions, mainly left sided.
99

100. INTRA-ABDOMINAL ABSCESS
• Abscesses are collections
of pus that may displace
adjacent structures
following their involvement
by inflammatory process
• Usually of soft tissue
density on plain films,but
frequently contain gas.
• Recognition of small gas
bubbles outside bowel
lumen,unchanged in
position on sequential films,
strongly s/o abscess. 100

101. SUBPHRENIC ABSCESS
• Nearly always occurs as a result of surgery
• Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
 Abdominal radiographs
- gas/fluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
 Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level/
irregular gas pockets 101

102. INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
• A gas/fluid level is seen
beneath the right
hemidiaphragm. Note
also the pleural
effusion. The abscess
developed in a 45-year-
old woman following a
cholecystectomy.
102

103. PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the
commonest causative lesions
Soft tissue mass, often containing gas
bubbles, and displacing colon – m.c
radiographic presentation
103

104. INTRAMURAL GAS
• Gas within walls of hollow viscus
• Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
104

105. Cystic pneumatosis
(Pneumatosis cystoides intestinalis)
• Cyst like collections of gas in the walls of the
hollow viscera
• Left half of colon most frequently involved-
pneumatosis coli
• Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
105

106. INTERSTITIAL EMPHYSEMA
• Linear gas, in single or double streaks, is found in the
bowel wall
• Common site- stomach & colon
• Associated with toxic megacolon
 Emphysematous gastritis-
- contracted stomach
- mottled lucency in the left upper abdomen
 Emphysematous cholecystitis
-occurs in absence of gallstones
106

107.  Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
 Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder & within
the lumen of the bladder
107

108. Linear or curvilinear
lucencies are seen in the
walls of the bowel
108

109. Emphysematous gastritis Emphysematous cysytitis09
1

110. Emphysematous Cholecystitis
110

111. OTHER CONDITIONS
111

112. RENAL COLIC
• A high proportion of patients with acute ureteric
obstruction due to calculus present with an acute
abdomen
• About 90% of renal stones are radio-opaque. Uric acid stones
especially may be missed
• Plain abdominal radiograph-
Calculi (90%)
Meteorism
Paralytic ileus
Urinoma- soft tissue mass
with loss of renal and psoas outines
112

113. 113

114. Emphysematous Pyelonephritis
• Recognised by gas
bubbles within the
kidney or linear gas
beneath the renal
capsule
• Occurs in uncontrolled
Diabetes or Obstructive
uropathy
114

115. ACUTE GYNAECOLOGICAL DISORDERS
• Torsion of an ovarian cyst- pelvic mass
• Dermoid cyst- contains calcification, teeth or fat
• Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
115

116. Ovarian teratoma
Pop corn like / cauliflower
– uterine leiomyoma
116

117. Abdominal Aortic Aneurysm
• Presents as acute abdomen with shock and
simulated renal colic
• Curvilinear calcification seen on AP radiograph but
is best detected on a lateral view
• Calcified walls of aorta can allow measurement
of lumen
• AAA if over 3 cm AP diameter
• Ultrasound and CT are much more sensitive
117

118. 118

119. ASCITES
• Only large amount of Ascites can be recognized on
abdominal radiograph
• Signs:
1.Obliteration of the inferior edge of the liver
2.Widening of the distance between the flank stripe and
ascending colon. Normal is 2-3 mm
3. Fluid accumulation in the pelvis
4. centrally located bowel loops with bulging flanks
5. Ground glass appearnace_ requires large amount of
fluid.
119

120. Supine view of the abdomen shows central displacement of the loops of
bowel,a uniform grayness to the abdomen, loss of any definition of the
edge of the spleen or liver and displacement of the bowel loops out of
120
the pelvis, all suggestive of ascites

121. Hydatid cyst in the Liver
121

122. FOREIGN BODY
IRON TABLETS BUTTON BATTERIES
122

123. • PAEDIATRICS
123

124. DUODENAL ATRESIA JEJUNAL ATRESIA
124

125. NECROTIZING ENTEROCOLITIS
125

126. Conclusion
• Following the history and clinical examination,
plain film radiographs have been one of the first
and most useful methods of further investigation.
• Plain picture continues to be initial imaging
modility in acute abdomen, particularly in
perforation and intestinal obstruction.
• In cases where definite diagnosis cannot be
reached, further evaluation with USG and CT
scan is required.
126

127. 127