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Approach to Abdominal Plain Film Radiology. Nalin Amin, MD, CCFP, FRCSC Assistant Professor Dept. Of Surgery, McMaster University. Objectives. What is the use of plain xrays anymore? Three views? Radiation concern? Flat Plate? KUB? Decub ? Develop approach CASES. What is the use?

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approach to abdominal plain film radiology

Approach toAbdominal Plain Film Radiology

Nalin Amin, MD, CCFP, FRCSC

Assistant Professor

Dept. Of Surgery, McMaster University

objectives
Objectives

What is the use of plain xrays anymore?

Three views?

Radiation concern?

Flat Plate? KUB? Decub?

Develop approach

CASES

slide3

What is the use?

    • Still good screening for:
      • Bowel obstruction
      • Ileus
      • Free air (on upright views)
      • NGT placement
      • Stones follow-up
      • etc
slide4

3 views

    • Upright/Standing
    • Supine (upper)
    • Supine (lower)
slide5

Supine (upper)

Supine

(lower)

Upright

slide6

Flat plate

    • b/c used ‘glass plate’ in old days
    • Now digital technology
  • KUB
    • ‘Kidneys/Ureters/Bladder’
      • Supine view with field-of-view from

kidney to bladder

      • +/- IV contrast
      • Assess for radiopaque calculi
  • Decub
    • Lying on side
      • Good for free air if cannot do upright
radiation
Radiation
  • 1 CXR ~ 0.1 mSv ≈ 1 cigarette ( risk of ca)
  • 1 abdo XR ~ 0.7 mSv ≈ 7 cigs
  • 1 pelvis XR ~ 0.6 mSv
  • CT abdo/pelvis ~14 mSv ≈ 140 cigs
  • CT chest ~7 mSv
approach
APPROACH

ABCS!

A = air

B = bowel

C = calcifications

S = soft tissues

slide10

Stomach

LB

SB

Bowel

slide11

L-Spine w/DDD

12th rib

anastomotic

staple

chole

clips

renal

stone

phlebolith

pelvic clips

Calcifications

slide12

Soft

Tissues

spleen

margin

liver edge

properitoneal

fat

left kidney

shadow

slide13

male pt XY

Soft

Tissues

bladder

cases
CASES

Case 1

cases19
CASES

Case 2

slide21

Free air (on supine)

    • harder to see
      • need significant amount more to see
    • Football sign
      • falciform is the laces
    • Rigler’s sign
      • bowel wall outlined by free air
        • normally not mesenteric side aspect seen
cases23
CASES

Case 3

slide25

left renal calculi

    • 80% radioopaque
      • ca2+ oxalate, phosphate
      • struvite
    • 20% radiolucent
      • uric acid (+ve on CT)
      • cystine (+ve on CT)
      • HIV indinavir (-ve on CT)
cases27
CASES

Case 4

slide29

SBO

    • multiple AF levels
    • varying heights
    • “string-of-pearls”
    • low grade vs high grade
    • early/partial vs complete
      • if gas is seen distally (early/partial)
      • decompressed distally (complete/high grade)
slide31

SBO causes

    • adhesions (50%)
    • hernias (15%)
    • ca (1º and mets) (15%)
cases32
CASES

Case 5

slide36

LBO causes

    • Cancer
    • Diverticulitis
    • Volvulus
    • Hernia
  • note if IC valve competent or incompetent
    • this case, competent
      • ie. no SBD
cases38
CASES

Case 6

slide40

paralytic ileus

    • hard to discriminate from BO
cases42
CASES

Case 7

slide45

pneumobilia

dilated SB loops

gallstone

slide46

triad

    • gallstone
    • SBO or ileus
    • pneumobilia
      • central
        • as opposed to PV gas (peripheral)
cases47
CASES

Case 8

slide49
thumbprinting
    • bowel wall edema
  • DDx (4 I’s)
    • ischemia
    • infectious colitis
      • PMC
    • inflammatory (UC/IBD)
    • infiltrative
    • other: edema, Rn, tumor, hemorrhage
cases51
CASES

Case 9

slide53

sigmoid volvulus

    • flips into RUQ
      • cecal volvulus flips into LUQ
    • kidney bean shaped
      • midline crease – mesenteric vessels
      • cecal volvulus coffee bean
cases55
CASES

Case 9a

cases58
CASES

Case 10

slide60

Bad News

    • Pneumatosis
    • Portal venous gas
  • pre-morbid
slide61

pneumatosis

portal venous gas

cases62
CASES

Case 10