Top

Published in:

01-04-2017 | Pictorial Essay

Abdominal radiograph pearls and pitfalls for the emergency department radiologist: a pictorial review

Authors: Jerry T. Loo, Vinay Duddalwar, Frank K. Chen, Tapas Tejura, Ilya Lekht, Mittul Gulati

Published in: Abdominal Radiology | Issue 4/2017

Abstract

Abdominal plain films are often the first imaging examination performed on a patient with abdominal pain in the emergency department. Radiograph findings can help guide clinical management and the need for advanced imaging. A pictorial review of a range of abdominal radiograph findings is presented, including bowel gas patterns, abdominal organ evaluation, pathologic gas, calcifications, implanted devices, and foreign bodies.

Ditkofsky NG, Singh A, Avery L, Novelline RA (2014) The role of emergency MRI in the setting of acute abdominal pain. Emerg Radiol 21(6):615–624. doi:10.1007/s10140-014-1232-2 CrossRefPubMed

Stoker J, van Randen A, Lameris W, Boermeester MA (2009) Imaging patients with acute abdominal pain. Radiology 253(1):31–46. doi:10.1148/radiol.2531090302 CrossRefPubMed

Rao PM, Rhea JT, Rao JA, Conn AK (1999) Plain abdominal radiography in clinically suspected appendicitis: diagnostic yield, resource use, and comparison with CT. Am J Emerg Med 17(4):325–328CrossRefPubMed

Kellow ZS, MacInnes M, Kurzencwyg D, et al. (2008) The role of abdominal radiography in the evaluation of the nontrauma emergency patient. Radiology 248(3):887–893. doi:10.1148/radiol.2483071772 CrossRefPubMed

van Randen A, Lameris W, Luitse JS, et al. (2011) The role of plain radiographs in patients with acute abdominal pain at the ED. Am J Emerg Med 29(6):582–589 e582.. doi:10.1016/j.ajem.2009.12.020 CrossRefPubMed

Eisenberg RL (2008) The role of abdominal radiography in the evaluation of the nontrauma emergency patient: new thoughts on an old problem. Radiology 248(3):715–716. doi:10.1148/radiol.2483080863 CrossRefPubMed

Pinto A, Lanza C, Pinto F, et al. (2015) Role of plain radiography in the assessment of ingested foreign bodies in the pediatric patients. Semin Ultrasound CT MR 36(1):21–27. doi:10.1053/j.sult.2014.10.008 CrossRefPubMed

Baker N, Woolridge D (2013) Emerging concepts in pediatric emergency radiology. Pediatr Clin North Am 60(5):1139–1151. doi:10.1016/j.pcl.2013.06.004 CrossRefPubMed

James B, Kelly B (2013) The abdominal radiograph. Ulster Med J 82(3):179–187PubMedPubMedCentral

10.

Brenner DJ, Hall EJ (2007) Computed tomography–an increasing source of radiation exposure. N Engl J Med 357(22):2277–2284. doi:10.1056/NEJMra072149 CrossRefPubMed

11.

Nair N, Takieddine Z, Tariq H (2015) Colonic interposition between the liver and right diaphragm: the ‘Chilaiditi sign’. Can J Gastroenterol Hepatol

12.

Bohm B, Milsom JW, Fazio VW (1995) Postoperative intestinal motility following conventional and laparoscopic intestinal surgery. Arch Surg 130(4):415–419CrossRefPubMed

13.

Kammen BF, Levine MS, Rubesin SE, Laufer I (2000) Adynamic ileus after caesarean section mimicking intestinal obstruction: findings on abdominal radiographs. Br J Radiol 73(873):951–955. doi:10.1259/bjr.73.873.11064647 CrossRefPubMed

14.

Kim SH, Park KN, Kim SJ, et al. (2011) Accuracy of plain abdominal radiography in the differentiation between small bowel obstruction and small bowel ileus in acute abdomen presenting to emergency department. Hong Kong J Emerg Med 18(2):68–79

15.

Spurk JH (1997) Fluid mechanics. New York: SpringerCrossRef

16.

Davis S, Parbhoo SP, Gibson MJ (1980) The plain abdominal radiograph in acute pancreatitis. Clin Radiol 31(1):87–93CrossRefPubMed

17.

Silva AC, Pimenta M, Guimaraes LS (2009) Small bowel obstruction: what to look for. Radiographics 29(2):423–439. doi:10.1148/rg.292085514 CrossRefPubMed

18.

Maglinte DD, Balthazar EJ, Kelvin FM, Megibow AJ (1997) The role of radiology in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol 168(5):1171–1180. doi:10.2214/ajr.168.5.9129407 CrossRefPubMed

19.

Miyazaki O (1995) Efficacy of abdominal plain film and CT in bowel obstruction. Nihon Igaku Hoshasen Gakkai Zasshi 55(4):233–239PubMed

20.

Frager D, Medwid SW, Baer JW, Mollinelli B, Friedman M (1994) CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause. AJR Am J Roentgenol 162(1):37–41. doi:10.2214/ajr.162.1.8273686 CrossRefPubMed

21.

Maglinte DD, Reyes BL, Harmon BH, et al. (1996) Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol 167(6):1451–1455. doi:10.2214/ajr.167.6.8956576 CrossRefPubMed

22.

Harlow CL, Stears RL, Zeligman BE, Archer PG (1993) Diagnosis of bowel obstruction on plain abdominal radiographs: significance of air-fluid levels at different heights in the same loop of bowel. AJR Am J Roentgenol 161(2):291–295. doi:10.2214/ajr.161.2.8333364 CrossRefPubMed

23.

Thompson WM (2008) Gasless abdomen in the adult: what does it mean? AJR Am J Roentgenol 191(4):1093–1099. doi:10.2214/AJR.07.3837 CrossRefPubMed

24.

Hayakawa K, Tanikake M, Yoshida S, et al. (2013) Radiological diagnosis of large-bowel obstruction: neoplastic etiology. Emerg Radiol 20(1):69–76. doi:10.1007/s10140-012-1088-2 CrossRefPubMed

25.

Slam KD, Calkins S, Cason FD (2007) LaPlace’s law revisited: cecal perforation as an unusual presentation of pancreatic carcinoma. World J Surg Oncol 5:14. doi:10.1186/1477-7819-5-14 CrossRefPubMedPubMedCentral

26.

Gingold D, Murrell Z (2012) Management of colonic volvulus. Clin Colon Rectal Surg 25(4):236–244. doi:10.1055/s-0032-1329535 CrossRefPubMedPubMedCentral

27.

Jaffe T, Thompson WM (2015) Large-bowel obstruction in the adult: classic radiographic and CT findings, etiology, and mimics. Radiology 275(3):651–663. doi:10.1148/radiol.2015140916 CrossRefPubMed

28.

Tiah L, Goh SH (2006) Sigmoid volvulus: diagnostic twists and turns. Eur J Emerg Med 13(2):84–87. doi:10.1097/01.mej.0000190278.30850.8a CrossRefPubMed

29.

Feldman D (2000) The coffee bean sign. Radiology 216(1):178–179. doi:10.1148/radiology.216.1.r00jl17178 CrossRefPubMed

30.

Burrell HC, Baker DM, Wardrop P, Evans AJ (1994) Significant plain film findings in sigmoid volvulus. Clin Radiol 49(5):317–319CrossRefPubMed

31.

Javors BR, Baker SR, Miller JA (1999) The northern exposure sign: a newly described finding in sigmoid volvulus. AJR Am J Roentgenol 173(3):571–574. doi:10.2214/ajr.173.3.10470881 CrossRefPubMed

32.

Delabrousse E, Sarlieve P, Sailley N, Aubry S, Kastler BA (2007) Cecal volvulus: CT findings and correlation with pathophysiology. Emerg Radiol 14(6):411–415. doi:10.1007/s10140-007-0647-4 CrossRefPubMed

33.

Lopez Perez E, Martinez Perez MJ, Ripolles Gonzalez T, Vila Miralles R, Flors Blasco L (2010) Cecal volvulus: imaging features. Radiologia 52(4):333–341. doi:10.1016/j.rx.2010.03.014 CrossRefPubMed

34.

Coulie B, Camilleri M (1999) Intestinal pseudo-obstruction. Annu Rev Med 50:37–55. doi:10.1146/annurev.med.50.1.37 CrossRefPubMed

35.

De Giorgio R, Knowles CH (2009) Acute colonic pseudo-obstruction. Br J Surg 96(3):229–239. doi:10.1002/bjs.6480 CrossRefPubMed

36.

Lang EV, Carson L, Gossler A (1998) Gas lock obstruction of the colon: Ogilvie’s syndrome revisited. AJR Am J Roentgenol 171(4):1014–1016. doi:10.2214/ajr.171.4.9762987 CrossRefPubMed

37.

Low VH (1995) Colonic pseudo-obstruction: value of prone lateral view of the rectum. Abdom Imaging 20(6):531–533CrossRefPubMed

38.

Mounsey A, Raleigh M, Wilson A (2015) Management of constipation in older adults. Am Fam Physician 92(6):500–504PubMed

39.

Hussain ZH, Whitehead DA, Lacy BE (2014) Fecal impaction. Curr Gastroenterol Rep 16(9):404. doi:10.1007/s11894-014-0404-2 CrossRefPubMed

40.

Saksonov M, Bachar GN, Morgenstern S, et al. (2014) Stercoral colitis: a lethal disease-computed tomographic findings and clinical characteristic. J Comput Assist Tomogr 38(5):721–726. doi:10.1097/RCT.0000000000000117 CrossRefPubMed

41.

Cunha TB, Tahan S, Soares MF, Lederman HM, Morais MB (2012) Abdominal radiograph in the assessment of fecal impaction in children with functional constipation: comparing three scoring systems. J Pediatr (Rio J) 88(4):317–322. doi:10.2223/JPED.2199 CrossRef

42.

Cowlam S, Vinayagam R, Khan U, et al. (2008) Blinded comparison of faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation. Clin Radiol 63(12):1326–1331. doi:10.1016/j.crad.2008.06.011 CrossRefPubMed

43.

Bartram CI (1976) Plain abdominal X-ray in acute colitis. Proc R Soc Med 69(8):617–618PubMedPubMedCentral

44.

Gore RM, Levine MS, Laufer I (1994) Textbook of gastrointestinal radiology. Philadelphia: W.B. Saunders Co.

45.

Prantera C, Lorenzetti R, Cerro P, et al. (1991) The plain abdominal film accurately estimates extent of active ulcerative colitis. J Clin Gastroenterol 13(2):231–234CrossRefPubMed

46.

O’Regan K, O’Connor OJ, O’Neill SB, et al. (2012) Plain abdominal radiographs in patients with Crohn’s disease: radiological findings and diagnostic value. Clin Radiol 67(8):774–781. doi:10.1016/j.crad.2012.01.005 CrossRefPubMed

47.

Kawamoto S, Horton KM, Fishman EK (1999) Pseudomembranous colitis: spectrum of imaging findings with clinical and pathologic correlation. Radiographics 19(4):887–897. doi:10.1148/radiographics.19.4.g99jl07887 CrossRefPubMed

48.

Autenrieth DM, Baumgart DC (2012) Toxic megacolon. Inflamm Bowel Dis 18(3):584–591. doi:10.1002/ibd.21847 CrossRefPubMed

49.

Boyer TD, Wright TL, Manns MP, Zakim D (2006) Zakim and Boyer’s hepatology: a textbook of liver disease, 5th edn. Philadelphia, PA: Saunders/Elsevier

50.

Kaude JV, DeLand F (1975) Hepatomegaly. Med Clin North Am 59(1):145–167CrossRefPubMed

51.

O’Reilly RA (1996) Splenomegaly at a United States County Hospital: diagnostic evaluation of 170 patients. Am J Med Sci 312(4):160–165CrossRefPubMed

52.

Quiroga O, Matozzi F, Beranger M, et al. (1982) Normal CT anatomy of the spine. Anatomo-radiological correlations. Neuroradiology 24(1):1–6CrossRefPubMed

53.

Bundrick TJ, Cho SR, Brewer WH, Beachley MC (1984) Ascites: comparison of plain film radiographs with ultrasonograms. Radiology 152(2):503–506. doi:10.1148/radiology.152.2.6739823 CrossRefPubMed

54.

Lee CH (2010) Images in clinical medicine. Radiologic signs of pneumoperitoneum. N Engl J Med 362(25):2410. doi:10.1056/NEJMicm0904627 CrossRefPubMed

55.

Chapman BC, McIntosh KE, Jones EL, et al. (2015) Postoperative pneumoperitoneum: is it normal or pathologic? J Surg Res 197(1):107–111. doi:10.1016/j.jss.2015.03.083 CrossRefPubMed

56.

Feczko PJ, Mezwa DG, Farah MC, White BD (1992) Clinical significance of pneumatosis of the bowel wall. Radiographics 12(6):1069–1078. doi:10.1148/radiographics.12.6.1439012 CrossRefPubMed

57.

Soyer P, Martin-Grivaud S, Boudiaf M, et al. (2008) Linear or bubbly: a pictorial review of CT features of intestinal pneumatosis in adults. J Radiol 89(12):1907–1920CrossRefPubMed

58.

Sebastia C, Quiroga S, Espin E, et al. (2000) Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. Radiographics 20 (5):1213–1224; discussion 1224–1216. doi:10.1148/radiographics.20.5.g00se011213

59.

Rajkovic Z, Papes D, Altarac S, Arslani N (2013) Differential diagnosis and clinical relevance of pneumobilia or portal vein gas on abdominal X-ray. Acta Clin Croat 52(3):369–373PubMed

60.

Brandon JC, Glick SN, Teplick SK, Silverstein GS (1988) Emphysematous cholecystitis: pitfalls in its plain film diagnosis. Gastrointest Radiol 13(1):33–36. doi:10.1007/BF01889020 CrossRefPubMed

61.

Wan YL, Lee TY, Bullard MJ, Tsai CC (1996) Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 198(2):433–438. doi:10.1148/radiology.198.2.8596845 CrossRefPubMed

62.

Bliznak J, Ramsey J (1972) Emphysematous pyelonephritis. Clin Radiol 23(1):61–64CrossRefPubMed

63.

Narlawar RS, Raut AA, Nagar A, et al. (2004) Imaging features and guided drainage in emphysematous pyelonephritis: a study of 11 cases. Clin Radiol 59(2):192–197CrossRefPubMed

64.

Grupper M, Kravtsov A, Potasman I (2007) Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore) 86(1):47–53. doi:10.1097/MD.0b013e3180307c3a CrossRef

65.

Gordon R (1980) The deep sulcus sign. Radiology 136(1):25–27. doi:10.1148/radiology.136.1.7384513 CrossRefPubMed

66.

Coursey CA, Casalino DD, Remer EM, et al. (2012) ACR Appropriateness Criteria(R) acute onset flank pain–suspicion of stone disease. Ultrasound Q 28(3):227–233. doi:10.1097/RUQ.0b013e3182625974 CrossRefPubMed

67.

Traubici J, Neitlich JD, Smith RC (1999) Distinguishing pelvic phleboliths from distal ureteral stones on routine unenhanced helical CT: is there a radiolucent center? AJR Am J Roentgenol 172(1):13–17. doi:10.2214/ajr.172.1.9888730 CrossRefPubMed

68.

Jindal G, Ramchandani P (2007) Acute flank pain secondary to urolithiasis: radiologic evaluation and alternate diagnoses. Radiol Clin North Am 45(3):395–410., vii. doi:10.1016/j.rcl.2007.04.001 CrossRefPubMed

69.

Baron RL (1991) Gallstone characterization: the role of imaging. Semin Roentgenol 26(3):216–225CrossRefPubMed

70.

Etemad B, Whitcomb DC (2001) Chronic pancreatitis: diagnosis, classification, and new genetic developments. Gastroenterology 120(3):682–707CrossRefPubMed

71.

Present AJ, Geyman MJ (1947) Diffuse calcification of the pancreas. Radiology 48(1):29–32. doi:10.1148/48.1.29 CrossRefPubMed

72.

Baker SR (1990) The abdominal plain film. Norwalk: Appleton & Lange

73.

Guy PJ, Pailthorpe CA (1983) The radio-opaque appendicolith–its significance in clinical practice. J R Army Med Corps 129(3):163–166CrossRefPubMed

74.

Ishiyama M, Yanase F, Taketa T, et al. (2013) Significance of size and location of appendicoliths as exacerbating factor of acute appendicitis. Emerg Radiol 20(2):125–130. doi:10.1007/s10140-012-1093-5 CrossRefPubMed

75.

Ernst CB (1993) Abdominal aortic aneurysm. N Engl J Med 328(16):1167–1172. doi:10.1056/NEJM199304223281607 CrossRefPubMed

76.

Golder WA (2008) Tortuosity and calcification of the splenic artery. More than an additional finding. Radiologe 48(11):1066–1067. doi:10.1007/s00117-008-1631-z CrossRefPubMed

77.

Hunter TB, Taljanovic MS (2005) Medical devices of the abdomen and pelvis. Radiographics 25(2):503–523. doi:10.1148/rg.252045157 CrossRefPubMed

78.

Fearn S, Lawrence-Brown MM, Semmens JB, Hartley D (2003) Follow-up after endovascular aortic aneurysm repair: the plain radiograph has an essential role in surveillance. J Endovasc Ther 10(5):894–901. doi:10.1583/1545-1550(2003)010<0894:FAEAAR>2.0.CO;2 CrossRefPubMed

79.

Dyer RB, Chen MY, Zagoria RJ, et al. (2002) Complications of ureteral stent placement. Radiographics 22(5):1005–1022. doi:10.1148/radiographics.22.5.g02se081005 CrossRefPubMed

80.

Gharib AM, Stern EJ, Sherbin VL, Rohrmann CA (1996) Nasogastric and feeding tubes. The importance of proper placement. Postgrad Med 99(5):165–168PubMed

81.

Niv Y, Abu-Avid S (1988) On the positioning of a nasogastric tube. Am J Med 84(3 Pt 1):563–564CrossRefPubMed

82.

Carmody K, Schwartz B, Chang A (2011) Extrauterine migration of a mirena(R) intrauterine device: a case report. J Emerg Med 41(2):161–165. doi:10.1016/j.jemermed.2010.04.024 CrossRefPubMed

83.

Aras MH, Miloglu O, Barutcugil C, et al. (2010) Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol 39(2):72–78. doi:10.1259/dmfr/68589458 CrossRefPubMedPubMedCentral

84.

Gerard PS, Wilck E, Schiano T (1993) Imaging implications in the evaluation of permanent needle acupuncture. Clin Imaging 17(1):36–40CrossRefPubMed

85.

Pucelikova T, Dangas G, Mehran R (2008) Contrast-induced nephropathy. Catheter Cardiovasc Interv 71(1):62–72. doi:10.1002/ccd.21207 CrossRefPubMed

86.

Older RA, Korobkin M, Cleeve DM, Schaaf R, Thompson W (1980) Contrast-induced acute renal failure: persistent nephrogram as clue to early detection. AJR Am J Roentgenol 134(2):339–342. doi:10.2214/ajr.134.2.339 CrossRefPubMed

Title: Abdominal radiograph pearls and pitfalls for the emergency department radiologist: a pictorial review
Authors: Jerry T. Loo
Vinay Duddalwar
Frank K. Chen
Tapas Tejura
Ilya Lekht
Mittul Gulati
Publication date: 01-04-2017
Publisher: Springer US
Published in: Abdominal Radiology / Issue 4/2017
Print ISSN: 2366-004X
Electronic ISSN: 2366-0058
DOI: https://doi.org/10.1007/s00261-016-0859-8

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Highlights from the ACC 2024 Congress

Year in Review: Pediatric cardiology

Pediatric Cardiology Video

Watch Dr. Anne Marie Valente present the last year's highlights in pediatric and congenital heart disease in the official ACC.24 Year in Review session.

Year in Review: Pulmonary vascular disease

Cardiopulmonary Comorbidity Video

The last year's highlights in pulmonary vascular disease are presented by Dr. Jane Leopold in this official video from ACC.24.

Year in Review: Valvular heart disease

Valvular Heart Disease Video

Watch Prof. William Zoghbi present the last year's highlights in valvular heart disease from the official ACC.24 Year in Review session.

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits

STEP AAG HeroTeaserCollection image/© Tarek / Generated with AI / Stock.adobe.com, ACC 2024 Pediatric and Congenital Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Pulmonary Vascular Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Valvular Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 HF and Cardiomyopathies: Year in Review/© 2024 American College of Cardiology, Woman out walking/© Seventyfour / stock.adobe.com (symbolic image with model), Woman checking smartwatch /© saltdium / stock.adobe.com (symbolic image with model), Cardiac catheterization/© Damian / stock.adobe.com

At a glance: The STEP trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 4/2017

Reporting standards for the imaging-based diagnosis of renal masses on CT and MRI: a national survey of academic abdominal radiologists and urologists

“Incidentalomas” on abdominal and pelvic CT in emergency radiology: literature review and current management recommendations

MRI features of perianal fistulas: is there a difference between Crohn’s and non-Crohn’s patients?

Crohn’s disease diagnosis, treatment approach, and management paradigm: what the radiologist needs to know

Classic signs in abdominal radiology “India ink” artifact

Effect of intravenous gadoxetate disodium and flip angle on hepatic proton density fat fraction estimation with six-echo, gradient-recalled-echo, magnitude-based MR imaging at 3T

Highlights from the ACC 2024 Congress

ACC 2024 Congress Coverage