Abdominal X-Rays

Question 1

Indications of Abdominal X-Rays (supine AP)

Answer 1

Emergent evaluation: suspected small bowel obstruction; pneumoperitoneum; foreign bodies; lines/tubes

Question 2

If suspected bowel perforation…

Answer 2

order an erect CXR

Question 3

Haustra

Answer 3

Mucosal folds of the Large bowel (colon, rectum, anus)

Question 4

Valvullae conniventes

Answer 4

Mucosal folds of the Small bowel (duodenum, jejunum, ileum)

Question 5

5 causes of Pneumoperitoneum

Answer 5

Perforation (PEPA FOR ME): Peptic ulcer/Endoscopic/Penetrating Abdominal injury/ingestion of FOReign body / imMEdiately post-surgery

Question 6

“Decubitus abdomen sign”

Answer 6

Pneumoperitoneum (air-fluid level in left lateral decubitus)

Question 7

“Rigler´s sign”

Answer 7

Pneumoperitoneum (double-wall sign -> we can see both sides of the bowel)

Question 8

“Apple core sign”

Answer 8

Colorectal cancer (an annular constricting carcinoma of the bowel, usually the colon, from circumferential involvement of the lumen)

Question 9

Causes of Hydronephrosis

Answer 9

PACT: Pelvic-ureteric obstruction, Aberrant renal vessels, Calculi, Tumours of the renal pelvis

Question 10

Causes of RUQ pain

Answer 10

“HePA, Ai”: Hepatitis, Pancreatitis, Acute colecistis, Ascending colangitis

Question 11

Gallstone obstructing distal small bowel + small bowel obstruction + pneumobilia

Answer 11

Rigler´s triad = Gallstone ileus

Question 12

Patient consumes lots of alcohol, radiopaque area on the pancreas (diffuse)

Answer 12

Pancreatic calcifications

Question 13

Causes of Pancreatic calcifications

Answer 13

Chronic pancreatitis due to heavy alcohol consumption (if focal/smaller calcifications: cystic fibrosis, pancreatic cancer, senile)

Question 14

Old patient who had osteoarthrosis of hips, radiopaque area on femur

Answer 14

Hip prosthesis

Question 15

Patient had fusion of their lumbar spine

Answer 15

Spinal hardware

Question 16

Intrauterine device correct position

Answer 16

Upright T position, in the midline just inferior to the pelvic rim

Question 17

Round metallic bright foreign body in the lower abdomen: concern

Answer 17

Foreign body - rule out if its a battery (can cause internal chemical burns leading to perforation, peritonitis and death): take history + review X-Ray with a Radiologist

Question 18

Causes of obstruction of the small bowel

Answer 18

GATAh: Gallstones, Adhesions (prior surgery), Tumour, Abdominal hernia

Question 19

Causes of obstruction of the large bowel

Answer 19

VoTu Di DiA: Volvulus, Tumour, Diverticular Disease, Abscess

Question 20

The 3-6-9 rule

Answer 20

Upper limit of normal diameter: small bowel (3cm), colon (6cm), rectum (9cm)

Question 21

“Lead pipe” appearance of colon (loss of haustral markings)

Answer 21

Ulcerative Colitis

Question 22

10y, IBD, proffuse diarrhea or constipation, abdominal tenderness, not able to eat, with a colon >6cm diffusely on ABD X-Ray, labs: leukocytosis, anemia, hypoK, hypoMg, raised CRP, raised ESR

Answer 22

Toxic megacolon (in this case as a complication of IBD - failed treatment)

Question 23

Causes of Toxic megacolon

Answer 23

3I: IBD (complication), Infection (C. difficile colitis), Ischaemic colitis

Question 24

Toxic megacolon: next step

Answer 24

Medical Emergency -> URGENT surgical referral (total colectomy) + IV Antibiotics (ampi+metro+cipro), IV Fluids, Steroids (if IBD related: IV hydrocortisone)

Question 25

“Double bubble sign” in ABD X-Ray (Yin and Yang)

Answer 25

Duodenal Atresia

Question 26

Patient has had previous abdominal surgery, “Stack of coins sign” on ABD X-Ray

Answer 26

Small bowel obstruction (central dilated loops, valvulae conniventes are visible)

Question 27

“Stepladder sign”

Answer 27

Small bowel obstruction (distended small bowell loops with gas-fluid levels that appear to be stacked on top of each other)

Question 28

“String of pearls sign”

Answer 28

Small bowel obstruction

Question 29

70y, chronic constipation, “Coffee bean sign”

Answer 29

Sigmoid Volvulus

Question 30

Sigmoid Volvulus: next step

Answer 30

Life-threatening (risk of perforation) -> Emergent management: Flexible sigmoidoscopy + decompression (if perforated = surgery)

Question 31

80y, lower abdominal pain, disturbed bowel habit, barium ABD X-Ray showing numerous small pouches along the descending colon

Answer 31

Colonic Diverticular disease (pain is caused by spasm in the intestinal muscles)

Question 32

Sitzmarks on ABD X-Ray

Answer 32

Constipation

Question 33

“Thumb-printing sign”

Answer 33

Oedema of the haustra = 3I (IBD (complication), Infection (C. difficile colitis), Ischaemic colitis) + diverticulitis

Question 34

Nephrolithiasis location

Answer 34

renal pelvis / ureter / bladder / urethra

Question 35

Complex renal stones that occupy the majority of the renal collecting system, on ABD X-Ray it looks like a horn

Answer 35

“Staghorn Calculus”

Question 36

Female, pelvic pain, heavy menstrual bleeding, overall discomfort in the lower abdomen, back pain (or 70y with hip pain), ABD X-Ray shows a “popcorn-like appearance” within a rounded mass in the right side of the pelvis

Answer 36

Calcified uterine fibroid

Question 37

Patient with hypotension, flank/back pain, and pulsatile mass in the ABD underwent a surgery, ABD X-Ray post-operation shows…

Answer 37

Endovascular aneurysm repair (repair of ruptured AAA)

Question 38

“S” image from kidney topography to the bladder topography on ABD X-Ray

Answer 38

Ureteral JJ stent