Abdominal Plain Film Radiography

for Emergency Cases

Preceptor : dr. NOVITA Sp. Rad

ELANG RANGGA WIGUNA

1420221114
 ABDOMINAL ANATOMY
• The abdomen is the largest in the body cavity. Oval shape and extends
from the top of the diaphragm to the pelvis. Described the abdominal
cavity into two parts, namely the actual abdominal cavity on the top and
the larger of the pelvis is the cavity underneath and smaller.

• The boundaries of the abdominal cavity is at the top of the diaphragm, in

the bottom of the entrance to the pelvis, in front and on both sides of the
abdominal muscles, bones illiaka and ribs side down, on the back of the
spine and muscles psoas and Quadratus lumborum. Part of the abdominal
cavity and pelvis as well as areas
 Information :
1. Right Hipokondrium
2. epigastric
3. Left Hipokondrium
4. Right Lumbar
5. Navel (umbilicus)
6. Lumbar left
7. The right ilium
8. hypogastric
9. The left ilium

• The contents of the abdominal

cavity is a large part of the
digestive tract, the stomach,
small intestine and colon.
 GASTRIC
• Gastric located in the upper left abdomen, partially cover behind
the lower rib-rib cartilage along. Cardia orifice located behind the
seventh rib cartilage left. The gastric fundus, reaches a height of
intercostal space (between ribs) left fifth.

• Corpus, the biggest part lies in the middle. Pylorus, a canal that
connects the corpus to the duodenum. Section close to the pylorus
corpus called anthrum pyloricum.
 SMALL INTESTINE
• The small intestine is a tube that is roughly about two and a half
meters long alive. The small intestine extends from the stomach to
the valve ileosecal place concatenated with a colon. The small
intestine is located in an area surrounded umbilicus and colon.

• The small intestine can be divided into several parts:

a. The duodenum is the first part of the small intestine, length 25 cm.
b. Yeyenum is occupying the upper two-fifths of the small intestine.
c. Ileum is the final occupy the first three.
 LARGE INTESTINE
• The large intestine has a length of 1.5 meters and a width of 5-6 cm
The large intestine is composed of:
1) Cecum
Below there is an appendix rectum vemivormis shaped like a worm that is
also called the appendix with a length of 6 cm.

2) Colon Ascending
Length 13 cm located under the right side of the abdomen stretched upwards
from the bottom to the liver osteum. Under the careful curving to the left,
this arch is called hepatic flexure continued as the transverse colon.
3) Appendix
Part of the colon that appears like a funnel from the end seikum and
have a narrow exit door but still allows bypassed by some intestinal
contents. Appendix depending intersect in linea terminalis into the
pelvic cavity minor lies horizontally behind seikum. As an organ of
defense against infection of the appendix sometimes react violently
and hyperactivity can cause perforation of the wall into the abdominal
cavity.

4) The transverse colon

38 cm in length, stretching from the colon to the colon ascendens
descendens, is under the abdomen; hepatic flexure to the right there
and to the left there is the splenic flexure.
5) Colon Descendens
Length 25 cm, located under the left side of the abdomen, stretching from
the top to the bottom of the splenic flexure to the front left ileum, contiguous
with the rectum.

6) rectum
Located under the sigmoid colon that connects major intestine to the anus, is
located in the pelvic cavity in front os os sacrumdan coxygeus.

7) Anus
Part of the digestive system that connects the rectum to the outside world
(outside air). Located at the base of the pelvis and reinforced by the internal
anal sphincter (the top), the sphincter levatorani (middle) and the external
anal sphincter (bottom).
 Information :
A. Diaphragm
B. esophagus
TO. side
D. Calix left
E. Pancreas
F. Kolon descending
G. transverse colon
H. Small intestine
I. The sigmoid colon
J. urinary bladder
Appendix K.
L. General Secretary
M. Illium
N. ascending colon
O. Gallbladder
• Front Abdomen Cavity
P. Liver
Q. The right lobe
R. lobe of the left
 LIVER
• The liver is located on the top of the abdominal cavity, right below the
diaphragm and weighs 1.5 kg. The liver is divided into two layers, the
upper convex surface lies below the diaphragm and below the surface
uneven and show the transverse fissure.

• The liver has two types of blood circulation, the hepatic artery and portal
vein. Hepatic artery is a branch coeliaka artery which is a branch of the
abdominal aorta and the top 20% of the blood to the liver through this
artery. Portal vein carries blood from the stomach, intestine, spleen, and
pancreas directly to the liver; 80% of the blood to the liver through these
veins.
 Gall bladder
• The gall bladder is a pouch-shaped eggplants
and a muscular membrane. It is located in an
indentation on the bottom surface of the liver,
reached the edges of the front. Eight to twelve
centimeters. The gall bladder is divided into a
fundus, body and neck.
 Pancreas

• The pancreas is a set of nodes that are structurally very

similar to the salivary glands, length 15 cm, width of 5 cm
from the duodenum to the spleen and weighs 60-90 grams.

• Stretching from the first and second lumbar vertebrae in

the back of the stomach. The pancreas is composed of
three parts, namely the head of the pancreas, pancreatic
body and tail of the pancreas.
 Kidney
• The kidneys are located on the posterior abdominal wall, especially
in the lumbar region to the right of the left spine, behind the
peritoneum. Can be estimated from the rear, from a height of
vertebre thoracalis until vertebre third lumbar, right kidney lower
than the left, because the heart occupies a lot of space on the right.

• Renal length of 6 to 7½ inches. In the adult weight of approximately

140 grams. Kidneys are divided into several lobes, namely: dexter
hepatic lobe, Quadratus lobes, caudate lobe, the left lobe.
KIDNEY
 Spleen
Located in the region of hipokondrium left in the abdominal cavity between
the fundus ventrikuli and diaphragm.

Spleen function is:

a. In fetal life and after birth is a manufacturer of erythrocytes and
lymphocytes.
b. Once an adult is destroying the old and forming homoglobin erythrocytes
and iron-free.

The spleen is divided into several parts, namely:

• Two facies are facies diafraghmatika and visceralis.
• Two poles are superior and inferior extremities.
• Two margo namely the anterior border and posterior
 Abstract
• The role of plain abdominal radiography examination in emergency
cases in modern country is now become less significant and limited.
Recently, it has beenreplaced by more sophisticated modalities
such as multi-slices CT scan and USG, and MRI.
• However, this examination is still much requested by physicians in
modern hospital due to its simplicity, low cost and faster result.
• In Indonesia, plain radiography still play an important role in health
centers in rural area which are equipped by the government and
decrease the need for referral to district hospital forcertain cases.
 Normal Abdominal Plain Film
Radiography
• Air will look black because of continuing an X-ray
emitted and cause black on film while the bones with
calcium dominant element will absorb all the rays
emitted so the movie will appear white.
• Among conditioned with bones eg soft tissue will
absorb most of the rays X emitted, causing grayish
sunny depend on the thickness of tissue passed X-ray.
• Air will look relatively much filling lumen of the stomach and colon, while
in small amounts will fill a portion of the small intestine. A bit of air and
fluid also fills lumen of the small intestine, and minimal air fluid level is
not the pathological features.

• Air fluid level can also be found in the lumen of the colon, and three to
five fluid levels with a length of less than 2.5 cm within limits normal and
is often found in the lower right quadrant.

• Two air fluid level or more with a diameter of more than 2.5 cm length or
caliber is an abnormal condition and always associated with ileus good
sign obstructive or paralytic.
EX : AIR FLUID LEVEL ON PNEUMOPERTINOEUM
• The amount of air to fill the intestinal lumen of the small and large
intestine depending on how much air is swallowed like the state a lot of
talk, laugh, smoke and other etc.

• In certain circumstances such as asthma or pneumonia will increase the

amount of air in the lumen small intestine and large intestine dramatically
so as to patients infants and young children with complaints of flatulence
should also photographed both lungs at the same time because it is very
probable cause bloating its origins from pneumonia in the lungs.

• Some of the other causes that have similar to the description of ileus
include pleuritis, pulmonary infarct, myocardial infarct, leakage or aortic
dissection thoracic, heart failure, pericarditis and pneumothorax
Normal Abdominal Plain Film Radiography
• In addition to components of the gastrointestinal tract, may also be
visible the contours of both kidney and bilateral psoas muscle. A
shadow blocking the contours of the kidney or m.psoas can showed
a pathological condition in the retroperitoneal area.

• Photos of plain radiographs abdmen normally done in a supine

patient position (supine). if the state allowing the patient would be
better if added position stand up.

• For certain cases performed plain radiography photo three

positions are supine, upright and slanting left (left lateral
decubitus). Usually such position is requested to ensure free air
shifts when photographed in different positions
 Pathological Abdominal Plain Film
Radiography
To determine the pathological state or not necessary understanding of the
anatomy of a good topography.
1. Single dark bubble in infants associated with Congenital abnormalities in
gastic outlet (gastric atresia outlet)

2. Double dark bubbles in infants is also associated with congenital

abnormalities in the duodenum (atresia duodeni)

3. Congenital abnormalities in infants and young children more like midgut

volvulus or malrotation for turnaround intestinal incomplete in its
formation period also sometimes be seen on photos Plain abdominal
radiography but will be clearer if the contrast media used in the form of
barium sulphate solution.
Double Dark Bubbles from Atresia Duodeni
 4. Atresia Ani
• For patients with anal atresia in infants, plain
radiography image capture with the head
below and in the anus should be given marker
from small metal to determine and define the
distance between the anus atresia will formed
or reconstructed.
Atresia Ani with Marker in Anus and Photos Under Head Position
 5. Congenital megacolon
(Hirschsprung disease)
• Congenital megacolon (Hirschsprung disease)
of anorectal usually provides an illustration of
the widening these organs. The cause children
Kelaian can not defecate and plain
radiography photo very similar to the picture
ileus.
Congenital megacolon (Hirschsprung disease)
6. Coil spring sign or pseudo ball sign is a picture invginasi
characteristics or intestinal intussusception. With help of barium
contrast media or known sufat barium enema, do experiment
reduction prior to surgery in children. for ages Adult those
descriptions can be found in patients with Ca Ca cecum or other
colon.

7. Coffee bean sign is a typical illustration volvulus of intestine

(sigmoid) and also a state of emergency surgery because it causes
intestinal necrosis and perforation.
8. Perforation abdomen can be seen in the presence of air free in the
area below the diaphragm in a standing position or sign Riegler is
that air is becoming Intestinal background so it can be clearer
intestine wall, especially the outer wall.

9. The state of necrotizing enterocolitis in children can seen the

presence of air in the intestinal wall or pneumatosis intestinal. For
adult patients usually associated with relatively benign conditions
such as commonly found in pulmonary obstructive disorder
cronies.
NECROTIZING ENTEROCOLITIS(NEC)
10. Disorders of the small intestine, or ileum passage is divided into Two groups
characterized by :

• obstruction ileus overview intestinal lumen dilation which can not be and regular
flow distal to the tumor caused by intra-lumen or lumens clamping extra intestinal
lumen.
 It said low-lying obstructive ileus when location at the level of anorectal
obstruction or obstructive ileus higher if the location of the blockage to be away
from anorectal like the sigmoid colon or seksum and others.

• Form Another paralytic ileus is ileus be widening lumen of the intestine caused by
infection, adhesions, diabetes, hepatic coma, drugs such as spasmolitik or
morphine after surgery and others. overview ileus Paralytic usually dilation lumen
of the intestine without being accompanied or a little air fluid level.
• When widening only a few local loop called as sential loop
such as pancreatitis. There is a widening state without signs
distention of the bowel lumen either small intestine or
large intestine especially post-gastroenteritis with or
without dehydration due to electrolyte balance disorders.

• The situation was also referred to a meteorismus.

ILEUS OBSTRUKTIF
ILEUS PARALITIK
• Release of gallstones in the intestinal lumen can
cause like ileus circumstances and referred to as
gallstone ileus is on imaging shows picture like
ileus obtruktif but without the significance of air
fluid levels and are usually found radiopaque
stones coming from gallstones.
Gallstone Ileus
 Abdominal trauma
• In addition to the gastrointestinal tract pathology, photos plain abdominal
radiography can also help to other disorders such as blunt trauma to the abdomen
evaluating the possibility of early kidney contusion or retroperitoneal bleeding to
assess renal contour or psoas contour that looks dingy or veiled.

• The air in the lumen of the biliary system and the intra ekstraepatik otherwise
known as the pneumobilier usually indicate infection or disorders of the biliary
system papilla of Vater in the duodenum so that the air in the lumen of the
duodenum fill the biliary duct. Calcification can be easily viewed directly on Plain
abdominal radiography photo
 Vesicolithiasis
• Stones in the urinary tract are typically multilayer and its
surface can be rough or smooth. Stone on vesica urinaria
more rounded with a regular surface, while stones in the
ureter or urethra usually shaped irregular.

• Sometimes encountered rock fill and resembles

pelviocalices called staghorn kidney stone. Small stone and
fine those found in both renal calices minores found in a
disorder called nephrocalcinosis.
Vesicolithiasis
 Cholelithiasis
• Gallbladder stones and regular channel found in the upper right
quadrant and is usually shaped polygonal.

• Lusen stone is a stone with a calcium content is minimal so it can

not be seen on plain radiography abdomen that typically contains
components of uric acid.

• In such a situation to do a CTplain scan without contrast medium to

evaluate it.
Cholelithiasis
 Eisenberg

• According to Eisenberg, in a small group in America 25 years ago,

the role of plain abdominal radiography examinations can be
reduced up to 50% without loss of invention clinically important so
it can be recommended that The examination is only intended for
patients with moderate to severe abdominal pain and with clinical
symptoms that lead to intestinal obstruction, ureter stones,
ischemia, or diseases of the gallbladder.
 Kellow et al. retrospective study
• Kellow et al. in this retrospective study found that out of 40% Photo plain
abdominal radiographs were assessed normal turns after followed up with
supplementary examination more advanced discovered the abnormal
condition by 72% thus, the role of plain abdominal radiographs photo benefits
taken over by CT scan and ultrasound.

• Instead, Field stated that examination plain radiography is still the inspection
very useful and valuable as the initial investigation and make the clinician can
decide whether patients with pain acute abdomen requiring surgery or not
and if necessary whether immediate surgery or they may be delayed so that
they can do other tests supports the diagnosis.
 Conclusion
• Kellow said that diagnostic value not too high or low but impressed examination
photo plain abdominal radiographs are still many done even one institution alone
inspection Plain abdominal radiography photo approaching 1000 examination in
sixths month.

• In Indonesia, although the data are very hard to come by, but the authors believe
that the examination Plain abdominal radiographs are still very useful and high
value especially if implemented properly, correctly and with high professionalism
and cooperation either by clinicians in the emergency department. Moreover,
deployment tools are more sophisticated still limited in the big city.
 Bibliography
1. Eisenberg LR. The role of abdominal radiography in the evaluation
of the non trauma emergency patient: new thought on an
old problem. Radiology 2008; 248:715-6.

2. Field. Plain abdomen in diagnostic and interventional radiology

in surgical practice. Dalam: amstrong, Peter, Wasti, Martin L,
editors. London: Chapman and Hall Medical; 1997.p.15-46.

3. Kellow SZ, Maclinnes M, Kurzencwyg D, Rawal S, Jaffer R, et al.

The role of abdominal radiography in the evaluation of the non
trauma emergency patients. Radiology 2008; 248 : 887-93.
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