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

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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.

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References

  1. 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

    Article  PubMed  Google Scholar 

  2. 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

    Article  PubMed  Google Scholar 

  3. 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):325–328

    Article  CAS  PubMed  Google Scholar 

  4. 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

    Article  PubMed  Google Scholar 

  5. 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

    Article  PubMed  Google Scholar 

  6. 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

    Article  PubMed  Google Scholar 

  7. 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

    Article  PubMed  Google Scholar 

  8. 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

    Article  PubMed  Google Scholar 

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

    PubMed  PubMed Central  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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):415–419

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Google Scholar 

  15. Spurk JH (1997) Fluid mechanics. New York: Springer

    Book  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    CAS  PubMed  PubMed Central  Google Scholar 

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

    Google Scholar 

  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):231–234

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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

    Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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):1907–1920

    Article  CAS  PubMed  Google Scholar 

  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):369–373

    PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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):192–197

    Article  CAS  PubMed  Google Scholar 

  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

    Article  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

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Correspondence to Jerry T. Loo.

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Loo, J.T., Duddalwar, V., Chen, F.K. et al. Abdominal radiograph pearls and pitfalls for the emergency department radiologist: a pictorial review. Abdom Radiol 42, 987–1019 (2017). https://doi.org/10.1007/s00261-016-0859-8

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