Plain Abdominal Radiographs: Can we Interpret Them?

INTRODUCTION Plain abdominal radiographs commonly form a part of medical assessments. Most of these films are interpreted by the clinicians who order them. Interpretation of these films plays an important diagnostic role and, therefore, influences the decision for admission and subsequent management of these patients. The aim of this study was to find out how well doctors in different specialties and grades interpreted plain abdominal radiographs. MATERIALS AND METHODS A total of 76 doctors from the Departments of Accident & Emergency, Medicine, Surgery and Radiology (17, 32, 23 and 4, respectively) participated in the study which involved giving a diagnosis for each of 14 plain abdominal radiographs (5 ‘normal’ and 9 ‘abnormal’). They were also asked the upper limit of normal dimensions of small bowel and large bowel. One point was awarded for correctly identifying whether a radiograph was normal/abnormal, 1 point for the correct diagnosis and 1 point for the correct bowel dimensions, giving a total score of 30. RESULTS Mean scores out of 30 for specialties were as follows: Accident & Emergency 13.1 (range, 2–22), Medicine 11.2 (range, 2–23), Surgery 15.0 (range, 8–24) and Radiology 17.0 (range, 14–20; P = 0.241). Mean scores out of 30 for different grades of doctors were as follows: pre-registration house officers 10.8 (range, 4–20), senior house officers 13.0 (range, 2–22), registrars/staff grades 13.8 (range, 2–23) and consultants 17.3 (range, 12–24; P = 0.028). Fifteen out of 76 (19.7%) doctors correctly identified the upper limit of normal dimension of small bowel; 24 out of 76 (31.6%) correctly identified the upper limit of normal dimension of large bowel. DISCUSSION The level of seniority positively correlated with skills of plain abdominal radiograph interpretation. A large number of doctors were unable to give the correct upper limit of normal dimensions for small and large bowel. CONCLUSIONS All doctors could benefit from further training in the interpretation of plain abdominal radiographs. This could perhaps take place as formal teaching sessions and be included in induction programmes. Until then, plain abdominal films should ideally be reported by radiologists where there are clinical uncertainties; important management decisions made by junior doctors based on these films should at least be confirmed with a registrar, if not a consultant.

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Differentiation between sigmoid volvulus and free air on supine abdominal radiographs: The 'liver overlap sign' versus the 'football sign'

South African Journal of Radiology ◽

10.4102/sajr.v2i2.1584 ◽

1997 ◽

Vol 2 (2) ◽

pp. 24-26

Author(s):

W. F.C. Van Gelderen

Keyword(s):

Correct Diagnosis ◽

Sigmoid Volvulus ◽

Abdominal Radiograph ◽

Hollow Viscus ◽

Free Air ◽

Abdominal Radiographs ◽

Contrast Studies

Two cases are presented which emphasize the difficulty of differentiating between a sigmoid volvulus, where the 'liver overlap sign' is the only sign present, and perforation of a hollow viscus where the only sign on a supine abdominal radiograph may be the 'football sign' simulating a 'liver overlap sign'. In the case of sigmoid volvulus described in this report, the correct diagnosis established only with much difficulty and after further conventional radiographs and contrast studies.

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Prolonged Intestinal Mucosal Barium Coating due to Ischemic Necrosis

Case Reports in Radiology ◽

10.1155/2011/193891 ◽

2011 ◽

Vol 2011 ◽

pp. 1-3

Author(s):

Vincent H. S. Low

Keyword(s):

Small Bowel ◽

Bowel Perforation ◽

Mucosal Damage ◽

Abdominal Radiograph ◽

Wall Thickening ◽

Plain Abdominal Radiograph ◽

Transplantation Surgery ◽

Abdominal Ct Scan ◽

Bowel Wall Thickening ◽

Fluid Collections

A case of a 63-year-old man with small bowel ischemia six weeks after transplantation surgery is presented. Plain abdominal radiograph obtained several days after ingestion of barium shows the sign of prolonged barium coating indicating severe mucosal damage. Abdominal CT scan demonstrates small bowel wall thickening as well as pockets of peritoneal fluid collections. Most critically, CT allows visualization of subtle traces of dense barium within the dependent portions of this fluid indicating bowel perforation.

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Sudden Unexpected Death Associated with Ileocecal Duplication Cyst and Clinical Review

Clinical Medicine Insights Pediatrics ◽

10.4137/cmped.s4850 ◽

2010 ◽

Vol 4 ◽

pp. CMPed.S4850 ◽

Cited By ~ 2

Author(s):

Y Kashiwagi ◽

S. Suzuki ◽

K. Watanabe ◽

S. Nishimata ◽

H. Kawashima ◽

...

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Duplication Cyst ◽

Multiple Organ ◽

Watery Diarrhea ◽

Abdominal Radiograph ◽

Unexpected Death ◽

Plain Abdominal Radiograph ◽

Abdominal Symptoms

Duplications of the alimentary tract are very rare. A one-month-old female presented with symptoms of anorexia, vomiting and continuous watery diarrhea. The plain abdominal radiograph showed thickened intestinal wall and signs of small bowel obstruction. The fevers, vomiting, and continuous wartery diarrhea persisted despite antibiotics, and worsened. The patient failed to respond to medical managements, 27 hours after admission, the patient died due to multiple organ failures. The autopsy was performed, small bowel obstruction due to an ileocecal duplication cyst (3 × 3 cm) was recognized. The ileocecal duplication cyst was attached to the ileum which was changed edematous and necrotic. This potential diagnosis should be borne in mind for a patient who complains of abdominal symptoms with an unknown cause, and duplication cyst should be recognized as a fatal cause in infant.

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Unexpected Radiologic Findings for a Casting Type of Radiolucent Colorectal Foreign Body Composed of Polyurethane Foam

Case Reports in Radiology ◽

10.1155/2016/4987105 ◽

2016 ◽

Vol 2016 ◽

pp. 1-3

Author(s):

Emi Sanjo ◽

Fumihiko Tamamoto ◽

Shoichi Ogawa ◽

Maiko Sano ◽

Tetsunori Yoshimura ◽

...

Keyword(s):

Foreign Body ◽

Polyurethane Foam ◽

Foreign Bodies ◽

Abdominal Radiograph ◽

Radiologic Diagnosis ◽

Careful Evaluation ◽

Plain Abdominal Radiograph ◽

Radiologic Findings ◽

Diagnostic Difficulties ◽

Abdominal Radiographs

Radiologic diagnosis of colorectal foreign bodies is usually not very difficult, because inserted materials are often clearly visible on plain abdominal radiographs. However, when they are radiolucent, a plain abdominal radiograph has been reported to be useless. As radiolucent colorectal foreign bodies appear as radiolucent artificial contours or air-trapped materials in the pelvis, almost always the diagnosis itself can be made by careful evaluation of plain abdominal radiographs. We encountered a case of casting type of radiolucent colorectal foreign body formed from polyurethane foam. It presented us with unexpected radiologic findings and led to diagnostic difficulties.

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Small bowel obstruction due to phytobezoar and adhesions following laparoscopic cholecystectomy

International Journal of Medicine ◽

10.14419/ijm.v3i2.4943 ◽

2015 ◽

Vol 3 (2) ◽

pp. 63

Author(s):

Nidal Abu jkeim ◽

Ahmad Al hazmi ◽

Awad Alawad ◽

Rashid Ibrahim ◽

Ahmad Abu damis ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Abdominal Radiograph ◽

Plain Abdominal Radiograph ◽

History Of ◽

Metallic Clip ◽

Fluid Levels ◽

Gallbladder Fossa

We report a case of 51 –year-old female with history of laparoscopic cholecystectomy presented with abdominal pain and diagnosed as small bowel obstruction caused by adhesions. The initial presentation was periumbilical pain with nausea and vomiting. Plain abdominal radiograph showed dilated small bowel loops and multiple air fluid levels. Due to failure of conservative treatment, laparotomy was performed. An open metallic clip was adhering the bowel to the gallbladder fossa causing sharp angulation. A phytobezoar proximal to this angulation was exteriorized through enterotomy. The patient was recovered smoothly and discharged from our hospital.

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Accuracy of Computed Tomography in Small Bowel Obstruction

The American Surgeon ◽

10.1177/000313481307900628 ◽

2013 ◽

Vol 79 (6) ◽

pp. 641-643 ◽

Cited By ~ 12

Author(s):

Rebecca E. Barnett ◽

Jason Younga ◽

Brady Harris ◽

Robert C. Keskey ◽

Daryl Nisbett ◽

...

Keyword(s):

Computed Tomography ◽

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Surgical Intervention ◽

Retrospective Chart Review ◽

Clinical Findings ◽

Abdominal Radiograph ◽

Plain Abdominal Radiograph ◽

Ischemic Bowel

Small bowel obstruction is a common clinical occurrence, primarily caused by adhesions. The diagnosis is usually made on the clinical findings and the presence of dilated bowel loops on plain abdominal radiograph. Computed tomography (CT) is increasingly used to diagnose the cause and location of the obstruction to aid in the timing of surgical intervention. We used a retrospective chart review to identify patients with a diagnosis of small bowel obstruction between 2009 and 2012. We compared the findings on CT with the findings at operative intervention. Sixty patients had abdominal CT and subsequent surgical intervention. Eighty-three per cent of CTs were correct for small intestine involvement and 80 per cent for colon involvement. The presence of adhesions or perforation was correctly identified in 21 and 50 per cent, respectively. Sixty-four per cent correctly identified a transition point. The presence of a mass was correctly identified in 69 per cent. Twenty per cent of the patients who had ischemic small bowel at surgery were identified on CT. CT has a role in the clinical assessment of patients with small bowel obstruction, identifying with reasonable accuracy the extent of bowel involvement and the presence of masses and transition points. It is less reliable at identifying adhesions, perforations, or ischemic bowel.

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Abdominal Radiograph Requesting in the Setting of Acute Abdominal Pain: Temporal Trends and Appropriateness of Requesting

Annals of The Royal College of Surgeons of England ◽

10.1308/003588406x98586 ◽

2006 ◽

Vol 88 (3) ◽

pp. 270-274 ◽

Cited By ~ 12

Author(s):

G Morris-Stiff ◽

RE Stiff ◽

H Morris-Stiff

Keyword(s):

Temporal Trends ◽

Surrogate Marker ◽

Abdominal Radiograph ◽

Junior Doctors ◽

Spinal Disease ◽

Abdominal Radiography ◽

Paramedical Staff ◽

Abdominal Radiographs ◽

Degenerative Spinal Disease

INTRODUCTION The biannual turnover of house surgeons has long been dreaded by paramedical staff because of fears of increased workloads generated by ‘untrained’ junior doctors. The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency abdominal radiographs made by ‘experienced’ house surgeons during the month of July and by the ‘novices’ during August. PATIENTS AND METHODS All adult patients undergoing abdominal radiography (AXR) following admission as emergencies via the surgical directorate with abdominal signs were identified prospectively. The reports of the AXRs were reviewed to determine the total number of requests and the number of positive findings for the two groups. In addition, the hand-written request forms were recovered to determine the suitability of the requests according to nationally-accepted guidelines produced by the Royal College of Radiologists (RCR). RESULTS During the study period, a total of 252 radiographs were performed consisting of 98 in July and 154 in August. The number of unreported films in each month were similar at 11 (11.2%) and 16 (10.4%), respectively, leaving 87 reported radiographs in July and 138 in August. There was no difference in the number of radiographs with positive findings (excluding degenerative spinal disease) for July (n = 19; 22%) and August (n = 33; 24%). Of the 225 reported films, RCR guidelines were followed in only 73 (32%) of 225 cases. When guidelines were adhered to, positive findings were identified in 56 (76.7%) of 73 cases whereas when guidelines were not followed positive findings were seen in only 13/139 (8.9%) of AXRs. CONCLUSIONS We have demonstrated that the popular myth of the ‘August syndrome’ is unsubstantiated at least using the surrogate marker of abdominal radiograph requests. The worrying finding of a high number of unacceptable indications for the performance of abdominal radiographs deserves urgent attention both in terms of its financial implications and with regards reducing radiation exposure. A programme of education is proposed to emphasise the RCR guidelines with re-audit to assess adherence to the guidelines.

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Primary Gastrointestinal Amyloidosis: An Unusual Cause of Acute Intestinal Pseudo-Obstruction

Case Reports in Gastroenterology ◽

10.1159/000503897 ◽

2019 ◽

Vol 13 (3) ◽

pp. 462-467

Author(s):

Panu Wetwittayakhlang ◽

Pimsiri Sripongpun ◽

Sawangpong Jandee

Keyword(s):

Small Bowel ◽

Clinical Symptoms ◽

Amorphous Material ◽

Polarized Light ◽

Abdominal Distension ◽

Abdominal Radiograph ◽

Plain Abdominal Radiograph ◽

Colicky Pain ◽

Intestinal Pseudo Obstruction ◽

Fluid Levels

Amyloidosis of the gastrointestinal tract is an uncommon disorder characterized by the extracellular deposition of an abnormal fibrillar protein. It is rarely proven by biopsy. Amyloid deposition interferes with organ structure and its function. We report a case of a 64-year-old male who presented with severe colicky pain, unable to pass feces, and progressive abdominal distension for 2 days. Physical examination revealed marked abdominal distension, visible peristalsis, high-pitched hyperactive bowel sounds, and generalized tenderness. Plain abdominal radiograph showed markedly diffuse disproportional dilatation of the small bowel with different heights of air-fluid levels in the same loop. Abdominal computed tomography showed an evidence of small bowel obstruction, which revealed no gross mass or cause of obstruction, but long segment narrowing of the terminal ileum was seen. Ileocolonoscopy showed diffuse edematous mucosa of the ileum without mechanical obstruction but loss of normal bowel peristalsis. A random biopsy of the ileum was performed for pathological diagnosis, which reported extensive deposits of amorphous material within the muscle layers and in the submucosal vessels that stained strongly with Congo red and displayed the typical apple-green birefringence of amyloid protein when viewed under plane polarized light. Serum electrophoretic tests disclosed a monoclonal band of IgG-kappa monoclonal protein. His clinical symptoms improved after receiving chemotherapy with melphalan and prednisolone. Our case illustrated the rare cause of acute intestinal obstruction which mimicked a surgical condition. Primary intestinal amyloidosis should be in a differential diagnosis in patients without a demonstrated cause of obstruction.

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Breath Hydrogen Gas Concentration Linked to Intestinal Gas Distribution and Malabsorption in Patients with Small-bowel Pseudo-obstruction

Biomarker Insights ◽

10.4137/bmi.s2139 ◽

2009 ◽

Vol 4 ◽

pp. BMI.S2139 ◽

Cited By ~ 3

Author(s):

Yoshihisa Urita ◽

Toshiyasu Watanabe ◽

Tadashi Maeda ◽

Yosuke Sasaki ◽

Susumu Ishihara ◽

...

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Close Association ◽

Bacterial Overgrowth ◽

Hydrogen Gas ◽

Abdominal Radiograph ◽

Breath Hydrogen ◽

Plain Abdominal Radiograph ◽

Intestinal Gas

Summary Background The patient with colonic obstruction may frequently have bacterial overgrowth and increased breath hydrogen (H2) levels because the bacterium can contact with food residues for longer time. We experienced two cases with intestinal obstruction whose breath H2 concentrations were measured continuously. Case 1 A 70-year-old woman with small bowel obstruction was treated with a gastric tube. When small bowel gas decreased and colonic gas was demonstrated on the plain abdominal radiograph, the breath H2 concentration increased to 6 ppm and reduced again shortly. Case 2 A 41-year-old man with functional small bowel obstruction after surgical treatment was treated with intravenous administration of erythromycin. Although the plain abdominal radiograph demonstrated a decrease of small-bowel gas, the breath H2 gas kept the low level. After a clear-liquid meal was supplied, fasting breath H2 concentration increased rapidly to 22 ppm and gradually decreased to 9 ppm despite the fact that the intestinal gas was unchanged on X-ray. A rapid increase of breath H2 concentration may reflect the movement of small bowel contents to the colon in patients with small-bowel pseudo-obstruction or malabsorption following diet progression. Conclusions Change in breath H2 concentration had a close association with distribution and movement of intestinal gas.

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Double-Balloon Enteroscopy in Detecting Small-Bowel Neuroendocrine Neoplasms: A Single-Center Prospective Study

Digestion ◽

10.1159/000511850 ◽

2020 ◽

pp. 1-9

Author(s):

Roberta Elisa Rossi ◽

Luca Elli ◽

Federica Branchi ◽

Dario Conte ◽

Sara Massironi

Keyword(s):

Small Bowel ◽

Neuroendocrine Neoplasm ◽

Unknown Primary ◽

Neuroendocrine Neoplasms ◽

Double Balloon Enteroscopy ◽

Balloon Enteroscopy ◽

Double Balloon ◽

Diagnostic Role ◽

Positive Results

Background and Aim: Small-bowel neuroendocrine neoplasm (sbNEN) diagnosis has improved with double-balloon enteroscopy (DBE). DBE efficacy in the detection of sbNENs is unknown. We aimed to report the experience at a single referral center for NENs. Methods: All consecutive patients with a suspected sbNEN selected for diagnostic DBE were enrolled. Results: Between 2011 and 2016, 25 patients were referred for a suspected sbNEN. In 15/25 patients, a primary NEN was detected outside the small bowel; in 4, NEN was excluded. After extensive workup, 6 patients (4 males, median age 50 years) underwent DBE (3 anterograde, 2 retrograde, and 1 both; median time: 60 min; median insertion 200 cm). DBE was positive in 3 patients: one had an ileal 2-cm NEN G1, one had an ileal 1.3-cm NEN G1, and one had an ileal 1-cm NEN G2, all surgically removed. Of the 3 other patients, one had a metastatic NEN of unknown primary, the other two had small intestinal NENs, both surgically removed (1.6-cm G1 and G2 NEN). DBE showed a sensitivity of 60% and, in absence of false-positive results, a specificity of 100%. Accuracy resulted 67%. No complications were observed. Conclusions: In line with data from the literature, the present series showed that DBE is a safe and effective procedure in the diagnosis of sbNENs. Further studies are needed to better clarify the diagnostic role of DBE in the neuroendocrine tumor setting and its relationship with other techniques.

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