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Chapter 38 • The Abdominal X-ray 461
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A BB
FIGURE 38-7 A, Supine view of the abdomen showing mechanical small bowel obstruction (black arrows) and no
air in the rectum (white arrow). B, Erect view of the abdomen showing small bowel obstruction. (From Herring W:
Learning radiology: recognizing the basics, St Louis, 2007, Elsevier.)
FIGURE 38-8 Nephrocalcinosis. (From Mettler F: Essentials
of radiology, ed 2, Philadelphia, 2005, Saunders.)
FIGURE 38-9 Pneumoperitoneum. (From Mettler F: Essentials
of radiology, ed 2, Philadelphia, 2005, Saunders.)
Upright Abdominal X-ray and Standing
Chest X-ray
If an obstruction or ileus is suspected, an upright
abdominal lm and a standing chest x-ray are ordered. The upright abdominal lm provides a view of
the air/uid levels within the bowel to differentiate
462 Chapter 38 • The Abdominal X-ray
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between an obstruction and an ileus. Additionally, if
free air in the abdomen is a concern, the standing image
will demonstrate free air underneath the hemidiaphragm,
which is unable to be seen on the plain abdominal x-ray.
A standing chest image should be viewed using the procedure outlined in Chapter 37. When looking for free air
in the abdomen, pay particular attention to the area under the right diaphragm. Extraluminal free air appears as
a crescent of radiolucent gas between the diaphragm and
the liver, and usually indicates a perforated viscus (see
Figure 38-9).
Left Lateral X-ray
If the patient is too ill to stand, a left lateral x-ray will
be useful in nding free air in the abdomen. In the left
lateral decubitus image, the patient is lying on the left
side for 10 to 15 minutes and a horizontal beam is
used. In this image, small amounts of free air can be
seen over the lateral aspect of the right lobe of
the liver. Often the free air is seen as a dark shadow
between the white of the abdominal wall and the liver
(Figure 38-10).
Additional Causes of Abdominal Pain
Abdominal pain may also be caused by chest pathology
mimicking abdominal pain, for example, pleurisy,
pneumonia, and pleural effusion. A chest x-ray should
be ordered.
What other imaging studies should I consider?
Key Questions (to self)
n What other common imaging studies are available
for the abdomen?
n What imaging studies would give me the best infor-
mation for a particular patient concern?
Upper GI Series
For an upper GI series, the patient drinks a barium solution that passes through the digestive tract and lls
and coats the esophagus, stomach, and rst part of the
small intestine, making them more visible with the
x-ray. A uoroscope is held over the body part being
examined and transmits continuous images to a video
monitor. This test is used to diagnose hiatal hernia,
reux, narrowing of upper GI tract, and esophageal
conditions.
Small Bowel Series
For a small bowel series, the barium ingested for the
upper GI series is allowed to pass through the stomach
into the small bowel and images are taken. This test is
used to detect tumors, and malabsorption syndrome.
Lower GI Series
In a lower GI series, barium enemas are used to examine the large intestine and the rectum. For this
test, barium or an iodine-containing liquid is introduced gradually into the colon through a tube inserted into the rectum. As the barium passes through
the lower intestines, it lls the colon. As in the upper
GI series, a uoroscope transmits continuous images
to the video monitor. A lower GI series is used
to diagnose colon polyps, tumors, diverticular disease, narrowing or obstructions, ulcerative colitis, or
Crohn disease.
FIGURE 38-10 Left lateral free air. (From Adam A, Dixon A:
Grainger & Allison’s diagnostic radiology, ed 5, Philadelphia,
2008, Churchill Livingstone, Elsevier.)
Colonoscopy
In a colonoscopy, a colonoscope is inserted into the
rectum and advanced through the large intestine and
part of the small bowel. The scope has a brotic light
and camera projecting images onto a monitor. Polyps
can be identied, biopsied, and/or entirely removed.
Colonoscopy is used to evaluate intestinal bleeding,
inammatory bowel disease, colorectal polyps, or
cancer.
Chapter 38 • The Abdominal X-ray 463
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Sigmoidoscopy
In a sigmoidoscopy, a exible sigmoidoscope is passed
through the rectum to view the last 2 feet of the colon.
The scope transmits images of the inside of the rectum
and colon. Biopsies may be taken of polyps or suspicious tissue on the intestinal wall. This test is useful for
viewing inammatory conditions in the rectum and
or a video screen that displays the images on a
monitor. The endoscope is inserted into the mouth
and threaded down the esophagus to the stomach and
small intestine. Endoscopy is useful for diagnosing
gastric bleeding, hiatal hernia, and swallowing difculties; for removing stuck objects such as food; and
for biopsy.
lower colon, polyps, bleeding, and ulcerations.
Ultrasound
Computed Tomography
Computed tomography (CT), or computed axial tomography (CAT), provides a cross-sectional slice of the area
examined (see Chapter 37). A CT is useful for diagnosing sigmoid diverticulitis, appendicitis, bowel obstruction, and extracolonic causes of abdominal pain.
Ultrasound is a noninvasive test that uses high
frequency sound waves to produce images. The
ultrasound images are captured in real time. They
can show the size, structure, and movement of the
body’s internal organs, as well as blood owing
through blood vessels and pathologic lesions. It is
useful for evaluating the size of the spleen, gall-
Endoscopy
A exible beroptic tube called an endoscope is
stones, aortic aneurysm, kidney stones, and abdominal masses.
equipped with a camera at the end. The camera is
connected to either an eyepiece for direct viewing
DIFFERENTIAL DIAGNOSIS OF the Abdominal Image
WHAT TO LOOK AT NORMAL FINDING ABNORMAL FINDING SUGGESTED CAUSE
Visible spine Image of good quality Spine not visible Poor quality image
Metallic objects History of piercing Present without history Foreign object ingested
Gastric air bubble Present on the right Not visible Image placement error, label
Liver Right upper quadrant Enlarged Many causes: CHF, ETOH
Spleen Left upper quadrant,
Kidneys Left higher than right,
Small bowel Central portion of image,
Large bowel Periphery of image,
Fluid In erect image, present
usually not seen
3 vertebrae in size
loops normally 2-3 cm,
little air
slight air in rectum
in stomach, 2-3 levels
in small bowel, never in
large bowel
error
abuse, hepatitis
Must be very enlarged to
be visualized
Enlarged, calcifications Renal calculi, hydrosis
Dilated more than 3 cm,
multiple distended loops
Dilated more than 5 cm,
multiple dilated loops
Mottled appearance
Fluid present in small
bowel
Many causes: infectious,
anemia, trauma, cancers
Constipation, ileus, small bowel
obstruction
Large bowel obstruction
Constipation
Small bowel obstruction
Continued
464 Chapter 38 • The Abdominal X-ray
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DIFFERENTIAL DIAGNOSIS OF the Abdominal Image—cont’d
WHAT TO LOOK AT NORMAL FINDING ABNORMAL FINDING SUGGESTED CAUSE
Free air Normally not seen Free air in abdomen Rupture of hollow viscus
Diaphragm Right higher than left;
right at level of 6th rib
Bladder Usually not visible Visible when full Full bladder, bladder stone
Uterus Sits on top of bladder,
usually not visible
Aorta Usually not visible Calcifications in abdominal
CHF, congestive heart failure; ETOH, ethyl alcohol.
Elevated Collapsed lobe or multi-segmental
collapse; pleural effusion
Radiolucent line present
that follows the curvature
of the diaphragm
Flattened diaphragm Emphysema, asthma, tension
Elevation on left Perforated ulcer, or gas
Bilateral elevation Pregnancy, obesity, peritoneal
Visible with uterine fibroids Possible fibroids
aorta
Free air present
pneumothorax
distention of stomach
fluid
Abdominal aortic aneurysm
Ultrasound often used for
diagnosis of size
REFERENCES AND READINGS
Adam A, Dixon A (eds): Grainger & Allison’s diagnostic radiology,
ed 5, Philadelphia, 2008, Churchill Livingstone, Elsevier.
Brickel I, Kelly B: Abdominal x rays made easy: normal radiographs,
Student BMJ 10:103, 2002.
Herring W: Learning radiology: recognizing the basics, St Louis,
2007, Mosby.
Mettler F: Essentials of radiology, ed 2, Philadelphia, 2005,
Saunders.
Novelline RA: Squire’s fundamentals of radiology, ed 6, Cambridge,
Mass, 2004, Harvard University Press.
Walsh T, Caraceni A, Fainsinger R, Foley K, Glare P, Goh C et al:
Palliative medicine, Philadelphia, 2009, Saunders.
A P P E N D I X
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A
Conversion Tables
LENGTH
in cm cm in
1 2.54 1 0.4
2 5.08 2 0.8
4 10.16 3 1.2
6 15.24 4 1.6
8 20.32 5 2.0
10 25.40 6 2.4
20 50.50 8 3.1
30 76.20 10 3.9
40 101.60 20 7.9
50 127.00 30 11.8
60 152.40 40 15.7
70 177.80 50 19.7
80 203.20 60 23.6
90 228.60 70 27.6
100 254.00 80 31.5
150 381.00 90 35.4
200 508.00 100 39.4
1 in 5 2.54 cm
1 cm 5 0.3937 in
From Seidel HM, Ball JW, Dains JE, Flynn J, Solomon B, Stewart R: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.
WEIGHT
lb kg kg lb
1 0.5 1 2.2
2 0.9 2 4.4
4 1.8 3 6.6
6 2.7 4 8.8
8 3.6 5 11.0
10 4.5 6 13.2
20 9.1 8 17.6
30 13.6 10 22
40 18.2 20 44
50 22.7 30 66
60 27.3 40 88
70 31.8 50 110
80 36.4 60 132
90 40.9 70 154
100 45.4 80 176
150 66.2 90 198
200 90.8 100 220
1 lb 5 0.454 kg
1 kg 5 2.204 lb
465
A P P E N D I X
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B
Temperature Equivalents
Celsius* Fahrenheit
34.0 93.2 38.6 101.4
34.2 93.6 38.8 101.8
34.4 93.9 39.0 102.2
34.6 94.3 39.2 102.5
34.8 94.6 39.4 102.9
35.0 95.0 39.6 103.2
35.2 95.4 39.8 103.6
35.4 95.7 40.0 104.0
35.6 96.1 40.2 104.3
35.8 96.4 40.4 104.7
36.0 96.8 40.6 105.1
36.2 97.1 40.8 105.4
36.4 97.5 41.0 105.8
36.6 97.8 41.2 106.1
36.8 98.2 41.4 106.5
37.0 98.6 41.6 106.8
37.2 98.9 41.8 107.2
37.4 99.3 42.0 107.6
37.6 99.6 42.2 108.0
37.8 100.0 42.4 108.3
38.0 100.4 42.6 108.7
38.2 100.7 42.8 109.0
38.4 101.1 43.0 109.4
*To convert Celsius to Fahrenheit: (9⁄5 3 Temperature) 1 32
†
To convert Fahrenheit to Celsius: (5⁄9 3 Temperature) 2 32
†
Celsius* Fahrenheit
†
466
Height*
Are you at a healthy weight?
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6´6˝
6´5˝
6´4˝
6´3˝
6´2˝
6´1˝
6´0˝
5´11˝
5´10˝
5´9˝
5´8˝
5´7˝
5´6˝
5´5˝
5´4˝
5´3˝
5´2˝
5´1˝
5´0˝
4´11˝
4´10˝
50 75 100 125 150 175 200 225 250 275
†
Pounds
Healthy Weight Overweight Obesity
The BMI (weight-for-height) ranges shown above are for adults. They are not exact ranges of healthy and unhealthy weights.
However, they show that health risk increases at higher levels of overweight and obesity. Even within the healthy BMI
range, weight gains carry health risks for adults.
A P P E N D I X
C
Body Mass Index Chart
BMI
2518.5 30
* Without shoes.† Without clothes.
Directions: Find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches
your height. Then look to find your weight group.
➣ BMI of 25 defines the upper boundary of healthy weight.
➣ BMI of 25 to 30 defines overweight.
➣ BMI of higher than 30 defines obesity.
From Dietary Guidelines Advisory Committee: The report of the dietary guidelines advisory committee on dietary guidelines for
Americans, 2000.
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INDEX
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A
Abdomen
anatomic diagram and review of, 458, 458f
examination of
in chest pain evaluation, 89
in constipation evaluation, 115
in cough evaluation, 126
in diarrhea evaluation, 140-141
in fatigue evaluation, 188
in male genitourinary evaluation, 213
in skin rash/lesion evaluation, 312
in syncope evaluation, 369
in urinary incontinence evaluation, 378
muscles, 16
pain (See abdominal pain)
quadrants, 9b
Abdominal aortic aneurysm, 9
Abdominal distention, 16, 213
Abdominal emergencies
indicators of, 21b
Abdominal masses, 17
Abdominal pain
acute conditions that cause
acute pancreatitis, 22, 25-29b
appendicitis, 21-23, 25-29b
cholecystitis/lithiasis, 22, 25-29b
dissection of aortic aneurysm, 22, 25-29b
ectopic pregnancy, 21, 25-29b
Henoch-Schönlein purpura, 23, 25-29b
ileus, 23, 25-29b
incarcerated hernia, 23, 25-29b
intussusception, 23, 25-29b
malrotation, 23, 25-29b
mesenteric adenitis, 22, 25-29b
myocardial infarction, 22, 25-29b
obstruction, 23, 25-29b
pelvic inammatory disease, 22-23, 25-29b
peptic ulcer perforation, 21, 25-29b
peritonitis, 22, 25-29b
pneumonia, 23, 25-29b
pyelonephritis, 22, 25-29b
salpingitis, 22-23, 25-29b
ureterolithiasis, 22, 25-29b
urinary tract infections (UTIs), 22, 25-29b
volvulus, 23, 25-29b
characteristics and severity of, 8
in children, 8-9
chronic conditions that cause lower
abdominal wall disorders, 24, 25-29b
diverticular disease, 24, 25-29b
dysmenorrhea, 24, 25-29b
habitual constipation, 24, 25-29b
hernia, 24, 25-29b
irritable bowel syndrome (IBS), 23-24, 25-29b
lactose intolerance, 24, 25-29b
ovarian cysts, 24, 25-29b
Abdominal pain (Continued)
simple constipation, 24, 25-29b
uterine broids, 24, 25-29b
chronic conditions that cause upper
esophagitis, 24-25, 25-29b
functional dyspepsia, 25, 25-29b
gastritis, 25, 25-29b
gastroenteritis, 25, 25-29b
gastroesophageal reux disease (GERD), 24-25, 25-29b
peptic ulcer, 25, 25-29b
recurrent abdominal pain (RAP), 25-29, 25-29b
classication of, 8-9
diagnostic reasoning/key patient history questions, 9-15
character of pain, 12
last bowel movement, 10
onset/duration, 9-10
organ system signs, 14-15
pain location, 10-11, 12t
precipitating or aggravating factors, 12-13
previous pain, 10
radiation of, 11-12, 13
relieving factors, 12-13, 14
severity and progression, 10
stool characteristics, 13-15
vomiting, 13
and fatigue, 186
laboratory and diagnostic studies, 18-20
with male genitourinary problems, 211-212
with penile discharge, 297-298
physical examination procedures, 15-18
referred pain to breast, 76
types and causes of, 8, 9b, 25-29b
vaginal bleeding with, 397
x-rays to evaluate, 460 (See also abdominal x-rays)
Abdominal ultrasound
for abdominal pain evaluation, 20
during chest pain evaluation, 90
denition and procedures for performing, 463
Abdominal wall disorders
causing lower abdominal pain, 24, 25-29b
Abdominal x-rays
and colonoscopy, 462
and computed tomography (CT scans), 463
diagnostic reasoning/viewing the image
anatomy review, 458, 458f
image box placement, 457
image quality, 457-458
verifying image with patient, 457
views, 457
endoscopy, 463
lower GI series, 462
sigmoidoscopy, 463
small bowel series, 462
ultrasound, 463
upper GI series, 462
upright and standing, 461-462, 461f
Page numbers followed by f, t, and b indicate gures, tables, and boxes, respectively.
469
470
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Index
Abscesses
brain, 231, 232-233b
breast, 70-71, 72-73b
perirectal, 322-323, 328-329, 331-332b
peritonsillar, 362, 364-365b
retropharyngeal, 362, 364-365b
Abstract reasoning problems, 102
Accommodation
eye lens, 431
Acetic acid test
for detect human papillomavirus (HPV), 418
Achilles tendinitis, 258, 262-265b
Acne vulgaris, 313, 316-320b
Acoustic nerves
examining for hearing acuity, 179
Acoustic neuroma
causing peripheral vertigo, 156
Acquired immunodeciency syndrome (AIDS)
fatigue symptoms with, 185
increased risk of headaches with, 223-224
questions during anorectal evaluation, 322-323, 324
as risk factor for confusional states, 101
and weight loss (unintentional), 444, 445-446b
Acromioclavicular joint injuries, 255, 262-265b
Actigraphy, 350
Activated partial thromboplastin time (aPTT), 90
Active range-of-motion tests
during limb evaluation, 252
Activities
assessing during HEEADSSS interview, 34-35, 36t
and chest pain, 84
causing dizziness and vertigo, 150
physical causing infections, 413
Activities of daily living
and fatigue, 185
Activity levels
and calorie balance, 435, 436b, 437b, 439, 440t
and weight gain (unintentional), 439, 440t, 444, 445-446b
and weight loss (unintentional), 436, 437b, 438
Acute abdominal pain
life-threatening conditions associated with, 9
Acute bacterial prostatitis
description and diagnosis of, 217, 219-220b
Acute bronchitis, 129, 131-132b
Acute closed-angle glaucoma, 343, 424-425, 431-432, 432b, 433-434b
Acute coronary insufciency, 91, 95b
Acute epiglottis
and dyspnea, 169, 171-172b
as possible cause of hoarseness, 239-240, 241-242b
and sore throat, 356
Acute laryngotracheobronchitis, 129, 131-132b
Acute leukemia, 259, 262-265b
Acute low back pain (ALBP)
AHRQ causative guidelines, 267
denition of, 267
diagnostic reasoning/key patient history questions
age, 268
aggravating factors, 270
alleviating factors, 270
bowel and bladder symptoms, 269
current illness, 271
family history of, 271
fever, 267
medication use, 269
night pain, 270
Acute low back pain (Continued)
numbness or tingling, 271
pain location, 269
pain onset and characteristics, 269-270
pain radiation, 270-271
recurring pain, 270
stumbling or movement problems, 271
systemic diseases, 268-269
trauma, 268
differential diagnoses of
ankylosing spondylitis, 275-276, 277-279b
aortic aneurysm, 276-277, 277-279b
cauda equina syndrome, 275, 277-279b
diskitis, 275, 277-279b
gallstones, 276, 277-279b
herniated disk, 275, 277-279b
musculoskeletal strains, 275, 277-279b
nonspinal causes of, 276-277, 277-279b
osteoblastoma, 275, 277-279b
osteoid osteoma, 275, 277-279b
osteomyelitis, 275, 277-279b
osteoporosis, 276, 277-279b
overuse strains, 275, 277-279b
pelvic inammatory disease (PID), 277, 277-279b
pleuritis, 276-277, 277-279b
postural strains, 275, 277-279b
psychological back pain, 277, 277-279b
pyelonephritis, 276, 277-279b
Scheuermann disease, 276, 277-279b
sciatica, 275, 277-279b
spinal fracture, 268, 274, 277-279b
spinal metastasis, 275, 277-279b
spinal stenosis, 276, 277-279b
spondylolisthesis, 275, 277-279b
laboratory and diagnostic studies, 274
lumbar nerve root compromise testing, 267, 268f
overview of, 267
physical examination procedures, 271-274
back and spine inspection and palpation, 272, 272f,
274
deep tendon reex tests, 273-274
FABER test, 272, 272f
gait assessment, 271
hip mobility test, 273
range-of-motion tests, 272
rectal sphincter tone, 274
sensory function test, 273
straight leg raising (SLR) test, 272-273
Acute myocardial infarction (MI), 91, 95b
Acute optic neuritis, 425
Acute otitis media (AOM)
and bottle propping, 175
denition of, 174
symptoms and earaches caused by, 181, 182-183b
Acute pancreatitis, 22, 25-29b, 94, 95b
Acute sinusitis, 281, 286, 287b
Addison disease
and weight loss (unintentional), 443, 445-446b
Adenomyosis, 406, 408-410b
Adequacy
as hypothesis testing characteristic, 3
Adolescents
activity and weight recommendations for, 436b, 437b
constipation from milk consumption, 112-113
“growing pains,” 247
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