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Abdominal X-Ray (AXR) Film Interpretation

This guide can be used to interpret an AXR film in a systematic manner


We begin by confirming the patient’s details and introducing the AXR Film for presentation.

  1. “This is an Abdominal Radiograph of …” 
  2. Check Name and Age. 
  3. When was it taken? 
  4. What position is the patient in? 
    • Are they standing (erect) or supine 

Note: X-Ray is the technique/radiation used during the procedure, not the resulting image. Therefore, you should refer to the resulting image as a Radiograph.

Image Quality
  1. What is the Projection? 
    • Is it AP or PA? – Almost all are AP
    • If there is no label, assume it is AP
  2. Is the film adequately Exposed? 
    • Is the whole abdomen visible from the diaphragm to the pelvis?
    • Quality is often poor, due to overlying bowel.
Bowel & Organs – BBC Approach 
  1. Start with the small and large bowel, which can be differentiated by:
    • Location – the small bowel is usually central
    • Folds:
      • The small bowel contains mucosal folds (valvular connlventes). They are seen across the entire lumen of the bowel.
      • The large bowel contains haustra pouches (separated by pilcae semilunaris). These appear thicker and usually do not cross the entire bowel lumen. However, during dilation, the pattern can transverse the bowel.
  2. Assess the size of the Intestines
    • The normal diameter on AXR is usually:
      • <3cm for small bowel
      • <6cm for large bowel
      • <9cm for caecum
  • Bowel Perforation:
    • If bowel perforation is suspected, an erect Chest X-Ray is prefered for diagnosis over an AXR.
    • When taken, free gas will be seen under the diaphragm of a Chest X-Ray.
  • Small Bowel Obstruction:
    • Usually seen as a dilation of the small bowel (>3cm)
    • The valvular connlventes are more visible
    • Causes include:
      • Adhesions from surgery (75%)
      • Abdominal Hernias (10%)
      • Intrisic or Extrisic masses
  • Large Bowel Obstruction:
    • Commonly caused by:
      • Colorectal carcinomas
      • Diverticular strictures
      • Hernias
    • Volvulus – a twisting of the bowel within the mesentery. High risk of ischaemia or perforation.
      • Sigmoid volvulus has a characteristic ‘coffee bean’ appearance on the film
      • Caecal volvulus is often described as having a fetal appearance
  • Inflammatory Bowel Disease:
    • Toxic Megacolon – colonic dilation without obstruction
    • Thumb-printing – mucosal thickening of haustra due to inflammation that appear like thumb-prints projecting into the lumen.
    • Lead-pipe colon (featureless) – loss of haustral markings on AXR due to chronic colitis.
  • Rigler’s Sign:
    • You can normally only see the inner bowel wall on the AXR
    • Sometimes, you can see a double wall along the bowel
      • Caused by pneumoperitoneum, which can be due to perforated duodenal ulcers, recent surgery or perforated bowel
  1. Observe other organs:
    • Liver – can be seen in the right upper quadrant
    • Gallbladder – normally not seen, but look for gallstones or cholecystectomy clips
    • Stomach – usually partially filled with air. Seen within the left upper quadrant
    • Bladder – variable appearance due to fullness
    • Kidneys – often visible
Bones – BBC Approach  

Many bones are visible on an AXR and can be used as landmarks to identify any soft tissues.

  • You should be able to identify the:
    • Coccyx
    • Femurs
    • Lumbar Vertebrae
    • Pelvic
    • Ribs
    • Sacrum
  • Whilst examining the bones, look for:
    • Fractures
    • Bony metastases
    • Osteoarthritis
Calcification & Artefact – BBC Approach
  • Areas of calcification or artefacts may be seen as high-density white areas. These may include:
    • Calcified gallstones
    • Renal stones
    • Vascular calcifications
    • Pancreatic calcification
    • Contrast (such as barium swallow)
    • Surgical clips
    • Naval jewellery artefact around the umbilicus
    • Presence of foreign objects – such as those swallowed or inserted rectally
  • Ensure you have looked at all areas of the radiograph 
Summarise Core Features/Abnormalities 

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