Plain film

• Airway disease
1. COPD

- Chronic bronchitis

- thickening of
bronchial wall

- Accentuation of
linear opacities through
out the lung

- Emphysema

- Overinflation & flattening of diaphragm (จุดสูงสดุ ของ dome of diaphragm
หา่ งกับเสน้ สมมุติท่ีลากจาก costophrenic to vertebrophrenic junction < 1.5 cm)

- Increase retrosternal air space >3cm วดั ทร่ี ะดบั 3cm ตา่ กว่า
sternomandibular junction

- Widen rib spaces, Decrease lung density, Vertical heart shape

>27cm >3cm

<1.5cm

- Bronchiectasis

Mediastinal mass

• Anterior- thyroidal mass, thymic mass,
terratoma, lymphoma, pericardial cyst

• Middle- aortic aneurysm, lymphadenopathy,
esophagus(Achalasia), hiatal hernia

• Posterior- Nerve sheath tumor, extramedullary
hematopoietic tissue

Pleural disease

• Pleural effusion
- Blunt costophrenic angle
- Tapered margin superiorly
Ex. Heart failure, inflammation of pleura, neoplasm

• Pleural thickening
Ex. Infection, neoplasm, trauma

• Pneumothorax
– Air in pleural cavity, ―white line of the
visceral pleural‖, volume loss of underlying

lung (passive atelectasis)
– Lateral decubitus, Upright expired film



PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver Stomach
Spleen Small intestine
Pancreas Large intestine
Kidneys Gallbladder
Ovaries Urinary bladder
Uterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1.Air/Gas density
2.Fat density
3.Water/Soft tissue density
4.Calcium/Bone density
5.Metalic density

NORMAL FINGINGS

 Fat density
• Peritoneum, retroperitoneum, pelvis
• Landmark ex.properitoneal fat lines, lateralmargin
of psoas muscle, kidneys, inferior surface of liver

 Air density
• Intestinal gas
─ Bowel loop
─ Small or large intestine
─ Diameter of intestines
─ Air in rectum
• Stomach gas : LUQ

 Soft tissue / water density







การจดั ท่าผ้ปู ว่ ย

Anteroposterior(AP)



Lateral



Left posteroanterior oblique



Bowel perforation

• Bowel perforation is a surgical emergency. the X-ray appearances

of pneumoperitoneum
• Erect chest X-ray should be requested if perforation is suspected

•This patient has a large volume of
free gas under the diaphragm.
Dark crescents have formed
separating the thin diaphragm from
the liver on the right, and bowel on
the left.

• This patient had a perforated
duodenal ulcer

Rigler's/double wall sign - diagram

• Normally only the inner wall of the bowel is visible
• If there is pneumoperitoneum both sides of the bowel wall
may be visible

Rigler's/double wall sign

• The double wall (Rigler's) sign is visible
• Gas separates bowel segments and forms sharp angles
and triangles (*)

Football sign

• 2 radiographs were required to completely cover the
abdomen in this large patient

•A large volume of
free gas has risen to
the front of the
peritoneal cavity
resulting in a large
round black area -
'football sign'

• The double wall sign
(Rigler's) is also visible
(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such
as the falciform ligament, or the liver edge

Abdominal calcification

•Renal calcification
•Ureteric calcification
•Bladder stones
•Retroperitoneal calcification
•Viscus calcification
•Artifact or foreign body

Renal calcification
Renal collecting systems (calculi/stones)

90 % of renal calculi contain enough calcium to be
visible on abdominal X-rays. Urate and matrix stones
are not visible.

Renal stones are often small, but if large can fill the
renal pelvis or a calyx, taking on its shape which is
likened to a staghorn.

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus Nephrocalcinosis

The irregularly shaped calcific The renal parenchyma contains
density has filled and taken on clusters of small calcific
densities
the form of the right kidney
lower pole calyx

Ureteric calcification

As with renal stones
approximately 90% are visible.

Ureteric stones originate as renal
stones.

May cause renal outflow tract
obstruction, which manifests
clinically with severe ipsilateral
flank/loin/groin pain, usually with

haematuria.

Look carefully for ureteric stones
which can be very subtle
Don't mistake a transverse process
for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis.
When seen on an abdominal/pelvic X-ray they are often multiple

and rounded.

Multiple well defined calcific
densities are seen within the bladder

Retroperitoneal calcification

retroperitoneal organs (pancreas or adrenal glands) only become
visible when calcified.

Adrenal calcification is usually
an incidental finding

The adrenal (suprarenal) glands form a
triangle shape lying directly above the

kidneys

• Pancreatitis
– Acute pancreatitis
อาจเหน็ adynamic ileus ซง่ึ อาจจะเป็นเฉพาะท่ี เช่น small
bowel ileus รอบๆ (sentinel loop) หรือ localized
dilatation ของ transverse colon ไปจรด splenic
flexure (colon cut-off sign) หรอื generalized
adynamic ileus
ไมจ่ าเพาะ อาจเห็นไดใ้ นโรคที่มี abdominal
inflammation,infection, trauma เชน่ acute
appendicitis, acute cholecystitis
อาจไมเ่ หน็ การเปล่ยี นแปลงจากภาพ x-ray abdomen
– Chronic pancreatitis

calcification







Viscus calcification
Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix
(appendicolith).
Gallstones
Only 10-15% of gallstones
contain enough calcium to
be visible on an abdominal
X-ray.

may be mistaken for renal stones

Appendicoliths are highly
predictive of appendicitis
in patients presenting with

right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

• ผ้ปู ่วยชาย อายุ 50 ปี
• X-ray Abdomen AP supine



• Disproportion of gas in bowel
• Small bowel dilate one loop at Right quadrant

(diameter > 3 cm)
• Gas filled in small bowel
• Mottling appearance in stomach (gastric

content)
• No calcification
• No free air, no sign of perforation
• Air in colon  Partial obstruction

แยกลกั ษณะของลาไส้เลก็ และลาไส้ใหญ่

ลักษณะของ fold Small bowel Large bowel
Fold ว่ิงครบวง Fold ไมค่ รบวง
จานวนของ loop ―valvulae Haustration
ตาแหน่ง conniventes‖
รศั มีการโคง้ ของลาไส้ น้ย
อุจจาระ มาก ด้านข้าง
กลางท้อง ใหญ่

เล็ก พบ
ไม่พบ

• ผปู้ ่วยชาย อายุ 50 ปี
• CC : อืดแนน่ ท้อง 3 สัปดาหก์ อ่ นมาโรงพยาบาล
• Past history : ผา่ ตดั ทางช่องทอ้ งเมื่อ 14 ปกี ่อน

• Dx : Partial small bowel obstruction due to
adhesion band

Cause SBO

• Adhesions
• Incarcerated hernia
• Neoplasm
• Inflammatory bowel disease
• Volvulus

• distended small bowel loops
with prominent valvulae
conniventes (small white
arrow). diameter > 3 cm

• Step ladder pattern

• Bowel wall between the
loops is thickened and
edematous (large white
arrow).

• No air is seen in the colon
or the rectum.

Step ladder pattern

Abdomen film : Upright position

• Multiple air-fluid levels in
dilated small bowel loops

• String of bead sign