PLAIN X-RAY OF ABDOMEN. MULTIPLE AIR FLUID LEVELS (FIGS 17.4 TO 17.

6)

Distended
jejunal loops

Valvulae
conniventes

pleair
fluid levels
35 years male
abdomer Distended
Xray
Erect ileal loop

Figure 17.4: This is a straight X-ray of abdomen with lower part of chest and upper part of pelvis taken in
erect posture showing multiple air fluid levels. The distended gut loops are situated in the central part of
the abdomen and are arranged ina step ladder fashion. The upper loops are showing presence of valvulae
conniventes which are closely packed and complete suggesting these to be distended jejunal loops. The
distended gut loops in right iliac fossa region do not show presence of any valvulae conniventes and appear as
characterless suggesting these to be distended ileal loops. This appearance is suggestive of acute small bowel
obstruction (Courtesy: Dr QM Rahaman, Registrar, WBUHS, Kolkata)

Dilated
jejunal
loops

Valvulae
conniventes

Multiple air
fluid levels

RXray abdoma ABDOMENERECI

Erect
Figure 17.5: Similar X-ray as in Figure 17.4 showing multiple air fluid levels. The gas filled intestinal loops
are central in location arranged in a stepladder fashion. Most of the distended loops do not valvulae
conniventes and appear characterless, suggesting these to be distended ileal loops. This appearance is
suggestive of acute small bowel obstruction
676 Section 4 X-rays

Dilated ileal
loops

Multiple air
fluid levels

Figure 17.6: Similar X ray-Showing multiple air fluid levels.

The air fiuid filled loops are central in location, arranged in
a stepladder pattern. Note the characterless appearance
(absence of valvulae conniventes) suggesting these to be
ileal loops (Courtesy: Dr Partha Bhar, IPGME & R, Kolkata)

What is the diagnosis?

This is likely to be a X-ray of patient with small bowel obstruction.
Why do you say these gas flled loops are jejunal loops?
These gas filled intestinal loops are likely to bejejunal loops because of following characteristics:
These gas filled loops are centrally located in the abdomen.
Theyare arranged in a stepladder pattern.
There are closely packed valvulae connivantes indicated by white lines in the gas filled gut.
What are the characteristics of gas filled ileal loops?
These are also central in location and may have step ladder pattern of arrangement.
But the valvulae conniventes if present are very sparse and incomplete.
The gas filled ileal loops are typically described as characterless.
What are the characteristics of colonic gas shadows?
The characteristics of colonic gas shadows are:
The colonic gas shadows are situated more peripherally.
There are haustrations in the walls. These are incomplete mucosa folds in the walls placed
at different levels.
Which X-ray is important for evaluation of patient with acute intestinal obstruction?
an erect film is
A supine abdominal film gives better delineation of the gas filled gut loop and
not required routinely.
How many fuid levels in abdomen X-ray may be regarded as normal?
In adults two inconstant fluid levels-one at duodenal cap another at terminal ileum may be
regarded as normal.
In infants few fluid levels (2-4) in small gut may be regarded as normal.

Chapter 17 X-rays 677

What are the important causes of small intestinal obstructions?

Causes in the wall of the intestine:
Inflammatory bowel disease-Crohn's and tuberculosis causing fibrous stricture in the
wall.
Fibrous stricture in the wall secondary to trauma, ischemia, radiation or intussusception.
Neoplastic lesion-benign or malignant tumors in the intestine.
Casuses in the lumen of the intestine:
.Bezoars, gallstones, worms or foreign body.
Causes outside the wall of the intestine
Postoperative adhesions or bands, hernias, internal volvulus, intussusception, infiltration
by adjacent malignant lesions.
What is the commonest cause of small bowel obstruction?
Adhesion and bands are the commonest cause of small bowel obstruction.
How Dostoperative adhesions are formed?
 SIGMOID VOLVULUS (FIGS 17.7 AND 17.8)

Inner borders
Outer border of the distended
of the sigmoia sigmoid colon loop
colon

Haustration

Distended
Sigmoid loop
42 years male
ray abdomen
Erect

Figure 17.7: This is a straight X-ray of abdomen along with upper part of the pelvis taken in erect posture
showing a hugely distended large gut loop extending from the pelvis to the upper abdomen. Two loops
are distinctly seen with outer borders and an intervening wall formed by inner walls of the sigmoid colon.
All these distended gut walls are seen converging towards the pelvis. This appearance is suggestive of
large bowel obstruction due to sigmoid volvulus

Outer border Innerborders

of the distended
of the sigmoid Sigmoid colon loop
colon

Haustration

Distended
sigmoid loop

Figure 17.8: Similar X-ray omega shaped distended large gut loop. All three lines converging towards the
pelvis suggesting sigmoid volvulus (labeling)
 hapter 17 X-rays 683

What is the likely diagn osis?

This is a typical X-ray appearance of sigmoid volvulus.
What is Dahl Froment's sign?
In sigmoid volvulus three distinct lines may be seen in plain X-ray of abdomen showing the
dilated sigmoid gut loop. The two outer lines indicating the outer margins of the dilated gut loop
and the intervening line formed by the two inner walls of the gut. Al these three lines converge
towards the pelvis. This is called Dahl Froment's sign.
What are the predisposing factors for development of sigmoid volvulus?
The following factors are important for development of volvulus of sigmoid colon:
Bands
Longredundant sigmoid colon
Longpelvic mesocolon
Narrow attachment of pelvic mesocolon
High residue diet and chronic constipation is also an important factor.
What is volvulus?
Volvulus is an abnormal rotation of a segment of bowel around its narrow mesentery causing
obstruction of its lumen and may subsequently lead to strangulation or gangrene. This is a form
of closed loop obstruction. The rotation usually occurs in an anticlockwise direction.
A rotation of 180° is required for luminal obstruction anda rotation of 360° are required for
vascular compromise.
What is compound volvulus?
This is also known as ileosigmoid knotting. The ileum twist around the long sigmoid mesocolon
and there may be gangrene in either ileum, sigmoid or both.
Plain X-ray shows both distended ileal and sigmoid loops.
What are the sites where volvulus may occur in the gastrointestinal tract?
Sigmoidcolon
Cecum
Transversecolon
Smallintestine
Stomach.
What are the important causes of large gut obstruction?
The important causes of large gut obstruction are:
Carcinoma colon
Volvulus
Stricture-tuberculosis, Crohn's disease, ischemic colitis, anastomotic and radiation induced
Hernias
Fecalimpaction
Pseudo-obstruction (ogilvie syndrome).
What are the presentation of a patient with sigmoid volvulus?
Abdominal pain
Distension
 Chapter 17 X-rays 689

RADIOPAQUEKIDNEY STONES AND BLADDERSTONE (FIGS 17.10 AND 17.11)

Multiple
radiopaque
shadows in
theIleft
kidney
region
Intestinal gas
shadows

30 years male
XrayKUEB region
Figure 17.10: This is a plain X-ray of kidney, ureter and part of
the bladder region showing multiple radiopaque shadows in
the left kidney region (Courtesy: Dr Soumen Das, IPGME & R,
Kolkata)

Oval radiopaque
shadow
R1 in the right side
of the pelVIS

Figure 17.11: This is plain X-ray of kidney, ureter and bladder

region showing a oval radiopaque shadow in the right half of the
pelvis (Courtesy: Dr Subhasis Saha, IPGEM & R, Kolkata)
690 Section 4 X-rays

What are the possibilities of such X-ray appearance?

See above.
How will you confirm your diagnosis?
Ultrasonography of kidney, ureter and bladder region will show the kidney, pelvicalyceal
system, ureter and the bladder region. Presence of calculi may be shown by an echogenic
mass casting acoustic shadow.
An intravenous urography is also required to assess the functional status of the kidney.
Which type of renal stones are radiopaque?
Oxalatestones
Phosphatestones
Cystine stones
Xanthinestones.
Which type of rena tones are radiolucent?
Uric acid and urate stones are radiolucent. If these stones are contaminated with calcium salts
they may be radiopaque.
How the patients with renal stones presents?
Asympomatic stones seen ona routine X-ray or ultrasonography for some other reason.
Symptomatic:
Fixed renal pain-dull aching constant pain in the loin or hypochondriac region.
Renal or ureteric colic-acute, colicky pain starts in the loin and radiates to the groin.
There may be associated nausea and vomiting and strangury.
.Hematuria-due to irritation by the stone.
.Pyuria-due to associated infection.
May present with hydronephrosis or pyonephrosis.
How renal stones are formed?
Anumber of factors are responsible for formation of renal stones:
Urinary infection-bacteria forms the nidus for formation of renal stones. Some bacteria like
proteus split urea and makes the urine strongly alkaline. The inorganic phosphate compounds
are less soluble in alkaline medium and results on formation of stones.
Urinary stasis-is associated with increased incidence of renal stones.
Vitamin A deficiency-this may cause desquamation of urinary epithelium, which becomes
the nidus for renal calculi.
Decreased urinary citrate-urinary citrate keeps the calcium phosphate in solution. Decreased
urinary citrate may result in precipitation of calcium phosphate in urine.
Prolonged immobilization-this causes demineralization of bones and increased excretion
of calcium phospahte in urine and is associated with increased incidence of renal stones.
Hyperparathyroidism-increased parathormone in circulation causes hypercalcemia and
hypercalciuria. There is gross demineralization of bones. Increased calcium in urine may
result in increased incidence of renal stones.
Altered urinary solutes and colloids-dehydration results in increased concentration of urinary
solutes and these may precipitate to form stones.
 Chapter 17 X-rays
691
Reduction of urinary colloids, which adsorb solutes or mucoproteins may result in formation
of stones.
Randall's plaque: The initial lesion is an erosion at the tip of a renal papila. Deposition of
calcium salts on this erosion forms a calcified plaque (Randall's plaque). These minute
plaques are carried by the lymphatics to the subendothelial region, where they accumulate.
These microliths grows further by deposition of calcium salts.
Why phosphate stones becomes very large before they produce any symptoms?
The phosphate calculi consisting of calcium phosphate and sometimes magnesium ammonium
phosphate usually has smooth surface. The stone grows in alkaline urine. The bacteria in urine
(Proteus sp) splits urea into ammonia and renders the urine alkaline allowing further increase
in size of this stone due to deposition of calcium phosphate.
Why oxalate stones are commonly associated with hematuria?
Oxalate stones are irregular in shape and covered with sharp projections, which may casue
recurrent bleeding. The stones gets discolored by the pigments of altered blood.
What are the complications of renal stones?
Renal infection-Acute pyelonephritis or pyonephrosis
Obstruction-Hydronephrosis, hydrourete
Ureteral stricture-Passage of stone may result in desquammation leading to fibrosis and
stricture formation in ureter, calyces or renal pelvis.
Chronic renal failure-In bilateral calculi with associated infection or obstruction.
Calculousanuria.
Epidermoid carcinoma-presence of stones in the renal pelvis may cause squamous
metaplasia and squamous cell carcinoma of the renal pelvis.
How the renal stones can be treated by nonoperative means?
Extracorporealshock wave lithotripsy is the modern method for nonoperative treatment of
renal stones. The earlier generation of ECSWL machine required the patient to be kept in a
water bath. The newer generation of machines does not require a water bath. The ultrasound
is focused on the stones, which results in fragmentation of the stones. These fragmented
stones are cleared subsequently. However, these fragments may block the ureter or some of
the fragment may be retained resulting in a recurrent calculus.
The success of treatment depends on the type of stone. Most oxalate and phosphate stones
fragment well, but the hard stone like cystine and xanthine calculi does not fragment well
and is difficult to treat by ECSWL.
What is percutaneous nephrolithotomy (PCNL)?
This is minimally invasive technique for extraction of renal stones:
Ahollowneedle is inserted percutaneously into the renal collecting system through the renal
parenchyma.
A guide wire is inserted through the needle and the needle is then withdrawn.
Following the guide wire the track is dilated using a series of dilators.
The nephroscope is then inserted through this dilated tract.
Smaller stones can be extracted under vision.
ARIUM SWALLOW X-RAY OF ESOPHAGUS-ACHALASIA CARDIA (FIG. 1

Heart shadow
Dilated segment of
the esophagus
proximal to the site
or narrowing

Left dome of the

Site of normal diaphragm
narrowing due to
compression by Smooth pencil
the aortic arch shaped narrowing
of the terminal
esophagus

30years female
Baswallow esophagus
Figure 17.24:This is one ofthe skiagram from barium swallow X-ray of the esophagus
showing a smooth pencil shaped narrowing at the lower end of the esophagus
with dilatation of the esophagus proximal to this narrowing. This appearance is
characteristic of achalasia cardia (Courtesy: Dr Swadapriya Basu, IPGME &R, Kolkata)
688 Section 4 X-rays

Ultrasonography will show the gallbladder outline. The gallbladder wall thickness may be
assessed and stone in the gall bladder will be confirmed by the presence echogenic mass inside
the gallbladder, which casts acoustic shadows. The size of the common bile duct and presence
of any stone in the bile duct may also be seen.
Kidney can be seen and its size may be measured. Cortex and medulla can be delineated.
The pelvicalyceal system can be seen and presence of renal calculi may also be demonstrated
by demonstrating the echogenic mass in the pelvicalyceal system showing acoustic shadows.
What is limey bile?
When the gall bladder contains a mixture of calcium carbonate and calcium phosphate, which
has a consistency of tooth paste. In plain X-ray, the gallbladder appears as a dense white shadow.
This occurs when there is gradual obstruction of the cystic duct or common bile duct. The bile
contained within the gallbladder is absorbed and gallbladder epithelium secretes this white bile.
What are the different types of galistones?
What are the characteristics of cholesterol gallstones?
What are the characteristics pigment stones?
What are the characteristics of mixed stones?
What are the composition of galstone ?

How does the cholesterol stone forms?

How does the pigment stone forms?
How patients with gallstone disease presents?
See Surgical Pathology Section-Gallstone Disease, Page No. 781-784, Chapter 18.
What do you mean by silent or asymptomatic gallstones?
Gall stone diagnosed in a patient in a routine health checkup or in the course of investigation
for some other disease. Patient has no symptom pertaining to gallstones.
What is the chance of such patients developing symptoms in follow-up?
Most of the series has shown that the chance of developing symptoms is around 10% in 5 years
follow-up and 15-20% in 15 years follow-up.
Do all patient with silent stone need treatment?
As the chance of developing symptoms in follow-up is not very high (10% in 5 years follow-up)
routine cholecystectomy for all silent gallstones is not indicated.
What are the indications oftreatment for silent gallstones?
Elderly patients with diabetes mellitus.
Patients on immunosuppressive therapy or on dialysis.
Family history of carcinoma gallbladder or patient living in an area with high incidence of
gall bladder carcinoma.
Large gall stones >2.5 cm.
Multiple small gallstones.
 Chapter 17 Xrays 687

In presence of gangrene or perforationresection and exteriorization of the proximal

segment is safe.
In absence of gangrene or perforation-tube cecostomy is ideal for decompression.

RADIOPAQUE GALLSTONE AND KIDNEY STONE (FIG. 17.9)

Multiple radiopaque
shadows in
theright
hypochondriac
region
Staghorn
radiopaquue
shadow
in the right
32 years male kidney region
X-ray KUB region

Figure 17.9: This is a plain X-ray of abdomen with upper part of pelvis showing
multiple radiopaque shadows in the right paravertebral region below the 12th rib
which appears closely packed. Apart from these there is another dense staghorn type
of radiopaque shadow in the right kidney region

What is your diagnosis?

This appearance suggests radiopaque gallstones and kidney stone.
What percentage of gallstone and kidney stones are radiopaque?
About 10% gallstones are radioopaque and about 90% kidney stones are radiopaque.
What are the D/D of a radiopaque shadow in this region?
Kidney stone
Gallstones
Pancreaticcalculi
Foreign body
Fecolith
Phleboliths
Calcified lymph node
Calcified renal tuberculosis
Calcified adrenal gland
Chip fracture of a transverse process of vertebra or calcification of costal cartilage.
How will you confirm your diagnosis?
Iwill take a lateral view
Gall stone lies anterior to the vertebral body
Kidney stone lies posterior to the vertebral body or overlaps the vertebral body
Confirmation will be by an ultrasonography.
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