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October 27, 2017
NORMAL RADIOGRAPHIC ANATOMY OF THE ABDOMEN AND PELVIS
Ma. Louven Urbano-Grasparil, MD
Department of Radiology

TOPIC OUTLINE  Borders of a plain abdominal AP: part of chest (above) and femoral
I. Overview heads (below)
a. Plain AP View Abdomen Pelvis
b. Upright and Supine Views Liver Urinary bladder
II. Evaluation Stomach (gastric bubble) Uterus
a. Normal Bowel Gas Pattern Spleen (not seen unless enlarged) Prostate
b. Normal Calcifications Psoas muscle (on both sides of vertebra)
c. Soft Tissues Renal shadow (latera to psoas)
d. Osseous structures Parts of the colon
e. Extraluminal Air
III. Plain KUB  Renal shadow is seen only if the patient was able to fast right
IV. KUB – IVP o Proper fasting is at least 8 with enema
V. Fluoroscopic Studies o For CT colonoscopy, 3 days fasting
a. Esophagogram o Removes the air and fecal material (both
b. Upper GI series radiopaque/white)
c. Small Intestine Series o If px is not properly fasted, fecal material covers the renal
d. Barium Enema shadow
o Renal shadows are lateral to the psoas shadow

UPRIGHT VIEW
OVERVIEW
Plain Abdomen AP View

 All upright views should include the diaphragm

 If the patient can stand
 Air-fluid levels are seen

SUPINE VIEW

 Patients who cannot stand up usually due to acute abdomen

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 Normal Abdominal and Pelvic X-Ray

EVALUATION
What to evaluate in an abdominal radiograph:
a. Bowel gas pattern
b. Calcifications
c. Soft tissues
d. Osseous structures
e. Extraluminal air
Normal Bowel Gas Pattern
 Dilated or not – check diameter wall-to-wall
Stomach  (+) air in upright, not always in supine
 Few air fluid levels d/t air being resorbed
 Air in the SI  think of ileus or obstruction
 Should be <3 cm in diameter, if >3 cm then it’s
Small bowels
dilated
 Valvulae conniventes – complete rings in the SI
 Centrally-located
 (+/-) air d/t presence of gas-forming bacteria
 Should be < 6 cm diameter
o Cecum can extend up to<9 cm
Large bowels (if >9 cm --> rupture)
 Rectum – always (+) air
 Haustrations – incomplete rings of the LI
 Peripherally-located
**REMEMBER: 3-6-9 RULE (3 for Small, 6 for Large, 9 for cecum)

 Supine because it’s just air, no air-fluid level visible

 Liver is enlarged
o Normally, its lower border reaches only up to 2 cm
below the subcostal margin
o Should do additional liver imaging: CT or US
 Transverse colon is displaced (by the enlarged liver) inferiorly
and to the left
o White dotted lines trace the course of the displaced
colon
o White arrows point to the air inside the colon
o Blue dotted lines indicate where the normal
transverse colon is

Calcifications
 Know when it is normal vs abnormal
NORMAL CALCIFICATIONS
Costal  Expected in the elderly
cartilage
 Oval
 Seen in cases of TB
 Nodes have the same course as the ureters
Mesenteric o Mistaken for ureteral lithiasis  confirm
lymph nodes with CT or US
o With ureteral lithiasis, you also expect
hydronephrosis (renal shadows are
enlarged)
 Calcifications within the pelvic vein due to
venous stasis
Phleboliths
 Have lucent centers
 DDX: Ureteral stones
 Mottled densities (radiopaque/white) are fecal material in the Prostate  Expected in the elderly, abnormal in the
bowels gland younger adults
 Urinary bladder is not well-delineated if it is collapsed or if it is filled concretions  Seen in the pelvic brim
with urine (becomes white)

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 Normal Abdominal and Pelvic X-Ray

Phlebolith
s

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 Normal Abdominal and Pelvic X-Ray

Soft Tissues
 For the soft tissues, you look for organ enlargement
 LIVER – RUQ, displaces the bowel if enlarged

PLAIN KUB (KIDNEYS, URETERS, BLADDER)

 Different from plain abdominal X-ray because:
o Requires bowel preparation to remove air
o Diaphragm is not included
 SPLEEN – LUQ, above and behind the stomach, usually not visible, o Spans the level of T12 (where the 12th rib is attached) to the
 PSOAS AND KIDNEYS pelvic floor (the UB reaches up to the pelvic floor)
o Psoas – straight diagonal lines along the lumbar spine
o Kidneys – about 3 vertebrae in size, L higher than the R
kidney (d/t the liver in the R)
 URINARY BLADDER, UTERUS, PROSTATE
o UB – seen as soft tissue density (white/opaque) when full
(urine is liquid)
o Uterus – Anterior and superior to the UB; indents the
uterus, not seen on plain images
o Prostate gland – in the pelvic brim, look for calcifications

Osseous Strustures
 Lower rib cage – you can see up to the 9th rib
 Lumbar spine – look for degenerative changes
 Sacrum, Pelvis, Hip joints

Extraluminal air
 Air in the abdomen are normally inside the stomach and the bowels
 Air outside these organs: pneumoperitoneum

KUB-IVP (INTRAVENOUS PYELOGRAM)

 Contrast injection followed by X-Ray series
 Series of Xrays taken at:

Immediately Scout plain KUB

(AP - upright or supine)
1 minute Nephrogram (AP) Renal parenchyma
5 minutes Pyelogram Renal pelvis, calyces
(AP/oblique)
15 minutes Excretory (AP) Ureters, skips are normal
in ureters d/t spasm of
ureter
Full bladder (AP/Lateral/Oblique) Mucosa, filling defects
(Px feels urge
 Chest X-Ray can also be used to diagnose pneumoperitoneum to urinate)
 Pneumoperitoneum – air beneath the diaphragm Postvoid (AP/Lateral/Oblique) Check if px was able to
 X- Table lateral is used to visualize the air-fluid interface (air up, (After excrete all the contrast
fluid down) urination) If >30% is retained after
urination  think of
obstruction

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 Normal Abdominal and Pelvic X-Ray

FLUOROSCOPIC STUDIES
 Used less frequently d/t high radiation
a. Esophagogram/ Barium Swallow
b. Upper GI series
c. Small Intestine Series
d. Barium Enema

Esophagogram/Barium Swallow
 Uses barium solution or non-ionic/water soluble contrast solution
 Px is asked to swallow the solution under fluorospy, a series of
xrays will be taken (AP/Lateral views)
 From oropharynx to GE junction
 Normal:
o Smooth mucosa
o No narrowing or obstruction
o Unimpeded flow of contrast

Upper GI Series
 Barium swallow  patient drinks carbonated drink  gas forms in
the stomach  stomach distends  contrast adheres to mucosal
folds/rugae  better view
 From esophagus  stomach  duodenum

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Small Intestinal Series QUIZ

 Indications: during post-op, to assess food movement 1. Complete rings of the small intestine
 Series of films (30 min- 1hr intervals) until the contrast reaches the 2. Normal diameter of small intestine
ileocecal valve 3. Normal diameter of cecum
 Should not be > 4 hours 4. Lower margin of liver in abdominal X-ray
 If after 4 hours, contrast still not visible in ileocecal valve  5. Phleboliths are calcifications in the _____.
obstruction
6. T/F. The left kidney is lower than the right.
 Pop Quiz: If you measure the diameter, should not be _____ cm.
7. Air outside the stomach or the bowel
8. Borders of plain KUB
9. In KU-IVP, what do you evaluate 15 minutes after injection?
10. Barium Swallow evaluates contrast flow from __ to __.

floor, Excretory/Ureters, oropharynx to GEJ

subcostal, pelvic vein, F, pneumoperitoneum, T12 – pelvic
Answers: Valvulae conniventes, <3 cm, <9 cm, 2cm below

jejunum

ileum

Barium Enema/ Colonogram

 Barium is introduced to the rectum followed by air (to distend)
 Aka double contrast examination
 Contrast reaches up to the ileocecal junction and terminal ileum

HF SF

AC

TC
DC
SC

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