Chapter 4 Abdomen study questions

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plain films

images (of the abdomen)

Most common abdomen radiograph

anterposterior supine abdomen - AKA KUB

KUB

kidneys, ureters, and bladder - taken before abd. exams without the use of contrast media for evaluation & diagnosis of diseases and conditions involving these systems.

Acute abdominal series

2-way or 3-way abdomen series where several abdominal radiographs are taken in different positions to show air-fluid levels and/or free air in the abd. cavity. Performed most commonly to evaluate and diagnose conditions or diseases related to bowel obstruction and/or perforation. Requires visualization of air-fluid levels and possible intraperitoneal "free" air wih the use of horizontal beam errect or decub body positions.

Conditions that call for an acute abdominal series

Bowel obstruction, perforations involving free intraperitoneal air (outside the digestive tract), excessive fluid in the abd., or possible mass.

3 most important abdominal muscles

Diaphragm - umbrella shaped muscle - separates the abdominal cavity from the thoracic cavity. Must remain perfectly motionless during rad exam. Two psoas major muscles located on either side of the lumbar vertebral column.

Abdominal organ system

digestive system (oral cavity, pharynx, Esophagus, stomach, small intestine, large intestine), Digestive system accessory organs (liver, gallbladder, pancreas) + spleen (lymphatic system)

Intraperitoneal organs

partially or completely covered by some type of visceral peritoneum but are not retroperitoneal or infraperitoneal. Intra (within). liver, gallbladder, spleen, stomach, jejunum, ileum, cecum and transverse and sigmoid colon.

retroperitoneal organs

organs that are back or behind - attached to posterior abdomen wall. Less mobile in abdomen than intraperitoneal organs. Kidneys and ureters, adrenal glands, pancreas, duodenum, ascending and descending colon, upper rectum, abdominal aorta, inferior vena cava.

infraperitoneal (pelvic) organs

organs that are under or beneath the peritoneum in the true pelvis are the lower rectum, urinary bladder, and reproductive organs

digestive system organs of the abdominal cavity

fills much of the abdominal cavity. - Includes stomach, small intestine, large intestine, along with liver, gallbladder and pancreas.

GI

gastrointestinal

small intestine

4.5 to 5.5 meters (15-18 feet). Has 3 parts: duodenum, jejunum, and ileum.

duodenum

first, shortest and widest portion. 25 cm in length. Letter "C". Proximal portion is duodenal bulb or cap. Receives ducts from liver, gallbladder and pancreas. Proximal portion is called the duodenal bulb or cap.

jejunum

Middle 2/5 of the small intestine after the duodenum. Has a feathery look on radiographs.

ileum

distal 3/5 of the small intestine, located after the jejunum.

ileocecal valve

orifice b/w the distal ileum and the cecum portion of the large intestine

right colic flexure

Another name for hepatic flexure of the large intestine (where the ascending colon joins the transverse colon)

left colic flexure

Another name for splenic flexure of the large intestine (where the transverse colon joins the descending colon)

rectum

final 15 cm (6 inches) of the large intestine. Ends at the anus

anus

sphincter muscle at terminal opening of the large intestine

large intestine location on hypersthenic types

transverse colon is located high in the abdomen

large intestine location on hyposthenic/asthenic types

transverse colon is located low in the abdomen

spleen

part of lymphatic system and circulatory system. It's an abdominal organ in LUQ, posterior and to the left of the stomach. May be visible on radiographs, especially if enlarged. Also subject to lacerations during trauma to lower left posterior rib cage. Fragile.

Accessory digestive organs in the abdomen

pancreas, liver and gallbladder

pancreas

NOT seen on a plain radiograph. Posterior to stomach and near posterior abd. wall. b/w the duodenum and spleen. 12.5 cm (6 inches). Its head is nestled in the C-loop of the duodenum, and its body and tail extend to the upper left abdomen. Part of the endocrine and exocrine secretion systems. Produces up to 1.5 quarts (1500 mL) of digestive juices. Produces essential hormones like insulin and glucagon to control blood sugar levels.

Liver

largest solid organ that occupies most of the RUQ. Produces bile to digest fats. Bile is stored and concentrated in the gallbladder

Gallbladder

pear-shaped sac below the liver. Stores and concentrates bile and releases bile when stimulated by CCK. Cannot be visualized without contrast media. It blends with other soft tissues. Only about 10-15% of gallstones contain enough calcium to bee seen on a plain rad. image.

Urinary system

2 kidneys - right is lower than left because of liver. Bean-shaped - located on either side of the lumbar vertebral column.

Excretory or intravenous urogram

IVU - radiographic exam of the urinary system - contrast medium is injected intravenously. Hollow organs of this system are visualized with contrast media. The contrast media is filtered from the blood by the kidneys.

Intravenous pyelogram

IVP - term used in the past for an IVU exam. Not an accurate term for the study.

EU and IVU

correct terms for the urinary system study (excretory urogram), but IVU is most common

4 terms that describe anatomy of the abdominal cavity

peritoneum, mesentery, omentum, mesocolon

peritoneum

large serous, double-walled saclike membrane that cover abdominal structures and organs.Total surface area of the peritoneum is about equal to the total surface area of the skin.

2 types of peritoneum

parietal, visceral

parietal peritoneum

adheres to the abdominal cavity wall

visceral peritoneum

partially covers certain organs. The ascending and descending color, aorta and inferior vena cava are only partially covered (retroperitoneal structures and organs)

peritoneal cavity

potential space b/w parietal and visceral peritoneum - contains lubricating-type fluid which allows organs to move against each other w/o friction.

ascites

abnormal accumulation of serous fluid in the peritoneal cavity caused by chronic conditions like cirrhosis of liver or metastatic disease to peritoneal cavity.

mesentery

Double fold of the peritoneum that completely envelopes and binds a loop of the small intestine to each other and to the posterior wall of the abdomen. Contain blood and lymph vessels and nerves.

omentum

double-fold peritoneum that extends from the stomach to another organ.

mesocolon

peritoneum that attaches the colon to the posterior abdominal wall. 4 forms depending on what part of the colon it's attached to: ascending, transverse, descending and sigmoid (pelvic)

greater and lesser sac

the 2 parts of the peritoneal cavity

meso

means mesentery

transverse mesocolon

mesentery-type folds that connect the transverse colon to posterior abdominal wall.

umbilicus level

b/w L4 &L5 - iliac crest on a female

RUQ anatomy

Liver, gallbladder, right colic flexure, duodenum, head of pancreas, right kidney, right suprarenal gland

LUQ anatomy

Spleen, left colic flexure, stomach, tail of pancreas, left kidney, left suprarenal gland

RLQ anatomy

ascending colon, appendix, cecum, 2/3 ileum, ileocecal valve

LLQ anatomy

Descending colon, sigmoid colon, 2/3 jejunum

9 abdominal regions

uses 2 transverse planes (transpyloric [L1] and transtubercular planes [L5] and 2 vertical planes (right and left lateral planes) [midway b/w midsagittal plane and each anterior superior iliac spine - ASIS]

Seven landmarks of the abdomen

xiphoid process, inferior costal rib margin, iliac crest, anterior superior iliac spine (ASIS), greater trochanter, symphysis pubis, ischial tuberosity

ASIS

anterior superior iliac spine.

xiphoid process (T9-10)

shows superior margin of abdomen [the superior anterior portion of the diaphragm]

Inferior costal (rib) margin (L2-L3)

locates upper abd. organs like gallbladder and/or stomach

Iliac crest (L4-L5 interspace)

found by pressing inward and down on midlateral margin of abd. Most common abd. landmark - corresponds to midabdomen - slightly below umbilicus on most people. Centering IR here will include lower abd. area. Ensuring upper abd. including diaphragm requires centering about 2 inches above the level of the crest which will cut off some important lower abd. Would require a 2nd IR centered lower to include lower region.

Anterior superior iliac spine (ASIS)

palpated anteriorly and inferiorly until a bump is felt. Used for pelvic or vertebral structures and as 2ndary landmark for general abd. positioning.

Greater trochanter

gentle, firm palpation is required to feel movement of trochanter with one hand while rotating leg internally and externally at knee area with other hand. About same level as upper border of symphysis pubis.

Symphysis pubis

anterior junction of the 2 pelvic bones. Palpated when pt is in a supine position. Corresponds to inferior margin of abdomen. May be embarrassing.

Ischial tuberosity

prone position. Most easily palpated on thin pts. Bears most weight of trunk when seated. 1-4 cm below symphysis pubis. Use for a PA projection of colon when rectal area is to be included on IR. May also be uncomfortable and embarrassing for pt. Use other landmarks when possible.

General positioning considerations

Use a pillow for head and under knees for comfort during supine abdomen. Cover patients to keep them warm and protect modesty.

Breathing instructions

Use shortest exposure time possible due to voluntary (breathing and patient movement) and involuntary (peristalsis) movement. Take most on expiration. Diaphragm will be in superior position for better visualization of abdominal structures. Use shortest exposure time possible and provide clear breathing instructions. Wait 1 second after breathing out has stopped.

Image markers

L, R, and up side markers.

Radiation protection

Avoid repeat exposures, use collimation as possible, and use gonadal shielding for males and only for females when shields do not obscure essential anatomy. Physician should determine whether anatomy will be obscured by shield.

Exposure factors

Medium kV (70-80)

pediatric applications

Do only a supine and one horizontal beam projection to show air-fluid levels. For those younger than 2-3, a lateral decub may be difficult, and Pigg-o-Stat (Modern way immobilizers, Inc.) is preferred. Use short exposure time and higher-speed film and screens. For pts under 12-13, use reduced kV and mAs.

Geriatric applications

Use patience and provide extra care with breathing instructions. Use padding under back and buttocks for thin patients and blankets to keep warm.

Digital imaging considerations

Close collimation and accurate centering are most important

Exposure factor

ALARA - highest kV and lowest mAs

Post-processing evaluation of exposure index -

check and verify that factors used were in correct range

CT and MRIs

Early diagnosis of small neoplasms of liver and pancreas. With IV contrast media, CT can discriminate b/w a simple cyst and a solid neoplasm. With MRI, Also can tell if neoplasms have spread and their blood vessel relationships. MRI can visualize biliary and pancreatic ducts, as is ERCP

ERCP

endoscopic retrograde cholangiopancreatogram - fluoroscopic procedure where contrast medium is injected endoscopically - to visualize biliary and pancreatic ducts, as does MRI

Sonography

method of choice when gallbladder is imaged to detect gallstones in gallbladder or bile ducts. Of limited use to evaluate hollow viscus of the GI tract for bowel obstruction or perforation, but with CT, it can detect lesions or inflammation of soft tissue organs like liver or pancreas. Demonstrates abscesses, cysts, or tumors involving kidneys, ureters or bladder. Wtih clinical evaluation, it can be used to diagnose acute appendicitis.

nuclear medicine

noninvasive means to evaluate GI motility and reflux as related to possible bowel obstruction and lower GI bleeding. With radionuclides, it can be used to see entire liver and major bile ducts and gallbladder.

Acute abdomen series

2-way or 3-way: 3-way with PA chest best visualizes free intraperitoneal air under the diaphragm and free air if IR is centered high enough to include the diaphgragm. 2-way and 3-way evaluates conditions/diseases of bowel obstruction and/or perforation. Requires visualization of air-fluid levels and possible intraperitoneal "free" air with use of horizontal beam erect or decub positions.

pneumoperitoneum

free air or gas in cavity. Serious condition - requires surgery, caused by perforation of gas-containing viscus such as by a gastric or duodenal ulcer. Can be caused by trauma that penetrates the abd. wall. Best seen with horizontal beam erect abdomen or chest radiograph. Thin, crest-shaped radiolucency under dome of rt. hemidiaphragm on erect. Decrease exposure factors. Use acute abdomen series - erect chest or abdomen.

Dynamic (with power or force) or mechanical bowel obstruction

complete or near complete blockage of flow of intestinal contents. Caused by:

fibrous adhesions

most common mechanical obstruction - fibrous band of tissue interrelates with the intestine, creating a blockage]; distended loops of air-filled small bowel - decrease exposure factors. Use acute abdomen series.

Crohn's disease

chronic inflammation of intestinal wall resulting in blockage - cause unknown. Common in young adults. Loops of small bowel joined by fistulas or connected openings with adjacent loops of intestine]; distended loops of air-filled small bowel - decrease exposure factors. Use acute abdomen series.

intussusception

telescoping of a section of bowel into another loop creating obstruction - most common in distal bowel, and in children - requires trtmt w/in 48 hours to prevent necrosis]; decrease exposure factors. Use acute abdomen series. Air-filled coiled spring appearance.

volvulus

twisting of a loop of intestine - creates obstruction. Slightly decrease exposure factors. Use acute abdomen series. Large amts. of air in sigmoid with tapered narrowing at site of volvulus.

ileus-nonmechanical bowel obstruction

adynamic (without power or force) - caused by peritonitis or paralytic ileus caused by lack of intestinal motility. Occurs in postoperative pts. 24-72 hours after abd. surgery. Rarely leads to perforation; characterized by large amount of air and fluid) - decrease exposure factors. Use acute abdomen series. Large amounts of air in entire dilated small and large bowel w/air-fluuid levels visualized.

ulcerative colitis

chronic disease involving inflammation of colon occuring in young adults, involving rectosigmoid region. Can cause toxic megacolon with potential perforation into the peritoneal cavity. Barium enemas are strongly CONTRAINDICATED - decrease exposure factors. Use acute abdomen series for possible free air for dilated loop of colon, or plain AP abdomen for deep air-filled mucosal, protrusions of colon wall, usually in rectosigmoid region.

Acute abdomen routine

PA chest may be included in some institutions to demonstrate free intraperitoneal air trapped under the diaphragm. Thus the supine AP and erect abdomen PLUS PA chest) is presented as basic or routine. PA chest may be included because it visualizes small amounts of free intraperitoneal air under the diaphragm.

AP Supine projection

Use for bowel obstruction, neoplasms, calcifications, ascites, and scout image for contrast medium studies.

PA projection - prone

Use for bowel obstruction, neoplasms, calcifications, ascites, and scout image for contrast medium studies. LESS DESIRABLE because if kidneys are of primary interest, OID is increased.

Lateral decub - AP projection

Use for abdominal masses, air-fluid levels, possible accumulations of intraperitoneal air (small amounts of air should use erect PA chest)

AP Projection, erect position

Use for abnormal masses, air-fluid levels, and accumulations of intraperitoneal air under diaphragm

Dorsal decub, right or left lat

Use for abnormal masses, accumulations of gas, air-fluid levels, aneurysms (widening or dilation of the wall of an artery, vein or heart), calcifications or aorta or other vessels, and umbilical hernias.

Acute abdominal series: acute abdomen

3-WAY: Supine, erect or lateral decub, and PA chest (if departmental routine protocol includes PA chest)

aneurysm

a widening or dilation of the wall of an artery, vein, or the heart

Ascites

abnormal accumulation of fluid in the peritoneal cavity of the abdomen. Caused by long-standing conditions like cirrhosis of the liver or by metastatic disease to the peritoneal cavity.

When are barium enemas contraindicated

symptoms of toxic megacolon - can cause potential perforation into the peritoneal cavity.

Which abdominal radiograph is taken without contrast media

The AP supine abdomen (KUB)

Digestive system accessory organs

liver, gallbladder, pancreas

Spleen

part of lymphatic system - partially visible in LUQ posterior to stomach.

6 organs of digestive system

Oral cavity, pharynx, esophagus, stomach, small intestine, large intestine

Oral cavity and pharynx

common to respiratory system and digestive system

esophagus

located in mediastinum of thoracic cavity

stomach

first organ of digestive system that is in the abdominal cavity. Expandable reservoir for swallowed food and fluids. Size and shape are highly variable depending on volume and on the body habitus.

Large intestine

6th and last organ of digestion - begins in RLQ at junction with small intestine at the ileocecal valve.

cecum

saclike area below the ileocecal valve

vermiform appendix

attached to the posteromedial aspect of the cecum. Verm means wormlike. Appendicitis: backup of fecal matter and bacteria.

ascending colon

joins the transverse colon at the right colic flexure

transverse colon

joines the descending colon at the left colic flexure

sigmoid colon

S-shaped - in LLQ.

romance of the abdomen

head of pancreas nestles in the C-loop of the duodenum

How much digestive juice daily does pancreas create

1.5 quarts - 1500 mL

RIght kidney is

lower than the other kidney due to the presence of the liver.

urinary bladder

above and behind the symphysis pubis - stores urine.

pyelo

refers to the renal pelvis of the kidney

excretory urogram (EU)

also a term for intravenous urogram. Not used as much as IVU.

omentum bursa

the lesser sac - one of the 2 parts of the peritoneal cavity

4 abdominal quadrants

If 2 perpendicular planes were passed through the abd. at the umbilicus:

Which quadrant system is used most in radiography

The 4-quadrant system

Patient prep

Removal of all clothing and any opaque objects. Wear hospital gown opening in back. Shoes and socks may stay on.

Collimation on small patients

side collimation to skin borders if it doesn't cut off abdominal anatomy

Collimation for adults

Top and bottom should be adjusted to margins of the IR or film holder, allowing for divergence. If extra collimation is used, essential anatomy will be cut off.

2-way series

AP supine and Erect or decub. abdomen

3-way series

AP supine and Erect or decub. abdomen + PA chest

descending colon

higher on left that the transverse or ascending due to the presence of the liver on the right side.

What is very important to movement of intestinal contents

muscle contraction and peristalsis

How much of a rotation is needed to see the kidney

30 degree oblique

LMP

last menstrual period

Abdomen exposure factors

Medium kVp - 70-80

the two large muscles that are found in the posterior abdomen adjacent to the lumbar vertebra and are usually visible on an anteroposterior (AP) radiograph

psoas muscles

gastro-

The medical prefix for stomach

The three parts of the small intestine

duodenum, jejunum, Ileum

Which portion of the small intestine is considered to be the longest

ileum

Which quadrant does the large intestine begin in?

Right lower quadrant

Saclike area that the large intestine begins?

cecum

The sigmoid colon is located between which two parts of the large intestine?

descending and rectum

Three accessory digestive organs

Pancreas, liver, gallbladder

the pancreas is located anteriorly or posteriorly to the stomach

posteriorly

Which one of the following organs is not directly associated with the digestive system? Gallbladder, spleen, jejunum, pancreas

spleen

which one of the following is considered to be part of the lymphatic system? Liver, spleen, pancreas, gallbladder

spleen

Why is the right kidney found in a more inferior position than the left kidney

because the liver is on the right side

what endocrine glands are superomedial to each kidney?

adrenal glands

T/F The correct term for the radiographic study of the urinary system is intravenous pyelogram (IVP)

False (IVU) intravenous urogram

The double walled membrane lining the abdominopelvic cavity is called the

peritoneum

The organs located posteriorly to, or behind the serous membrane lines the abdoninopelvic cavity are referred to as

retroperitoneal

What structure helps stabilize and support the small intestine?

Mesentery

Which structure is a double fold of peritoneum that connects the transverse colon to the greater curvature of the stomach?

Greater omentum

What is the correct name for the abdominal region found in the middle of the abdomen

Umbilical

Which abdominal region contains the rectum

Pubic

the superior margin of the greater trochanter is 1.5 inches superior or inferior to the level of the sysmphysis pubis?

superior

The ischial tuberosity is about 1.5 inches superior/inferior to the superior aspect of the symphsis pubis?

inferior

Which topographic landmark corresponds to the inferior margin of the abdomen and is formed by the anterior junction of the two pelvic bones?

symphsis pubis

Which topographic landmark is found at the level of L2-L3?

Inferior costal margin

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