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)
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.
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.
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.
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)
large intestine location on hyposthenic/asthenic types
transverse colon is located low in the abdomen
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.
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.
largest solid organ that occupies most of the RUQ. Produces bile to digest fats. Bile is stored and concentrated in the 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.
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.
IVP - term used in the past for an IVU exam. Not an accurate term for the study.
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.
partially covers certain organs. The ascending and descending color, aorta and inferior vena cava are only partially covered (retroperitoneal structures and organs)
potential space b/w parietal and visceral peritoneum - contains lubricating-type fluid which allows organs to move against each other w/o friction.
abnormal accumulation of serous fluid in the peritoneal cavity caused by chronic conditions like cirrhosis of liver or metastatic disease to peritoneal cavity.
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.
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)
mesentery-type folds that connect the transverse colon to posterior abdominal wall.
Liver, gallbladder, right colic flexure, duodenum, head of pancreas, right kidney, right suprarenal gland
Spleen, left colic flexure, stomach, tail of pancreas, left kidney, left suprarenal gland
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
xiphoid process (T9-10)
shows superior margin of abdomen [the superior anterior portion of the diaphragm]
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.
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.
anterior junction of the 2 pelvic bones. Palpated when pt is in a supine position. Corresponds to inferior margin of abdomen. May be embarrassing.
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.
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.
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.
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.
Use patience and provide extra care with breathing instructions. Use padding under back and buttocks for thin patients and blankets to keep warm.
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
endoscopic retrograde cholangiopancreatogram - fluoroscopic procedure where contrast medium is injected endoscopically - to visualize biliary and pancreatic ducts, as does MRI
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.
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.
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:
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.
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.
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.
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.
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)
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.
6 organs of digestive system
Oral cavity, pharynx, esophagus, stomach, small intestine, large intestine
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.
6th and last organ of digestion - begins in RLQ at junction with small intestine at the ileocecal valve.
attached to the posteromedial aspect of the cecum. Verm means wormlike. Appendicitis: backup of fecal matter and bacteria.
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.
higher on left that the transverse or ascending due to the presence of the liver on the right side.
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
Which one of the following organs is not directly associated with the digestive system? Gallbladder, spleen, jejunum, pancreas
which one of the following is considered to be part of the lymphatic system? Liver, spleen, pancreas, gallbladder
Why is the right kidney found in a more inferior position than the left kidney
because the liver is on the right side
T/F The correct term for the radiographic study of the urinary system is intravenous pyelogram (IVP)
False (IVU) intravenous urogram
The organs located posteriorly to, or behind the serous membrane lines the abdoninopelvic cavity are referred to as
Which structure is a double fold of peritoneum that connects the transverse colon to the greater curvature of the stomach?
the superior margin of the greater trochanter is 1.5 inches superior or inferior to the level of the sysmphysis pubis?
The ischial tuberosity is about 1.5 inches superior/inferior to the superior aspect of the symphsis pubis?
Which topographic landmark corresponds to the inferior margin of the abdomen and is formed by the anterior junction of the two pelvic bones?
T/F Because the liver margin is visible in the right upper quadrant of the abdomen, it is not necessary to place a right or let anatomic side marker on the cassette before exposure
T/F gonadal shielding should not be used during abdomen radiography if if obscures essential anatomy
T/F For an adult abdomen, a collimation margin must be visible on all four sides of the radiograph
Gonadal shielding for females involves placing the top of the shield at or slightly above the level of ________, with the bottom at the _____.
ASIS, symphysis pubis
Exposure factor for AP abdomen of a small to average size adult
75 kV, 600 mA, 1/30 second, grid, 40 inch SID
What technical factors are essential when performing abdomen studies on a young pediatric patient
short exposure times, high-speed image receptor, high milliamperage
With the use of iodinated contrast media _____ is able to distinguish between a simple cyst or tumor of the liver
Pathologic indicator: Chronic inflammation of the intestinal wall that may result in bowel obstruction
Pathological condition: Large amount of air trapped in sigmoid colon with a tapered narrowing at the site of obstruction
The central ray is centered to the level of _____ for a supine AP projection of the abdomen
Exposure for an AP projection of the abdomen should be taken on (inspiration or expiration)
Rotation can be determined on a KUB radiograph by the loss of symmetric appearance of these 4 things?
ilica wings, obturator foramina (if visible), ischial spines, outer rib margins
Which type of body habitus may require two crosswise images to be taken if the entire abdomen is to be included
hypersthenic body type
T/F A tall asthenic patient may require two 14x17 inch image receptors placed lengthwise if the entire abdomen is to be included?
Which of the following generates the largest gonadal dose:Female AP abdomen, male lateral decubitus abdomen, female posteroanterior (PA) abdomen, Male erect AP abdomen
Female AP abdomen
What is the gonadal dose range for an average size female patient with an AP projection of the abdomen?
35 to 75 mrad
Which one of the following abdominal structures is not visible on a properly exposed KUB? kidneys, margin of liver processes, pancreas, lumbar transverse processes
why may the PA projection of a KUB generally be less desirable than the AP projection?
Increased object image receptor distance (OID) of kidneys on PA
Which ducubitus position of the abdomen best demonstrates intraperitoneal air in the abdomen?
Left lateral decubitus
Why should a patient be placed in the decubitus position for a minimum of 5 minutes before exposure?
To allow intraabdominal air to rise or abnormal fluids to accumulate
Which decubitus position best demonstrates possible aneurysms, calcifications of the aorta, or umbilical hernias?
Which position best demonstrates a possible aortic aneurysm in the prevertebral region of the abdomen?
List the projections commonly performed for an acute abdominal series or three-way abdomen series
AP supine, AP erect or lateral decubitus abdomen, PA erect
Which position of the three way acute abdominal series best demonstrates free air under the diaphragm?
Which positioning routine should be used for an acute abdominal series if the patient is too ill to stand?
2 way abdomen; AP supine abdomen, left lateral decubitus
To ensure that the diaphragm is included on an erect abdomen projection, the central ray should be at the level of ____inches above/below _____?
2, above, iliac crest
A properly set up Erect Abdomen projection, the top of the 14 x 17 inch cassette should be at what level?
When using automatic exposure control systems, which ionization chambers should be activated for an average to large size patient when performing an AP projection of the abdomen?
Center and upper left chambers
T/F A larger patient receives a greater amount of skin dose and midline dose as compared with a smaller patient during an AP projection of the abdomen?
A KUB radiograph reveals that the symphysis pubis was cut off along the bottom of the image. Is this an acceptable radiograph? If it is not, how can this problem be prevented during the repeat exposure?
No. A KUB must include the symphysis pubis on the radiograph to ensure that the bladder is seen. The positioning error involves centering of the central ray to the iliac crest. The technologist should also palpate the symphysis pubis or grater trochanter to ensure that it is above the bottom of the cassette.
A radiograph of an AP projection of an average size adult abdomen was produced using the following exposure factors: 90 kV, 400 mA, 1/10 second, grid and 40 inch SID. The overall density of the radiograph was acceptable, but the soft tissue structures, such as the psoas muscles and kidneys, were not visible. Which adjustment to the technical factors will enhance the visibility of these structures on the repeat exposure?
The selected kilovoltage (90 kV) was too high. The technologist needs to lower the kilovoltage to between 70 and 80 kV. The milliamperage and exposure time can be altered to maintain the density.
A radiograph image of an AP projection of the abdomen demonstrates motion. The following exposure factors were selected: 78 kV, 200 mA, 2/10 second, grid, and 40 inch SID. The tech is sure that the patient didn't breathe or move during the exposure. What may have caused this blurriness? What can be done to correct this problem on the repeat exposure?
The blurriness may be caused by involuntary motion. To control this motion, the technologist needs to increase the milliamperage and decrease the exposure time (400 mA at 1/10 second).
A radiograph of an AP abdomen reveals that the left iliac wing is more narrowed than the right. What specific positioning error caused this?
Patient was rotated into a slight right posterior oblique (RPO) position. (The downside ilium will appear wider)
A patient with a possible dynamic ileus enters the ER. The patient is able to stand. The physician has ordered an acute abdominal series. What specific positioning routine should be used?
The three-way acute abdominal series, including the anteroposterior (AP) supine and erect abdomen and posteroanterior (PA) erect chest projections
A patient with a possible perforated duodenal ulcer enters the ER. The ER physician is concerned about the presence of free air in the abdomen. The patient is in severe pain and cannot stand. What positioning routine should be used to diagnose this condition?
The two way acute abdomen series: AP supine abdomen and left lateral decubitus
The ER physician suspects a patient has a kidney stone. The patient is sent to the radiology department to confirm the diagnosis. What specific positioning routine would be used to rule out the presence of a kidney stone?
A KUB would be performed with the correct exposure factors to visualize the possible stone
A patient in intensive care may have developed intraabdominal bleeding. The patient is in critical condition and cannot go to the radiology department. Thee physician has ordered a portable study of the abdomen. Which specific position or projection can be used to determine the extent of bleeding?
A bedside portable left lateral decubitus projection could be performed to demonstrate any fluid levels in the abdomen.
A patient with a history of ascites comes to the radiology department. Which one of the following positions best demonstrates this condition?
The erect AP abdomen position best demonstrates air/fluid levels. Ascites produces free fluid in the intraperitoneal cavity.
A KUB radiograph reveals that hte gonadal shielding is superior to the upper margin of the symphysis pubis. The female patient has a history of kidney stones. What is the next step the tech should take?
Repeat the exposure without using gonadal shielding. Because the patient may have renal calculi in the distal ureters and urinary bladder, gonadal shielding cannot be used.
A hypersthenic patient comes to the radiology department for a KUB. The radiograph reveals that the symphysis pubis is included on the image, but the upper abdomen, including the kidneys, is cut off. What is the next step the tech should take.
Repeat the exposure using two 14 x17 inch cassettes placed crosswise. The hypersthenic patient often requires this type of IR placement for abdomen studies.
A patient comes from the ER with a large distended abdomen caused by an ileus. The physician suspects that the distention is caused by a large amount of bowel gas that is trapped in the small intestine. The standard technique for a KUB on an adult is 76 kV, 30 mAs. Shoudl the technologist change any of these exposure factors for this patient? (AEC is not being used)
Yes, Decrease the mAs. Because trapped air is easier to penetrate than soft tissue with x-rays, reducing the mAs will prevent overexposing the radiograph
A child goes to radiology for an abdomen study. It is possible that he swallowed a coin. The ER physician believes it may be in the upper GI tract. Which of the following routines would best identify the location of the coin?
KUB and lateral abdomen. With any foreign body study, two projections 90 degrees opposite is recommended to pinpoint the location of the foreign body.
Name the 9 regions of the abdomen
Right hypochondriac, epigastric, left hypochondriac, right lateral, umbilical, left lateral, right inguinal, pubic, left inguinal
What is the name of the double fold of peritoneum that extends from the lesser curvature of the stomach to portions of the liver?
name intraperitoneal organs
liver, gallbladder, spleen, stomach, jejunum, ileum, cecum, transverse colon, sigmoid colon
name retroperitoneal organs
kidneys, ureters, adrenal glands, pancreas, duodenum, ascending colon, descending colon, upper rectum, major abdominal blood vessels (aorta & inferior vena cava)
name infraperitoneal (pelvic) organs
lower rectum, urinary bladder, reproductive organs, Male-closed sac, Female-open sac (the female uterus, tubes and ovaries, extending into the peritoneal cavity)
Radiographic positioning of the abdomen
KUB, Acute abdomen series ( AP supine abdomen, AP erect abdomen, PA erect Chest) Decubitus positions (lateral decubitus, dorsal decubitus)
Criteria for AP supine abdomen shot and a PA supine abdomen shot
symphysis pubis is visible, kidneys and lower liver margin are included, no rotation, no motion, exposure factors optimal
Which abdomen shots are centered 2 inches above iliac crest
Left lateral decubitus position, Erect AP, Right latera dorsal decubitus
Criteria for Left Lateral decubitus position
diaphragm demonstrated, both sides of body included, no rotation, no motion, exposure factors
Criteria for Dorsal decubitus right lateral position
diaphragm included, no rotation, no motion, exposure factors
Criteria for Right lateral abdomen position
diaphragm included, no rotation, no motion, exposure factors
Pathologic indications for acute abdomen series
ileus, ascites, perforated hollow viscus, intraabdominal mass, postop (abdominal surgery)
A pathologic condition in which twisting of a loop of intestine creates an obstruction is termed
What is the preferred length of time a patient should lie on his side prior to a lateral decubitus projection
minimum 5 minutes, preferred 10-20
Where is the CR centered for an AP erect abdomen projection as part of an acute abdomen series
1 to 2 inches above iliac crest