Plain Film Radiography

Plain films remain the workhorse imaging study for the emergency department evaluating a patient with abdominal pain. Plain films can be obtained quickly, cause no discomfort to the patient, and are relatively inexpensive compared to other gastrointestinal (GI) imaging modalities. The emergency physician can interpret plain films. Unlike the chest, where the organs have great differences in water and air content and therefore in radiodensity, the abdomen contains structures of similar radiodensities. Only the presence of air and fat in the bowel or other structures allows indentification of organ boundaries, and the air is transient. A plain film of the abdomen represents a "snapshot" of a dynamic system and should be examined systematically. A time-honored technique is to first examine the bones (spine, ribs, pelvis, and hips); then the upper quadrants, flanks, and mid-abdomen for organ masses and calcifications; and finally the lower abdomen. The physician should attempt to look at the area of special interest last.

At most centers, an "acute abdominal series" includes a supine film centered at the iliac crest, an upright film centered at the crest, and an upright posteroanterior (PA) chest film. The supine film detects fluid or blood in the peritoneum as well as gas in the bowel, and the upright film displays any air-fluid levels. If the patient is too ill to stand, a left lateral decubitus (left side down) view is acceptable, but a right lateral decubitus is not. On a left lateral decubitus view, free air can be detected between the liver and the peritonuem; this is not possible in a right lateral decubitus view (right side down) because air in the bowel loops will contact the peritoneum. The standard upright PA chest view is best for demonstrating free air in the peritoneal cavity as well as other pathologic conditions of the chest that cause abdominal pain, such as pneumonia, pneumothorax, or atelectasis.

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