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Diagnostic values of supine and erect abdominal radiographs for patients with acute abdomen: which is better for decision making?

Lee, Chia-Yinga; Chen, Jen-Dara,b,*

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Journal of the Chinese Medical Association: June 2022 - Volume 85 - Issue 6 - p 709-716
doi: 10.1097/JCMA.0000000000000714
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Acute abdomen is a common complaint in emergency departments (EDs). Plain abdominal radiography (PAR) is one of the essential tools in the diagnosis of this condition in addition to clinical laboratory data and physical examination. There has been a significant debate over the use of PAR as a diagnostic modality in cases of acute abdomen. Much literature states that the sensitivity of PAR is low and can result in unnecessary radiation exposure in the most of the case.1–7 The 2017 Royal College of Radiologists iRefer guidelines for PAR only lists a few indications for PAR, including bowel obstruction and constipation.8 However, due to some reasons, such as financial concerns or difficult access to the advanced instruments, many hospitals still choose PAR for preliminary diagnosis. For patients whose PAR shows an imaging finding (eg, bowel dilatation, free air, abnormal calcifications, or soft tissue density) or who exhibit severe symptoms, an abdominal computed tomography (CT) scan is additionally performed.

PAR can be categorized into two types: (1) supine abdominal radiograph (SAR) and (2) erect abdominal radiograph (EAR). Both these types have pros and cons, resulting in dilemma in doctors’ decision making over the choice of modality for their patients. An incorrect choice can cause difficulties and doubts in making a diagnosis.

This study aimed to explore which one of the SAR and EAR has a higher diagnostic value in diagnosis of overall acute abdomen and their respective advantages over each other for the various underlying diseases. When we encounter a patient with acute abdomen in ED and are considering a PAR, we want to answer the following question: which should I choose to ensure a better result for a more precise diagnosis, SAR or EAR?


2.1. Study subjects

This study retrospectively included 1009 patients who presented with acute abdomen to the ED of a medical center in northern Taiwan and underwent PAR and subsequent abdominal CT within 24 hours between October 2019 and February 2020. Patients with abdominal trauma were excluded. The patients received one of two types of PAR: SAR and EAR. SAR was performed with radiograph perpendicular to the patient’s abdomen in supine position with the lower margin of the image field including the patient’s symphysis pubis. EAR was performed with radiograph perpendicular to the patient’s abdomen in standing position, with the upper margin of image field including the patient’s diaphragm. These patients with acute abdomen were divided into two groups in the study: SAR group and the EAR group.

2.2. Study design

The final clinical diagnoses of patients were based on the CT reports and clinical data such as symptoms and signs, lab data, endoscopy results, and surgical findings. The clinical diagnoses were categorized according to the disease classification into 6 main groups and 20 subgroups (see Table 1). All PAR images of the patients were reviewed by two certified general radiologists. The PAR images were evaluated first to determine whether there were findings listed in Table 2. The readers are blinded to the clinical data when interpretating the PARs. A PAR is defined to have “diagnostic relevance” (or have relevant findings) when the PAR findings are related to the disease and helpful in the clinical diagnosis. The diagnostic relevance of imaging findings of PAR to the clinical diagnosis were determined by consensus of the two certified radiologists.

Table 1 - Disease classification (6 main groups and 20 subgroups)
System Disease classification
A: GI system A1: Hollow organ perforation
A2: Bowel obstruction
A3: Adynamic ileus
A4: Appendicitis
A5: Diverticulitis
A6: Gastritis, peptic ulcer (without perforation)
A7: GI cancer (without obstruction)
A8: Stool impaction
A9: Enteritis/colitis
B: Hepatobiliary system B1: Diffuse liver disease (eg, liver cirrhosis, fatty liver, hepatomegaly, hepatitis)
B2: Focal liver lesion (eg, liver tumor, abscess, cyst)
B3: Gallbladder or biliary tract disease
C: Pancreas Pancreatitis, pancreatic tumor
D: Urinary system D1: Urolithiasis
D2: Urinary tract infection (UTI) (eg, pyelonephritis, ureteritis, cystitis)
D3: Ureter diseases (Not urolithiasis nor UTI, eg, tumor, stricture)
D4: Renal diseases (Not urolithiasis nor UTI, eg, tumor, polycystic kidney disease)
D5: Urinary bladder diseases (Not urolithiasis nor UTI, eg, tumor, acute urine retention)
E: GYN system Tubo-ovarian abscess, pyometra, GYN tumors
G: Others Mesenteric adenitis, panniculitis, peritoneal tumors, abscess (unspecified), hernia
GI = gastrointestinal; GYN = gynecological; UTI = urinary tract infection.

Table 2 - Plain abdominal radiography findings
1: Negative or nonspecific
2: Free air
3: GI tract dilatation
4: GI tract fold/wall thickening
5: Air-fluid level in bowel
6: Small bowel feces sign
7: Excessive stool in colon
8: Hepatomegaly
9: Splenomegaly
10: Gallbladder stone
11: Pneumobilia
12: Urolithiasis
13: urinary bladder distention
14: Obliterated psoas muscle margin
15: Abnormal soft tissue density
16: Abnormal air collection
17: Abnormal calcifications unspecified
18: Ascites
19: Intra-abdominal foreign body
20: Postoperative appearance
21: Extra-abdominal position of GI tract
22: Bone lesion
GI = gastrointestinal.

2.3. Statistical analysis

The case numbers and the percentages of each group of SAR and EAR and their diagnostic relevance were calculated. The case numbers and percentages of each disease under the disease classification whose PAR (SAR or EAR) presented with relevant findings were also calculated. For patients whose PAR showed relevant findings, the number of occurrences of findings were calculated. The relevance between the imaging findings of PAR and clinical diagnosis in the group with SAR were compared with those in the group with EAR. The difference in their diagnostic relevance for various diseases between the groups with SAR and EAR was additionally analyzed. A chi-squared test was performed with SPSS for Windows version 19.0 (IBM Corp., Armonk, NY, USA) for statistical analysis. The significance level of the chi-square test was set at 0.05 (two-tailed) with a 95% confidence interval. Institutional review board approval was obtained before conducting the study.


This study included 1009 patients (males, 525; females, 484) aged 4–99 years (mean age 56.6; median age 58) who presented acute abdomen in the ED. Among these, 668 (66.2%) underwent SAR and 341 (33.8%) underwent EAR. All patients underwent CT scan within 24 hours after their PAR. Among all the patients, there were 820 cases whose CT scans indicated a definite clinical diagnosis (81.3% of the total), of which 542 (66.1%) underwent SAR and 278 (33.9%) underwent EAR. The other 189 cases showed negative CT findings and inconclusive clinical diagnosis; therefore, they were excluded in the statistical analysis. Overall, there was no statistical difference in PAR diagnostic relevance for acute abdomen between the SAR and EAR groups (sensitivity: 43.5% vs 43.9%, p > 0.05), as shown in Table 3. For respective disease, a statistical difference in the diagnostic relevance between SAR and EAR was only found in bowel obstruction. There was no definite statistical difference in any of the other abdominal diseases. For patients whose PAR showed relevant findings, the most frequently seen findings and their possible diagnoses were listed in Table 4.

Table 3 - The case numbers, numbers of those whose PAR showed relevant findings, and the difference between SAR and EAR for each disease
Disease classification PAR SAR EAR p
Total With relevant finding (%) Total With relevant finding (%) Total With relevant finding (%) (SAR vs EAR)
A: GI system 395 206 (52.2) 259 130 (50.2) 136 76 (55.9) NS
A1: Hollow organ perforation 25 15 (60.0) 8 5 (62.5) 17 10 (58.8) NS
A2: Bowel obstruction 126 116 (92.1) 78 68 (87.2) 48 48 (100) 0.010*
A3: Adynamic ileus 22 22 (100) 20 20 (100) 2 2 (100) NS
A4: Appendicitis 81 11 (13.6) 47 5 (10.6) 34 6 (17.6) NS
A5: Diverticulitis 52 3 (5.8) 44 3 (6.8) 8 0 (0.0) NS
A6: Gastritis, peptic ulcer 15 0 (0.0) 10 0 (0.0) 5 0 (0.0) NS
A7: GI cancer 14 6 (42.9) 10 4 (40.0) 4 2 (50.0) NS
A8: Stool impaction 14 13 (92.9) 13 13 (100) 1 0 (0.0) <0.001***
A9: Enteritis/colitis 46 20 (43.5) 29 12 (41.4) 17 8 (47.1) NS
B: Hepatobiliary system 160 47 (29.4) 82 22 (26.8) 78 25 (32.1) NS
B1: Diffuse liver disease 8 4 (50.0) 5 1 (20.0) 3 3 (100) 0.028*
B2: Focal liver lesion 14 3 (21.4) 11 1 (9.1) 3 2 (66.7) 0.031*
B3: Gallbladder or biliary tract disease 138 40 (30.0) 66 20 (30.3) 72 20 (27.8) NS
C: Pancreas 37 2 (5.4) 22 2 (9.1) 15 0 (0.0) NS
D: Urinary system 125 68 (54.4) 108 58 (53.7) 17 10 (58.8) NS
D1: Urolithiasis 81 55 (67.9) 71 47 (66.2) 10 8 (80.0) NS
D2: Urinary tract infection 20 2 (10.0) 17 2 (11.8) 3 0 (0.0) NS
D3: Ureter disease 4 0 (0.0) 4 0 (0.0) 0 0 (0.0) NS
D4: Renal disease 11 5 (45.5) 9 4 (44.4) 2 1 (50.0) NS
D5: Urinary bladder disease 9 6 (66.7) 7 5 (71.4) 2 1 (50.0) NS
E: GYN system 44 14 (31.8) 29 9 (31.0) 15 5 (33.3) NS
G: Others 59 21 (35.6) 42 15 (35.7) 17 6 (35.3) NS
Total 820 358 (43.7) 542 236 (43.5) 278 122 (43.9) NS
*p < 0.05.
***p < 0.001.
EAR = erect abdominal radiograph; GI = gastrointestinal; GYN = gynecological; NS = no significance; PAR = Plain abdominal radiography; SAR = supine abdominal radiograph.

Table 4 - Frequently seen PAR findings and their related diseases
PAR findings Related disease
GI tract dilatation (n = 276)
Gastric/small bowel/colon dilatation (n = 219)
Air-fluid level in bowel (n = 57)
Bowel obstruction, enteritis, ischemic bowel, adynamic ileus, local irritation caused by pancreatitis
Gastric/small bowel/colon wall thickening (n = 21) Ischemia, infectious/inflammatory process, neoplasm
Excessive stool in colon (n = 40) Stool impaction
Extraluminal air (n = 29)
Free air (n = 12)
Abnormal air collection (n = 12)
Pneumobilia (n = 5)
Hollow organ perforation
Cholangitis, postoperative change
Abnormal calcifications (n = 108)
Gallbladder stone (n = 28)
Urolithiasis (n = 66)
Abnormal calcifications unspecified (n = 14)
Infectious/ inflammatory process, neoplasm
Abnormal soft tissue density (n = 94)
Urinary bladder distention (n = 11)
Obliterated psoas muscle margin (n = 3)
Abnormal soft tissue density unspecified (n = 56)
Ascites (n = 24)
Urinary bladder diseases, GYN diseases, neoplasms, abscess, or ascites


Many past studies have indicated that PAR does not help diagnose acute abdomen in EDs.4–6 Others have argued that PAR is only helpful in diagnosing those patients with bowel obstruction or bowel perforation.1–3,7 A meta-analysis in 20207 stated that the sensitivity of PAR for acute abdomen ranged from 30% to 46% with specificity from 75% to 88%, and for suspected bowel obstruction, the range of sensitivity was 48% to 96% with specificity from 50% to 100%. Our study found that among the diseases diagnosed by CT, the overall sensitivity of PAR was 43.7%, while the sensitivity of PAR for bowel obstruction is 92.1%.

In terms of comparing SAR and EAR, two studies9,10 showed that when EAR was added to SAR of acute abdomen, the diagnostic accuracy did not improve significantly. On the other hand, two studies11,12 believe that EAR is very helpful in evaluation of bowel obstruction. There is no clear conclusion about which of EAR or SAR is better. Our study has answered the question: There is no significant difference between SAR and EAR in evaluation of overall acute abdomen.

Regarding gastrointestinal (GI) diseases, PAR was significantly helpful in diagnosing the following diseases (sensitivity of having relevant findings in images ≥50%): hollow organ perforation (HOP), bowel obstruction, adynamic ileus, and stool impaction. In general, in patients having bowel dilatation or free air in their peritoneal cavity, PAR exhibits a satisfactory diagnostic effect. The conditions in which SAR and EAR exhibited significantly different diagnostic relevance were bowel obstruction and stool impaction.

For diagnosing free air, a study13 has shown that the sensitivity of SAR on HOP is 80.4%, which is higher than that of 62.5% in this study. We also unexpectedly noticed that there was no statistical difference in the sensitivities between EAR and SAR in terms of free air detection (Fig. 1).

Fig. 1:
The SAR (A) of a 67-year-old female with peptic ulcer perforation showed the dolphin sign (dotted arrows), the hyperlucent liver sign (asterisk), and the inverted V sign (solid arrows), demonstrating the presence of free air, which was confirmed by abdominal CT (hollow arrows in B). The EAR (C) of a 58-year-old male with peptic ulcer perforation demonstrated bilateral subphrenic free air (solid arrows), which was confirmed by abdominal CT (hollow arrows in D). CT = computed tomography; EAR = erect abdominal radiographs; SAR = supine abdominal radiographs.

Regarding bowel obstruction, a meta-analysis in 20207 stated that the sensitivity of PAR for suspected bowel obstruction ranged from 48% to 96% with specificity from 50% to 100%. Our study showed that the sensitivity of PAR was 92.1%. The diagnostic sensitivities of EAR and SAR were 100% and 87.2%, respectively (p = 0.010). By further analyzing, the cases of intestinal obstruction that SAR could not detect, we found that these patients’ bowels were almost completely filled with fluid, which led to a failure in their radiographic visibility. In contrast, in patients who underwent EAR, the fluid in the obstructed bowel had moved to the dependent part, which led to a radiographically notable air-fluid level and thereby identifiable bowel dilation in the abdomen, resulting in a more favorable diagnostic effect (Fig. 2). Two studies11,12 also mentioned the importance of the air-fluid levels in EAR for diagnosing small bowel obstruction and distinguishing its severity.

Fig. 2:
The SAR (A) and the coronal reformatted image of abdominal CT (B) of a 53-year-old female with small bowel obstruction. The dilated small bowel filled with fluid demonstrated on CT (dotted arrows) cannot be observed on the SAR except mild localized dilatation of jejunum in left upper abdomen (solid arrows). The EAR (C) and the coronal reformatted image of abdominal CT (D) of a 27-year-old male with small bowel obstruction. The dilated jejunum loops with intraluminal air-fluid level could apparently be identified by EAR in the left upper abdomen (arrows). CT = computed tomography; EAR = erect abdominal radiographs; SAR = supine abdominal radiographs.

Regarding stool impaction, SAR showed high diagnostic sensitivity (100% in our study). On the other hand, EAR may miss the stool in rectum because it does not cover the lowermost part of the pelvic cavity. The statistical difference between EAR and SAR may fall short of a clinical significance due to the small sample size.

Regarding liver and gallbladder diseases, PAR was found to be only significantly helpful in diagnosing diffuse liver disease (sensitivity ≥50%).

For diagnostic relevance in diffuse and focal liver disease, there was a statistical difference between EAR and SAR; however, given the small sample size of this study, this finding may fall short of a clinical significance. On further analysis of each cases, we found that PAR could diagnose liver cirrhosis mainly by the detection of ascites (Fig. 3). For focal liver lesion, PAR is only helpful in air-containing liver abscesses. For other diseases, such as metastasis, hepatocellular carcinoma, and liver abscess without air, PAR has no diagnostic value.

Fig. 3:
Increased soft tissue densities in bilateral paracolic gutters with medial displacement of the colon (arrows) in the SAR (A) of a 66-year-old female indicated the presence of the ascites, as shown in the coronal reformatted image of abdominal CT (arrows in B). The ascites is caused by the underlying liver cirrhosis. CT = computed tomography; SAR = supine abdominal radiographs.

The diagnostic relevance of PAR on pancreatic diseases was below 50%, and there was no difference in terms of diagnostic relevance between SAR and EAR.

For the diseases of the urinary system, PAR was found to be helpful in diagnosing urolithiasis and urinary bladder problems (sensitivity ≥50%), but the diagnosis of bladder problem can only be made when the patients had a distended urinary bladder. In diagnosis of all urinary diseases, no statistical difference was found between SAR and EAR.

The diagnostic relevance of PAR with regards to gynecological (GYN)–related diseases was below 50%, and there was no statistical difference in diagnostic relevance between SAR and EAR, which was unexpected. In our expectation, SAR should have a higher diagnostic effect than EAR because SAR includes the whole pelvic cavity; however, we did not note this difference in diagnosis by our study. If a GYN lesion can be detected by PAR (which means the lesion is dense or large enough), usually the field covering by the EAR is sufficient for lesion detection in patients with ordinary body size (Fig. 4).

Fig. 4:
The SAR (A) and the coronal reformatted image of abdominal CT (B) of a 75-year-old female with pyometra. The oval soft tissue density (solid arrows) with abnormal focal air collection (dotted arrows) was confirmed to be pyometra by abdominal CT (arrows). The EAR (C) and the coronal reformatted image of abdominal CT (D) of a 72-year-old female with tubo-ovarian abscess. The abnormal soft tissue density in the pelvic cavity (arrow in C) and its indentation to the rectal air seen on EAR were consistent with the CT finding of tubo-ovarian abscess (arrow in D).CT = computed tomography; EAR = erect abdominal radiographs; SAR = supine abdominal radiographs.

PAR is not adequately sensitive for diagnosing many diseases, but the presence of certain findings can help in detecting abnormalities. Some frequently encountered findings are listed in Table 4. Paying particular attention to these findings is essential for radiologists and emergent physicians in decision making at ED:

  • • GI tract dilatation: This often suggest bowel obstruction, but other causes include enteritis, adynamic ileus, and local irritation caused by pancreatitis.
  • • GI tract wall thickening: This may relate to ischemia, infectious/ inflammatory diseases of GI tract or even the GI tract neoplasms.
  • • Extraluminal air: This may indicate HOP (free air), the existence of abscess (localized mottled air), or pneumobilia (branching air in liver).
  • • Abnormal calcification: This includes gallstones, urolithiasis, other calcifications in the inflammatory diseases (Fig. 5), chronic granuloma, organized hematoma, foreign body (eg, fish bone) or calcified neoplasm.
  • • Abnormal soft tissue density: This may indicate urinary bladder distention, GYN diseases (Fig. 6), neoplasms (GI, renal, biliary) (Fig. 7), abscess, or ascites.
Fig. 5:
The SAR (A) and the coronal reformatted image of abdominal CT (B) of a 51-year-old male under long-term peritoneal dialysis with encapsulating peritoneal sclerosis. Diffuse curvilinear calcifications in the whole abdomen (arrows) seen on SAR were confirmed to be the peritoneal calcifications by abdominal CT (arrows). CT = computed tomography; SAR = supine abdominal radiographs.
Fig. 6:
The SAR (A) of a 39-year-old female demonstrated soft tissue density (arrows) in the pelvic cavity, which was confirmed to be an ovarian cystic tumor by abdominal CT (arrows in B). CT = computed tomography; SAR = supine abdominal radiographs.
Fig. 7:
The SAR (A) of a 63-year-old male demonstrated soft tissue densities (arrows) in bilateral flank regions, which were confirmed to be bilateral polycystic kidneys by abdominal CT (arrows in B). CT = computed tomography; SAR = supine abdominal radiographs.

In comparison of the frequently used image modality for acute abdomen (PAR, ultrasound [US], CT), several studies had discussed the pros and cons of each modality.8,14,15 CT has the most accurate and reproducible diagnosis to acute abdomen, but it has higher cost, lower availability, and high radiation exposure. On the contrary, US and PAR have lower diagnostic sensitivity but lower cost and higher accessibility. PAR has low radiation dose and US has no radiation dose. Because PAR has the lowest cost and highest availability in Taiwan Health Care System, PAR is often the first line imaging evaluation of acute abdomen at ED, which could help the emergency physicians for further decision making. PAR is most valuable in diagnosing bowel obstruction, HOP, urolithiasis, and foreign body, but low sensitivity and specificity for other causes of acute abdomen.

This study has some limitations. The first limitation is the selection bias. All the patients in this study underwent a CT scan following their PAR (which could possibly indicate a more serious condition), and the choice of SAR or EAR depended on the doctors’ preference at the ED. Second, the sample size was small for several diseases. Finally, there may be difference in interpretation between radiologists and emergency physicians.

In conclusion, among the cases with definite clinical diagnosis by CT and clinical data, 43.7% showed relevant findings in PAR. PAR is more helpful in diagnosing the following diseases/conditions: HOP, bowel obstruction, adynamic ileus, stool impaction, liver cirrhosis with ascites, urolithiasis, and urinary bladder distention. PAR is not adequately sensitive for diagnosing many diseases, but the following findings are helpful and should be especially monitored: GI tract dilatation and wall thickening, extraluminal air, abnormal calcifications, and abnormal soft tissue density. There is no significant difference between SAR and EAR in evaluation of overall acute abdomen. However, EAR does have a diagnostic advantage over SAR for the patients with suspected bowel obstruction. Thus, if bowel obstruction is clinically suspected in ED, EAR is strongly advised for the emergency physicians for further imaging diagnosis.


We wish to acknowledge the help of doctor Rivero in English editing.


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Acute abdomen; Bowel obstruction; Plain abdominal radiograph

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