Pediatric abdomen (PA erect view)
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The PA erect abdominal radiograph is the standard view for assessing air-fluid levels and free air in the pediatric abdomen. This view may be taken alongside the AP supine and lateral decubitus views. As radiation protection is an essential consideration in pediatrics, some departmental protocols may only perform one view (either the PA erect or AP supine view) depending on the clinical indications 1.
This view is often performed supplementary to the supine radiograph. It demonstrates air-fluid levels in pathologies such as bowel obstruction or pneumoperitoneum.
patient is standing facing the upright bucky with no rotation of the shoulders and hips
remove any radiopaque items (e.g. ECG dots, diaper, shiny decorative clothing)
take the x-ray in full inspiration
hands are placed by the patients side and away from the abdomen
approximately 2 cm above the iliac crests at the midsagittal plane
laterally to the lateral abdominal wall
superior to the diaphragm
inferior to the inferior pubic rami
it is not advised to collimate too tightly laterally in case of missing bowel loops and/or organs 2
will vary depending on the child's body habitus
if patient thickness is above 10 cm, use of a grid is advisable 3
Image technical evaluation
lateral abdominal wall
inferior pubic rami inferiorly
must include the diaphragm superiorly
the abdomen should be free from rotation with symmetry of the:
iliac crests (middle)
obturator foramen (inferior)
no blurring of the bowel gas due to respiratory motion
sometimes to reduce the child's anxiety, it may be necessary to perform this view anteroposterior; children may feel more comfortable being able to see their parent (instead of facing the bucky)
pediatric patients may feel uncomfortable when bony landmarks are felt for, therefore an appropriate explanation to the patient beforehand is ideal for improving patient comfort
to achieve sufficient inspiration, using child-appropriate language will be useful
e.g. 'breathe in, as if you are about to go diving underwater!', 'breathe in, as if you are about to blow out a birthday candle!'
It is important for the image to be free from movement artefact and rotation to avoid repeated x-rays.
it may be necessary for the parent or radiographer to stand with the patient or hold them in position
sometimes it is only necessary to keep the child's arms away from the abdominal area; in these cases, asking the child to hold onto something to their side (e.g. toy, mother's hand, pole) may be useful.
techniques will vary based on the department
- 1. Kwon H, Jung JY. Effectiveness of a radiation reduction campaign targeting children with gastrointestinal symptoms in a pediatric emergency department. (2017) Medicine. 96 (3): e5907. doi:10.1097/MD.0000000000005907 - Pubmed
- 2. Maryann Hardy, Stephen Boynes. Paediatric Radiography. (2003) ISBN: 9780632056316
- 3. A paediatric X‐ray exposure chart. (2014) Journal of Medical Radiation Sciences. 61 (3): 191. doi:10.1002/jmrs.56 - Pubmed