Incidental Findings on Abdominal X-Rays—Worry, Watch, or Leave Alone?

Abdominal radiographs remain a widely used first-line investigation for both acute and chronic abdominal conditions. In routine clinical practice, they often reveal findings unrelated to the patient’s presenting complaint. While many of these are benign or reflect normal anatomical variation, they can sometimes resemble significant disease and lead to unnecessary investigations, patient anxiety, and added healthcare costs. This review presents a practical approach to interpreting such incidental findings, using a simple classification based on their radiographic appearance. These include calcifications, gas patterns, soft tissue and organ-related findings, as well as foreign bodies and procedure-related materials. Common examples, such as phleboliths, costal cartilage calcifications, gallstones, and vascular calcifications, are discussed, along with important mimics, such as pseudopneumoperitoneum. Normal variants, including Riedel’s lobe, renal anomalies, and bowel malposition, are also described. Attention is given to recognising typical imaging appearances and avoiding common sources of error in interpretation. The continued importance of abdominal radiography in settings with limited access to advanced imaging is also acknowledged. Selected radiographic examples are included to support pattern recognition and day-to-day clinical application. A clear, structured approach allows incidental findings to be interpreted with greater confidence and guides appropriate clinical decisions. This reduces unnecessary imaging, limits patient anxiety, and supports more effective and focused patient care.