OBJECTIVE: The purposes of this study were to determine the accuracy of abdominal radiography in the detection of acute small-bowel obstruction (SBO), to assess the role of reviewer experience, and to evaluate individual radiographic signs of SBO. MATERIALS AND METHODS: A retrospective study was performed in which the subjects were 90 patients with suspected SBO who underwent CT and abdominal radiography within 48 hours of each other. The patients were enrolled from June 1, 2003, to February 2004. Twenty-nine of the patients had proven SBO. Hard-copy radiographs were reviewed by three groups of radiologists: senior staff, junior staff, and second-year radiology residents. Each reviewer evaluated the quality of the radiographs, patient position for acquisition of the radiographs, and whether SBO was present. The reviewers rated their confidence on a five-point scale and recorded the presence or absence of specific radiographic signs of SBO. Chi-square tests were used to compare the three groups. A statistically significant finding was considered p < 0.05. Receiver operating characteristic (ROC) curves were fit with a 10-point confidence scale. RESULTS: The sensitivity for SBO among the six reviewers ranged from 59% to 93%. The senior staff members were significantly more accurate. The mean sensitivity, specificity, and accuracy for all six reviewers were 82%, 83%, and 83%, respectively. Three radiographic signs were highly significant (p < 0.001): two or more air-fluid levels, air-fluid levels wider than 2.5 cm, and air-fluid levels differing more than 5 mm from one another in the same loop of small bowel. ROC analysis showed that senior staff is significantly more accurate than the other groups in the detection of acute SBO. CONCLUSION: Our results confirmed that abdominal radiographs are accurate in the detection of acute SBO, that more-experienced radiologists are more accurate than less-experienced reviewers in the evaluation of abdominal radiographs, and that three types of air-fluid levels are highly predictive of the presence of SBO.