28-y-o female with rlq pain, nausea, low-grade fever, wbc zissin r, head of ct meir medical center
TRANSCRIPT
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28-y-o female with RLQ pain, nausea, low-grade fever, WBC
Zissin R, Head of CT
Meir Medical center
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Ac abd. pain - a diagnostic challenge
RLQ - DD• Acute appendicitis (AA)• Epiploic appendagiitis / Omental
infarction - non-surgical mimicker of AA
• GI related: Crohn’s disease (CD), Rt-sided diverticulitis, Inf. enteritis (Yersinia), Perforated cecal ca
• Mesenteric lymphadenitis • Acute GUT pathology:
Ac Pyelonephritis Renal colic
Gynecologic etiology
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• The most common cause of RLQ pain and 28% of ac. abdominal pain
• Treated surgically !!! Perforation rate ~ 20%, (more common <9y and >60y)
• The most common emergency in children and pregnant women.
• 6% chance during lifetime for each person• Classic history: periumbilical pain
migrating to RLQ only in 50%, atypical presentation mainly children, women 20-40y, elderly
Acute appendicitis
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Imaging modalities in acute abdomen
• Plain abdominal films: supine & erect – LIMITED INDICATIONS
• US – non invasive, no radiation• CT – semi invasive, radiation ! • Contrast media studies: imaging of
bowel only (barium, gastrografin) – radiation
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Plain abdominal films - Indications:
1. Detection of free air: Common causes: perforation of hollow viscus, post-operation, peritoneal dialysis
2. Gas (air) distribution: intestinal obstruction – dilated loops, air/fluid levelsdisplaced loops – a secondary sign of mass effect
3. Detection of pathological calcificationsMost common: calculi (20% of gallstones; 80% urolithiasis), vascular, intra-abdominal radiopaque foreign bodies
• Usually insensitive in AA but can suggest an alternative diagnosis
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Ultrasound
• Advantages: - Lack of radiation, non-expensive and availability
- Aids in diagnosing alternative causes• Disadvantages :
- Operator dependent !! - Sen 85-90%, Spec 92-96%,
As NPP is too low CT• Mainly in children & childbearing age
women
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• Aperistaltic, noncompressible, blind-ended, fluid-filled, tubular structure with distinct wall layers arising from the cecal base
• Outer diameter > 6 mm • Appendicolith • Periappendiceal fluid
collection
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Computed Tomography - CT
• Radiation! (excludes pregnancy, consider benefit versus radiation risk)
• Semi invasive exam. – IV injection of CM
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19721972
-זהו מכשיר ה-זהו מכשיר הCTCT 19721972 הראשון בעולם משנת הראשון בעולם משנת : : ,ניתן היה לסרוק איתו רק את המח, ניתן היה לסרוק איתו רק את המח – רזולוציה נמוכהרזולוציה נמוכה,, דקות דקות 55זמן סריקת תמונה – זמן סריקת תמונה
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20052005
התפתחות בחומרה ותוכנההתפתחות בחומרה ותוכנה -כיום מכשירי ה- כיום מכשירי הCTCT מסוגלים לסרוק את כל הגוף מסוגלים לסרוק את כל הגוף
תוך מספר שניות, במהירות גבוהה וברזולוציה תוך מספר שניות, במהירות גבוהה וברזולוציה מצוינת מצוינת
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Type of CT examinations
• Diagnostic study• Interventional
procedure:- F. N. A (fine needle aspiration)
- Diagnostic puncture (bacteriological evaluation)
- Drainage of abscess, fluid collections
• Screening - Virtual colonoscopy- Cardiac CT- Low dose chest CT
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Radiation on CT
• Abd CT (~ 500 CXR)(BE-350 CXR, Upper GIT-150 CXR)
• Typical effective dose 10mSv (time provide for equivalent effective dose from background radiation – 3.3y)
• Malignancy risk: 5%/1Sv 1 to 2000
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Technical notes – Abdominal CT
• Optimal technique: Oral+IV Contrast Media - Oral (for maximum GIT opacification)
-IV (semi-invasive) ~120cc 2,5-4cc/sec
Optional: - Rectal - Cysto CT • Delayed scan as necessary
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5 tissues
densities
Everything should be made as simple as possible, but not simpler.
Albert Einshtein
air ca++
fluidfat soft tissue
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Acute Appendicitis• CT diagnosis depends on combined
appendicular and periappendicular signsCT sens. 94-97%; spec. 97-99%; accuracy 93-98%; NPV & PPV 94-98%
• Appendicular signs: distended (>6mm), unopacified thickened wall (>2mm) app. appendicolith
• Periappendicular signs: pericecal fat strandingscecal mural thickening-“arrowhead”
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Periap. Abscess
Conservative therapy + P.C. abscess drainage > 3cm
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Epiploic appendagitis
• Torsion of EA-infarction and sec. inflammatory changes
• Clinical presentation – L/RLQ signs of peritonitis, mimicking ac. diverticulitis/ appendicitis
• Benign, self-limited course
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An oval-shaped fat density with a rim of soft-tissue density juxtaposed to the serosal colonic surface
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Crohn’s Disease (CD) - terminal ileitis
• Diarrhea- most common presentation• Gradual, progressive RLQ pain - 45-95%• Role of CT:
In known cases - for detection of:- complications (abscess, enterovesical fistula, perianal disease)- alternative diagnosis (look for the appendix)
* CD may be first diagnosed on CT in pts. presented with acute abdomen – RLQ pain
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CT in CD
• Direct imaging of the bowel wall (normal <3mm)
• Secondary signs in surrounding mesentery:-mesenteric vascular engorgement-fluid within the mesenteric root-peri-bowel fat stranding, ”creeping fat”-mesenteric adenopathy
• To guide P.C. interventional procedures
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Stones and Obstruction
• Non contrast scan• Determine the level
of obstruction: calculi, and associated parenchymal changes
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GOOD LUCKGOOD LUCK