Download - Acute abdomen
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Acute Abdomen Radiological
Approach
Acute Abdomen Radiological
Approach
Prof Dr. Haney A Sami
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Acute Abdomen
Bowel Gastric Small Large
Visceral GB Pancreas Kidney
Vascular Aorta Mesenteric
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DefinitionAcute abdominal pain Is Pain unrelated to trauma
It is one of the most common conditions in patients presenting to the hospital emergency department.
It is a syndrome characterized by the sudden onset of severe abdominal pain, requiring early medical or surgical treatment
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Acute appendicitis Acute cholecystitis Bowel obstruction Urinary colic Perforated peptic ulcer Acute pancreatitis Acute diventricular disease
Causes
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Imaging techniques
Clinical assessment is often difficult and laboratory investigations are often non specific.
Plain X-ray
Ultra sonography
CT examinations
Contrast studies
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Imaging techniques
Plain radiographs of the abdomen, is of significant diagnostic limitations, It is the initial radiological approach.
Two views are usually taken a
supine and an erect.
If the patient is unable to stand, a decubitus view
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CT is clearly superior to plain radiography :- Confirming the diagnosis (site and level) Revealing the cause of bowel obstruction Detecting pneumoperitoneum Identifying ureteric stones. Examining solid organs.
The major obstacle to replace plain abdominal radiography with unenhanced CT appears to be its cost, availability, and radiation dose.
Value of CT
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Common causes of acute pain in an abdominal quadrant
Right upper quadrant:
Acute calculous / non calculous Cholecystitis.
Amebic liver abscess. Spontaneous rupture of hepatic
neoplasm. Myocardial infarction.
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Common causes of acute pain in an abdominal quadrant
Left upper quadrant:
Splenic infarction.
Splenic abscess.
Gastritis.
Gastric ulcer.
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Common causes of acute pain in an abdominal quadrant
Right lower quadrant:
Acute appendicitis. Acute terminal ileitis. Acute typhlitis.
Pelvic inflammatory disease.
Complications of overian cyst.Endometriosis.Ectopic pregnancy.
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Common causes of acute pain in an abdominal quadrant
Left lower quadrant:
Diverticulitis. Epiploic appendagitis.
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PancreatitisUlcer
Diverticulitis
Cholecystitis
Appendicitis
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What to Examine by Plain X-ray
Gas pattern Extraluminal air Soft tissue masses Calcifications Skeletal pathology
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Key to densities in AXRs
● Black—gas
● White—calcified structures
● Gray—soft tissues
● Darker gray—fat
● Intense white—metallic objects
The clarity of outlines of structures depends, on the differences between these densities.
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Normal Gas Pattern
Stomach Always
Small Bowel Two or three loops of non-distended bowel Normal diameter = 2.5 cm
Large Bowel In rectum or sigmoid – almost always
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Gas in stomach
Gas in a few loops of small bowel
Gas in rectum or sigmoid
Normal Gas Pattern
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Normal Fluid Levels
Stomach Always (except supine film)
Small Bowel Two or three levels possible
Large Bowel None normally
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Erect Abdomen
Always air/fluid level in stomach
A few air/fluid levels in small bowel
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Large vs. Small Bowel
Large Bowel Peripheral Haustral markings don't extend
from wall to wall
Small Bowel Central Valvulae extend across lumen
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Haustra films Faecal mottling
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Complete AbdomenObstruction Series
Supine Erect or left decubitus Chest - erect or supine Prone or lateral rectum
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Complete AbdomenSupine
Looking for Scout film for gas
pattern Calcifications Soft tissue masses
Substitute – none
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Complete AbdomenErect
Looking for Free air Air-fluid levels
Substitute – left lateral decubitus
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Complete AbdomenErect Chest
Looking for Free air Pneumonia at bases Pleural effusions
Substitute – supine chest
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Complete AbdomenProne
Looking for Gas in rectum/sigmoid Gas in ascending and
descending colon
Substitute – lateral rectum
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Abnormal Gas Patterns
1. Functional Ileus Localized (Sentinel Loops) Generalized adynamic ileus
2. Mechanical Obstruction SBO LBO
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Sentinel Loops
Supine Prone
One or two persistently dilated loops of large or small bowel
Gas in rectum or sigmoid
Localized Ileus Key Features
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PancreatitisUlcer
Diverticulitis
Cholecystitis
Appendicitis
Sentinel LoopsLocalized Ileus
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Localized IleusPitfalls
May resemble early mechanical SBO
Clinical course Get follow-up
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Gas in dilated small bowel and large bowel to rectum Long air-fluid levels Only post-op patients have generalized ileus Other causes:-
Peritonitis Hypokalemia Metabolic disorder as hypothyroidism Vascular occlusion
Generalized IleusKey Features
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Generalized Adynamic Ileus
Supine Erect
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Is It An Ileus?
Is the patient immediately post-op? Are the bowel sounds absent or hypoactive?
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Mechanical SBOKey Features
Dilated small bowel Fighting loops Little gas in colon,
especially rectum Key: disproportionate
dilatation of SB
SBO
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Mechanical SBOCauses
Adhesions Hernia* Volvulus Gallstone ileus* Intussusception
*Cause may be visible on plain film
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Mechanical SBOPitfalls
Early SBO may resemble localized ileus -get F/O
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Differentiation between SBO & ILEUS
Obstruction transition of dilated loops Degree of dilatation is greater with
obstruction Spacing between the bowel loops
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Mechanical LBOKey Features
Dilated colon to point of obstruction Little or no air in rectum/sigmoid Little or no gas in small bowel, if…
Ileocecal valve remains competent
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LBO
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LBO
Supine
Prone
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Mechanical LBOCauses
Tumor Volvulus Hernia Diverticulitis Intussusception
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Mechanical LBOPitfalls
Incompetent ileocecal valve Large bowel decompresses into small bowel May look like SBO Get BE or follow-up
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Carcinoma of Sigmoid – LBO – Decompressed into SB
ProneSupine
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The goals of imaging in a patient with suspected intestinal obstruction have been defined and are as follows:
1. To confirm that it is a true obstruction and to differentiate it from an ileus.
2. To determine the level of obstruction.
3. To determine the cause of the obstruction.
4. To look for findings of strangulation.
5. To allow a good management either medically or surgically by laparoscopy or laparoscopy).
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Air in biliary
tree
Gallstone Gallstone Ileus
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Post-op C-section Adynamic Ileus
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Mesenteric Occlusion
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Abnormal Gas PatternsIleus and Obstruction
Localized ileus Generalized ileus Mechanical SBO Mechanical LBO
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Conditions causing extraluminalair
Perforated abdominal viscus Abscesses (subphrenic and other) Biliary fistula Cholangitis Pneumatosis coli Necrotising enterocolitis Portal pyaemia
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Chilaiditi’s syndrome
Chilaiditi’s syndrome is an important normal variant on the erect chest radiograph,
which must be distinguished from pathological free gas under the diaphragm. (apparent, as haustra are seen within the gas filled structure). This gas is still contained in the bowel loop.
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Extraluminal AirFree Intraperitoneal Air
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Signs of Free Air
Air beneath diaphragm Both sides of bowel wall Falciform ligament sign In the biliary system
Crescent sign
Free Intraperitoneal Air
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Free AirCauses
Rupture of a hollow viscus Perforated ulcer Perforated diverticulitis Perforated carcinoma Trauma or instrumentation
Post-op 5–7 days NOT perforated appendix
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Extraperitoneal Air
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Soft Tissue Masses
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Soft Tissue Masses
Hepatosplenomegaly Plain films poor for judging liver size
Tumor or cyst Bowel displacement
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Splenomegaly
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Myomatous Uterus
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Bladder Outlet Obstruction – pre- and post- cath
Hours later
Hours later
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Right Renal Cyst
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RLQ Abscess
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AbdominalCalcifications
AbdominalCalcifications
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Normal structures thatcalcify
● Costal cartilage
● Mesenteric lymph nodes
● Pelvic vein clots (phlebolith)
● Prostate gland
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Abnormal structures thatcontain calcium
Calcium indicates pathology
● Pancreas
● Renal parenchymal tissue
● Blood vessels and vascular aneurysms
● Gallbladder fibroids (leiomyoma)
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Abnormal structures thatcontain calcium
Calcium is pathology● Biliary calculi● Renal calculi● Appendicolith● Bladder calculi● Teratoma
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Abdominal CalcificationsPatterns
Rimlike Linear or track-like Lamellar Cloudlike
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Renal Cyst Gallbladder Wall
Rimlike Calcification Wall of a hollow viscus
Cysts Renal cyst
Aneurysms Aortic aneurysm
Saccular organs e.g. GB Porcelain Gallbladder
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Atherosclerosis Calcification Vas Deferens
Linear or Track-like Walls of a tube
Ureters Arterial walls
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Stone in UreterocoeleStaghorn Calculi
Lamellar or Laminar Formed in lumen of a hollow viscus
Renal stones Gallstones Bladder stones
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Nephrocalcinosis Myomatous Uterus
Cloudlike, Amorphous, Popcorn
Formed in a solid organ or tumor Leiomyomas of uterus Ovarian cystadenomas
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Visceral Inflammation
Colitis
Appendicitis
Diverticulitis
Bowel Inflammation
Cholecystitis
Pancreatitis
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Inflammation- Cholecystitis Acute cholecystitis is inflammation of the gallbladder
usually from impaction of a gallstone within the cystic or common bile duct.
Ultrasound is the preferred imaging method to confirm cholecystitis in the appropriate clinical setting.
CT findings of cholecystitis include:
1. Cholelithiasis2. Gallbladder wall thickening 3. Pericholecystic fluid.
Complicated cases may reveal perforation or hepatic abscess formation.
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Acute calculous cholecystitis:
Calculus obstructs the cystic duct
The trapped concentrated bile irritates the gallbladder wall, causing increased secretion, which in turn leads to distention and edema of the wall.
Rising intra luminal pressure compresses the vessels, resulting in thrombosis, ischemia, and subsequent necrosis and perforation of the wall.
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Thickening of gallbladder wall Cholelithiasis.
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Pancreatitis
Acute pancreatitis is most often secondary to alcohol abuse or gallstone impaction in the distal common bile duct.
Other causes include trauma, cryptogenic, tumor, infection, hyperlipidemia, and ERCP.
CT Findings typical of pancreatitis include:
1. An enlarged pancreas with infiltration of the surrounding fat2. Peripancreatic fluid collections can often be seen3. Pseudocysts, (encapsulated fluid collections containing pancreatic secretions, are later complications of pancreatitis)
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Notice the peripancreatic stranding (bars) as well as the fluid thickening of the interfascial space
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A common complication of pancreatitis is the development of pancreatic necrosis.
Lack of gland enhancement following IV contrast administration is diagnostic. When over half the pancreas becomes necrosed, the mortality rate may reach as high as 30%.
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Pancreatic necrosis
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Pancreatic pseudocyst
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Appendicitis
Right lower quadrant pain, fever and leukocytosis are the classical clinical findings.
CT and US are being used more often to confirm clinical suspicions and reduce the number of unnecessary laporotomies.
General CT findings for acute appendicitis include:1. Dilated appendix greater than 6 mm or visualization of an appendicolith with an appendix of any size 2. Peri-appendicial fat stranding
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This image of an acute abdomen (arrow) displaysperiappendicial stranding and dilattion of its terminal portion.
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For comparison, this image of a normal appendix can be visualized at the ileocecal junction. Also notethe fat ventralcontaining heria
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Inflammation- Colitis
Colitis, or inflammation of the colon, is a frequent cause of abdominal pain.
Specific entities which produce inflammatory thickening of the colon include:-
Diverticulitis, inflammatory bowel disease, pseudomembranous colitis, and other
bacterial infections ( i.e. typhlitis).
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This example of colitis shows thickening of the colonand pericolonic stranding typical of inflammation.
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Thickening of sigmoid colon due to pseudomembranous colitis
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A case of diverticulitis showing a thickened sigmoid colon and a diverticulum
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Diverticulitis
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Distal ureteral stone lead ing to righthyrdronephrosis in above image
Ureteral junctional stone
Renal Colic
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Renal stone right sided hydronephrosis
Renal Colic
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Aortic aneurysms
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Case give a diagnosis
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The End