imaging in pain abdomen
TRANSCRIPT
Imaging in Pain Abdomen
Dr.Runal Shah3rd year Resident,
Masters in Emergency MedicineKDAH.
Introduction
Acute Abdomen : Clinical syndrome characterized by
the sudden onset of severe abdominal pain requiring emergency medical or surgical treatment.
Need for immediate surgical exploration can be identified by history and physical examination.
Establishing an accurate working diagnosis is often difficult because the clinical presentation of many entities overlap and physical and laboratory examinations are often non-specific.
8 common causes for 90% patients –
1) Acute Appendicitis2) Acute Cholecystitis3) Acute Pancreatitis4) Small Bowel Obstruction5) Acute Gynecological diseases6) Renal Colic7) Perforated peptic ulcer8) Acute Diverticulitis
Objectives Cases Scenarios
Abdominal quadrants
Imaging modalities
Case 1 67/ Male, pain in abdomen with bloating & nausea since 3
days.
Past h/o Ca.GB operated by Open cholecystectomy 7 years ago
O/E : Abd distended, Tenderness diffuse, Tympanic on percussion, Bowel sounds Not heard !
Case 2 30/ Female, pain in lower abdomen with per vaginal spotting,
? last period 15 days ago
H/O – i-pill taken 1 month ago.
O/E – Suprapubic tenderness, forniceal tenderness on PV
Case 3 72/ Female, pain in abdomen since 2 days
Past H/O – Chronic Afib on Amiodarone, HT on Telmisartan, DM on OHAs
O/E – Soft, diffuse abdominal tenderness with voluntary guarding, Bowel sounds sluggish
Abdominal Quadrants Right Upper Quadrant
Acute cholecystitis Choledocholithiasis Pancreatitis
Liver Abscess Hepatitis
Cecal diverticulitis Retrocecal appendicitis
Peptic ulcer disease Pneumonia (RLL) / PE
Left Upper Quadrant Splenic infarction Splenic abscess Sickle cell disease
Gastritis Gastric ulcer
Pneumonia (LLL) / PE
Abdominal Quadrants Right Lower Quadrant
Appendicitis Diverticulitis Mesenteric adenitis
Inguinal hernia (incarcerated/strangulated)
Testicular Torsion
Ureteric Colic
Ovarian torsion Ectopic Pregnancy Ovarian cyst (ruptured)
Left Lower Quadrant Diverticulitis (Sigmoid) Ischemic Colitis Regional Enteritis
Inguinal hernia (incarcerated/strangulated)
Testicular Torsion
Ureteric Colic
Ovarian torsion Ectopic Pregnancy Ovarian cyst (ruptured)
Abdominal Quadrants Diffuse Pain
Aortic Aneurysm (Leaking / Ruptured)
Aortic Dissection
Bowel Obstruction Volvulus Perforated bowel Acute Gastro-enteritis Mesenteric Ischemia Peritonitis
Pancreatitis
Metabolic causes Diabetic Keto Acidosis Alcoholic Keto Acidosis Uremia Addisonian crisis
Sickle cell anemia
X Ray Abdomen Supine vs. Erect Supine – Dilated bowel loops Erect – Air under diaphragm (Sn~30%), air-fluid levels
+ CXR to add To include inguinal region – to look for incarcerated hernia
To screen for Obstruction Severe constipation Sigmoid volvulus Perforation of bowel
X Ray Abdomen
String of pearls
X Ray Abdomen
Air under diaphragm – 80% Sensitive for perforation – in an erect film
X Ray Abdomen vs. Chest
X Ray Abdomen
• Coffee bean sign
Sigmoid Volvulus
Ultrasonography For RUQ pain
(Hepatobiliary)
Population in whom radiation exposure is major concern –
Children Women of child bearing age
group.
Pros : Dynamic Real time imaging Readily available in ER
Cons : Operator dependent Need for a proper acoustic
window Disturbance by gas, bone
and obesity ed time consumption
Ultrasonography
Gall stones with acoustic shadow
There is a thin layer of pericholecysticfluid (arrow), a sign of acute cholecystitis.
Ultrasonography
UltrasonographyWomen with lower abdominal pain ± PV bleed &UPT Negative heralds strong suspicion of Hemorrhagic Ovarian cyst – corpus luteal or functional cyst with free fluid in pelvis.
Ultrasonography AAA (Abdominal Aortic Aneurysm)
Transverse image Saggital image
Ultrasonography Renal calculi
Young children and Women of child bearing age.
Kidneys and Bladder (VUJ) are visualized well. Kidney – Stones : filling defects, Pyonephrosis, Hydronephrosis Bladder – Debris : cystitis changes
Ureteric stones are poorly localized as obscured by bowel shadows..!! CT should be done.
Ultrasonography Bedside USG
For Bladder screening in acute retention of urine
FAST (Focused Abdominal Sonography in Trauma)
CT Scan CT scan is a sensitive and specific tool in acute abdomen. Radiation dose is 10x of plain abdomen X ray.
Non contrast CT is the diagnostic modality of choice for kidney and ureteric calculi.
IV contrast CT provides superior visualization of bowel mucosa, visceral organs and vascular structures.
It can identify small and large bowel obstruction and the transition point.
It is the initial test of choice for suspected abdominal aortic aneurysm rupture or mesenteric ischemia.
CT Scan Contrast scan has the risk of Nephrotoxicity and Allergic
reactions.
If the S.Creatinine is >1.5 or the GFR is <60, the use of IV contrast is generally not recommended except in life threatening situations.
Patients receiving IV contrast should be hydrated with 1 to 2 L of normal saline as long as there are no contraindications to vigorous hydration.
Adjunct Laboratory Tests CBC Random Blood Sugar
Metabolic profile – Electrolytes Serum Creatinine ±
BUN Venous Blood Gas
Amylase & Lipase
Liver function test Coagulation profile
Blood group & cross-match
Don’t forgetECG, Chest X ray
Reference1) Tintinalli’s Emergency Medicine, 8th edition2) Emergency Radiology – case studies by David T. Schwartz3) Emergency Radiology – Imaging and Intervention by Borut Marincek ,
Robert F. Dondelinger (Eds.)4) Radiology – The oral boards primer