Abnormal Gas..Basic     concepts       Dr/Ahmed Bahnassy     Consultant Radiologist        MBCHB-MD-FRCR E-mail:aatteya200...
Where is the gas ? IP RP BW             Intraperitoneal GB             Retroperitoneal AB             Bowel wall  ...
PNEUMOPERITONEUM
FREE AIR     SENSITIVITY OF IMAGING STUDIES   COMPUTED TOMOGRAPHY                       99%   LATERAL UPRIGHT CHEST RADI...
PNEUMOPERITONEUM     SENSITIVITY OF IMAGING STUDIES   RADIOLOGIC DEMONSTRATION DEPENDS ON:    –   VOLUME OF FREE AIR    –...
UPRIGHT CHEST
PNEUMOPERITONEUM     UPRIGHT RADIOGRAPHS                            UPRIGHT ABD CENTRAL TENDONUNDER RIGHT HEMIDIAPHRAGM   ...
FREE AIR…….DECUBITUS VIEW   GAS BETWEEN LIVER AND BODY WALLBUT MAY ALSO BE IN OR ONLY IN THE PELVIS
FREE AIRCENTRAL TENDON
FREE AIRCENTRAL TENDON
RIGLER’S SIGNBOTH SIDES OF BOWEL WALL VISIBLEDOUBLE WALL SIGN
MASSIVE PNEUMOPERITONEUM      FOOTBALL SIGN
FALCIFORM LIGAMENTGAS BUBBLE OVER LIVER
FALCIFORM LIGAMENT
PNEUMOPERITONEUMSUBHEPATIC GAS BUBBLE
DIVERTICULITISPNEUMOPERITONEUM
ANTERIOR ABDOMINAL WALL    ANATOMIC FOLDS
FREE AIR INFERIOR EPIGASTRIC VESSELS(LATERAL UMBILICAL LIGAMENTS)
PSEUDO-PNEUMOPERITONEUM
CENTRAL TENDON GAS         YES, BUT JUST THE STOMACH
GAS UNDER THE RIGHT HEMIDIAPHRAGM    HEPATIC FLEXURE ANTERIOR-SUPERIOR TO LIVER
SUBDIAPHRAGMATIC FAT SIMULATING FREE AIR
FREE AIR OR NOT FREE AIR?  THAT IS THE QUESTIONPNEUMOTHORAX SIMULATES FREE AIR
RETROPERITONEAL GAS SIMULATES FREE AIR
RETROPERITONEAL GAS
RETROPERITONEAL GAS                             CAUSES   IATROGENIC    –   SURGERY    –   DIAGNOSTIC PROCEDURE   TRAUMA ...
RETROPERITONEAL GAS                           IMAGING   LITTLE CHANGE IN POSITION OR SHAPE WHEN    COMPARING SUPINE, UPRI...
Severe dysuria-left flank pain
RETROPERITONEAL GAS                        IMAGING   BENEATH DIAPHRAGM CAN SIMULATE    PNEUMOTHORAX   LARGE VOLUME OF GA...
RETROPERITONEAL GAS
13-YEAR-OLD GIRL WITH CROHN’S DISEASE  HAS SUBACUTE FEVER AND ABD PAIN
RETROPERITONEAL GASEXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT
AFTER COLONOSCOPY AND             BIOPSYEXTENSIVE RETROPERITONEAL GAS
BAROTRAUMAMEDIASTINUM – RETROPERITONEUM – FREE AIR
BOWEL WALL GAS
PNEUMATOSIS OF COLON          INFANT                 ADULTNECROTIZING ENTEROCOLITIS                            ISCHEMIC CO...
WHAT IS THE ABNORMALITY               HERE?USE LUNG WINDOWS TO LOOK FOR GAS
72-YEAR-OLD WOMAN WITH DIARREHA
58-YEAR-OLD WOMANMILD ABDOMINAL PAIN FOR 2 DAYS                     SCLERODERMA,                   GAS IN COLON WALL
PNEUMATOSIS 2 DAYS AFTER SEGMENTAL SB RESECTIONRESOLVED SPONTANEOUSLY
ASYMPTOMATIC 40-YEAR-OLD MANBENIGN STEADY STATE PNEUMATOSIS
ISCHEMIC BOWEL
ISCHEMIC BOWEL            IMAGING SIGNS– DILATION   PSEUDOOBSTRUCTION– BOWEL WALL   THICKENED   PNEUMATOSIS   UNENHANC...
ACUTE ONSET OF ABDOMINAL PAIN             SMA EMBOLIS
Thumprinting
SBO            ISCHEMIC BOWELAT SURGERY: SB TWISTED UNDERADHESION
ISCHEMIC SMALL BOWEL     ETIOLOGY ? SMV CLOT
Gall bladder and Biliary GAS
BILE DUCT GAS   IATROGENIC    –   BILE DUCT SURGERY    –   SPHINCTEROTOMY   BILIARY FISTULA    –   GALLSTONE ERODING INT...
BILE DUCT GAS   BILE DUCT GASCHUNKY AND CENTRAL
BILE DUCT GAS AND SBO
SBO GALLSTONE ILEUS
GALLSTONE ILEUS
GALLSTONE ILEUSBILE DUCT GAS, SBO, STONE
GALLBLADDER GAS   GALLBLADDER LUMEN    – GALLBLADDER-BOWEL FISTULA    – GALLSTONE ILEUS    – EMPHYSEMATOUS CHOLECYSTITIS...
EMPHYSEMATOUS CHOLECYSTITIS
PORTAL VEIN GAS
SMALL BOWEL ISCHEMIAGAS IN MESENTERIC AND PORTAL VEINS                     48 SubPhrenic Abs CT
65-YEAR-OLD MAN          ABDOMINAL PAIN    PORTAL VEIN GASDELICATE AND PERIPHERAL
36-YEAR-OLD MAN        MULTIPLE CONGENITAL ANOMALIES             FEVER , WBC 17.8, 15 BANDSISCHEMIA OF SB AND STOMACH
ABSCESS
ABSCESS SUSPECT AN ABSCESS WHEN RADIOGRAPHS  SHOW A GAS COLLECTION THAT IS ABNORMAL  BECAUSE OF PERSISTENCE ON MULTIPLE  ...
APPENDICEAL ABSCESS      RETROCECAL APPENDIXABNORMAL GAS… UNCHANGED ON MULTIPLE VIEWS
SIGMOID DIVERTICULITISGAS FILLED “DIVERTICULUM!!
Huge Abscess !
FEVER 10 DAYS AFTERABDOMINAL SURGERY
CROHN’S DISEASE WITH ABSCESS
PANCREATIC ABSCESS
PANCREATIC GAS           -only 3 causes   GAS IN PANCREATIC BED    – ABSCESS    – POST PANCREATIC DRAINAGE      PROCEDURE...
PANCREATITIS WITH ABSCESS  LESSER SAC ABSCESS                       GAS IN PANCREATIC ABSCESS
PANCREAS-GAS BUT NO ABSCESSPANCREAS-COLON FISTULA
LESSER SAC
GAS IN LESSER SACPERFORATED GASTRIC ULCER
GASTRIC ULCERPERFORATION INTO LESSER SAC
Pancreatic Abscess.
Summary          IP          RP          BW          GB          AB
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Abnormal gas

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The lecture illustrates the different patterns of abnormal gas in abdominal plain X-rays.

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Abnormal gas

  1. 1. Abnormal Gas..Basic concepts Dr/Ahmed Bahnassy Consultant Radiologist MBCHB-MD-FRCR E-mail:aatteya2001@yahoo.com
  2. 2. Where is the gas ? IP RP BW  Intraperitoneal GB  Retroperitoneal AB  Bowel wall  Gall bladder and biliary  Abscess
  3. 3. PNEUMOPERITONEUM
  4. 4. FREE AIR SENSITIVITY OF IMAGING STUDIES COMPUTED TOMOGRAPHY 99% LATERAL UPRIGHT CHEST RADIOGRAPH 98% AP UPRIGHT CHEST RADIOGRAPH 80 - 90% SUPINE ABDOMEN RADIOGRAPH ?
  5. 5. PNEUMOPERITONEUM SENSITIVITY OF IMAGING STUDIES RADIOLOGIC DEMONSTRATION DEPENDS ON: – VOLUME OF FREE AIR – TIME INTERVAL BEFORE IMAGING – TYPE OF IMAGING – CONDUCT OF IMAGING EXAMINATION AS LITTLE AS ONE CC CAN BE DEMONSTRATED 10% OF PATIENTS WITH PERFORATED ULCERS DO NOT DEMONSTRATE PNEUMOPERITONEUM
  6. 6. UPRIGHT CHEST
  7. 7. PNEUMOPERITONEUM UPRIGHT RADIOGRAPHS UPRIGHT ABD CENTRAL TENDONUNDER RIGHT HEMIDIAPHRAGM AND HEMIDIAPHRAGM
  8. 8. FREE AIR…….DECUBITUS VIEW GAS BETWEEN LIVER AND BODY WALLBUT MAY ALSO BE IN OR ONLY IN THE PELVIS
  9. 9. FREE AIRCENTRAL TENDON
  10. 10. FREE AIRCENTRAL TENDON
  11. 11. RIGLER’S SIGNBOTH SIDES OF BOWEL WALL VISIBLEDOUBLE WALL SIGN
  12. 12. MASSIVE PNEUMOPERITONEUM FOOTBALL SIGN
  13. 13. FALCIFORM LIGAMENTGAS BUBBLE OVER LIVER
  14. 14. FALCIFORM LIGAMENT
  15. 15. PNEUMOPERITONEUMSUBHEPATIC GAS BUBBLE
  16. 16. DIVERTICULITISPNEUMOPERITONEUM
  17. 17. ANTERIOR ABDOMINAL WALL ANATOMIC FOLDS
  18. 18. FREE AIR INFERIOR EPIGASTRIC VESSELS(LATERAL UMBILICAL LIGAMENTS)
  19. 19. PSEUDO-PNEUMOPERITONEUM
  20. 20. CENTRAL TENDON GAS YES, BUT JUST THE STOMACH
  21. 21. GAS UNDER THE RIGHT HEMIDIAPHRAGM HEPATIC FLEXURE ANTERIOR-SUPERIOR TO LIVER
  22. 22. SUBDIAPHRAGMATIC FAT SIMULATING FREE AIR
  23. 23. FREE AIR OR NOT FREE AIR? THAT IS THE QUESTIONPNEUMOTHORAX SIMULATES FREE AIR
  24. 24. RETROPERITONEAL GAS SIMULATES FREE AIR
  25. 25. RETROPERITONEAL GAS
  26. 26. RETROPERITONEAL GAS CAUSES IATROGENIC – SURGERY – DIAGNOSTIC PROCEDURE TRAUMA – PENETRATING – RUPTURED VISCUS  RETROPERITONEAL DUODENUM, COLON, RECTUM PERFORATED BOWEL  SECONDARY TO TUMOR, INFECTION, OBSTRUCTION, NECROSIS CAUDAL EXTENSION OF PNEUMOMEDIASTINUM GAS WITHIN ABSCESS
  27. 27. RETROPERITONEAL GAS IMAGING LITTLE CHANGE IN POSITION OR SHAPE WHEN COMPARING SUPINE, UPRIGHT, DECUB RADIOGRAPHS  BUT FREE INTRAPERITONEAL GAS IS FREELY MOBILE TENDS TO STAY IN ONE RETROPERITONEAL COMPARTMENT  DUODENAL PERFORATION…..RUQ ANTERIOR PARARENAL SPACE  SIGMOID DIVERTICULITIS….. LLQ  PERIRENAL ABSCESS…………. PERINEPHRIC SPACE OFTEN FORMS LINEAR, CURVILINEAR GAS COLLECTIONS
  28. 28. Severe dysuria-left flank pain
  29. 29. RETROPERITONEAL GAS IMAGING BENEATH DIAPHRAGM CAN SIMULATE PNEUMOTHORAX LARGE VOLUME OF GAS CAN OUTLINE RETROPERITONEAL STRUCTURES  KIDNEY, LIVER MARGIN, PSOAS, FLANK STRIPE RETROPERITONEAL GAS CAN EXTEND  CEPHALAD TO MEDIASTINUM  FASCIAL PLANES OF BODY WALL AND EXTREMITIES  INTO PERITONEAL CAVITY
  30. 30. RETROPERITONEAL GAS
  31. 31. 13-YEAR-OLD GIRL WITH CROHN’S DISEASE HAS SUBACUTE FEVER AND ABD PAIN
  32. 32. RETROPERITONEAL GASEXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT
  33. 33. AFTER COLONOSCOPY AND BIOPSYEXTENSIVE RETROPERITONEAL GAS
  34. 34. BAROTRAUMAMEDIASTINUM – RETROPERITONEUM – FREE AIR
  35. 35. BOWEL WALL GAS
  36. 36. PNEUMATOSIS OF COLON INFANT ADULTNECROTIZING ENTEROCOLITIS ISCHEMIC COLITIS
  37. 37. WHAT IS THE ABNORMALITY HERE?USE LUNG WINDOWS TO LOOK FOR GAS
  38. 38. 72-YEAR-OLD WOMAN WITH DIARREHA
  39. 39. 58-YEAR-OLD WOMANMILD ABDOMINAL PAIN FOR 2 DAYS SCLERODERMA, GAS IN COLON WALL
  40. 40. PNEUMATOSIS 2 DAYS AFTER SEGMENTAL SB RESECTIONRESOLVED SPONTANEOUSLY
  41. 41. ASYMPTOMATIC 40-YEAR-OLD MANBENIGN STEADY STATE PNEUMATOSIS
  42. 42. ISCHEMIC BOWEL
  43. 43. ISCHEMIC BOWEL IMAGING SIGNS– DILATION  PSEUDOOBSTRUCTION– BOWEL WALL  THICKENED  PNEUMATOSIS  UNENHANCING– GAS IN VESSELS  MESENTERIC, SMV, PORTAL VEINS– OBSTRUCTED VESSELS  SMA, SMV – HIGH DENSITY CLOT ON UNENHANCED CT – FILLING DEFECTS ON CT WITH IV CONTRAST– ASCITES, FREE AIR AFTER PERFORATION
  44. 44. ACUTE ONSET OF ABDOMINAL PAIN SMA EMBOLIS
  45. 45. Thumprinting
  46. 46. SBO ISCHEMIC BOWELAT SURGERY: SB TWISTED UNDERADHESION
  47. 47. ISCHEMIC SMALL BOWEL ETIOLOGY ? SMV CLOT
  48. 48. Gall bladder and Biliary GAS
  49. 49. BILE DUCT GAS IATROGENIC – BILE DUCT SURGERY – SPHINCTEROTOMY BILIARY FISTULA – GALLSTONE ERODING INTO BOWEL – DUODENAL ULCER – UPPER ABDOMINAL MALIGNANCY – TRAUMA CHOLANGITIS – GAS FORMING ORGANISM
  50. 50. BILE DUCT GAS BILE DUCT GASCHUNKY AND CENTRAL
  51. 51. BILE DUCT GAS AND SBO
  52. 52. SBO GALLSTONE ILEUS
  53. 53. GALLSTONE ILEUS
  54. 54. GALLSTONE ILEUSBILE DUCT GAS, SBO, STONE
  55. 55. GALLBLADDER GAS GALLBLADDER LUMEN – GALLBLADDER-BOWEL FISTULA – GALLSTONE ILEUS – EMPHYSEMATOUS CHOLECYSTITIS GALLBLADDER WALL GAS – EMPHYSEMATOUS CHOLECYSTITIS
  56. 56. EMPHYSEMATOUS CHOLECYSTITIS
  57. 57. PORTAL VEIN GAS
  58. 58. SMALL BOWEL ISCHEMIAGAS IN MESENTERIC AND PORTAL VEINS 48 SubPhrenic Abs CT
  59. 59. 65-YEAR-OLD MAN ABDOMINAL PAIN PORTAL VEIN GASDELICATE AND PERIPHERAL
  60. 60. 36-YEAR-OLD MAN MULTIPLE CONGENITAL ANOMALIES FEVER , WBC 17.8, 15 BANDSISCHEMIA OF SB AND STOMACH
  61. 61. ABSCESS
  62. 62. ABSCESS SUSPECT AN ABSCESS WHEN RADIOGRAPHS SHOW A GAS COLLECTION THAT IS ABNORMAL BECAUSE OF PERSISTENCE ON MULTIPLE VIEWS GET HISTORY, PX, LAB DATA BY CONSULTATION WITH ORDERING MD. CONFIRM WITH CROSS-SECTIONAL IMAGING
  63. 63. APPENDICEAL ABSCESS RETROCECAL APPENDIXABNORMAL GAS… UNCHANGED ON MULTIPLE VIEWS
  64. 64. SIGMOID DIVERTICULITISGAS FILLED “DIVERTICULUM!!
  65. 65. Huge Abscess !
  66. 66. FEVER 10 DAYS AFTERABDOMINAL SURGERY
  67. 67. CROHN’S DISEASE WITH ABSCESS
  68. 68. PANCREATIC ABSCESS
  69. 69. PANCREATIC GAS -only 3 causes GAS IN PANCREATIC BED – ABSCESS – POST PANCREATIC DRAINAGE PROCEDURE  PERCUTANEOUS OR SURGICAL – PUESTOW PROCEDURE – PSEUDOCYST – PANCREATIC FISTULA
  70. 70. PANCREATITIS WITH ABSCESS LESSER SAC ABSCESS GAS IN PANCREATIC ABSCESS
  71. 71. PANCREAS-GAS BUT NO ABSCESSPANCREAS-COLON FISTULA
  72. 72. LESSER SAC
  73. 73. GAS IN LESSER SACPERFORATED GASTRIC ULCER
  74. 74. GASTRIC ULCERPERFORATION INTO LESSER SAC
  75. 75. Pancreatic Abscess.
  76. 76. Summary IP RP BW GB AB
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