Acute Abdomen
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Imaging the Acute Abdomen Imaging the Acute Abdomen Objectives • Definition • Clinical Evaluation • Radiologic Evaluation Appendicitis Pancreatitis Infectious colitis Bowel perforation Angela ...

Imaging the Acute Abdomen Imaging the Acute Abdomen Objectives • Definition • Clinical Evaluation • Radiologic Evaluation Appendicitis Pancreatitis Infectious colitis Bowel perforation Angela D. Levy, COL, MC, US...

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Acute Abdomen Document Transcript

  • 1. Imaging the Acute Abdomen Imaging the Acute Abdomen Objectives • Definition • Clinical Evaluation • Radiologic Evaluation  Appendicitis  Pancreatitis  Infectious colitis Angela D. Levy, COL, MC, USA  Bowel perforation Department of Radiologic Pathology Armed Forces Institute of Pathology Washington, DC and Associate Professor of Radiology and Nuclear Medicine Uniformed Services University of the Health Sciences Bethesda, MD Definition Acute Abdomen • Acute Abdomen • History  Abdominal pain that persists for more than a few  Past medical history hours  History of the present illness  Abdominal tenderness • Physical examination  Evidence of inflammatory reaction or visceral  Pelvic examination in females dysfunction • Laboratory examination • Radiologic evaluation 55-old-man with right lower quadrant pain, Radiologic Evaluation fever, malaise, and poor appetite • Abdominal Radiographs  Supine (KUB) and upright abdominal films • Ultrasound • Computed Tomography 1
  • 2. Normal Acute Appendicitis Acute Appendicitis • Most common surgical emergency • Peak incidence second and third decades of life • Complications  Perforation 20%  Abscess/phlegmon 5%  Septic thrombophlebitis (rare) 2
  • 3. Normal Appendix Normal Appendix • Posteromedial cecum • Posteromedial cecum  Convergence of the  Convergence of the taenia coli taenia coli • Variable position • Variable length  8 to 10 cm Acute Appendicitis • Pathogenesis: luminal obstruction  Stones, food, mucus, adhesions, mucosal edema, parasites, tumors, endometriosis, foreign objects, lymphoid hyperplasia • Appendicolith  7-12% adults  50% children Appendicitis Why Order Imaging Studies? Computed Tomography • Confusing clinical picture • Pregnancy  Ultrasound is modality of choice • Older age patient  Suspect neoplasm as etiology • Suspected complication  Alter operative management Appendicitis Normal 3
  • 4. Appendicitis Appendicitis Computed Tomography “Arrowhead Sign” Sign” Appendicitis Normal Differential Diagnosis Appendiceal Abscess RLQ Pain • Appendicitis • PID • Inflammatory bowel disease • Complications of ovarian cysts • Right-sided diverticulitis  Hemorrhage  Ileal, cecal  Rupture • Complications of GI tumors  Torsion  Intussusception • Ectopic pregnancy  Perforation • Ureteral obstruction  Obstruction  Stones, tumors, • Meckel’s diverticulitis Meckel’ inflammatory disease • Small bowel obstruction • Mesenteric adenitis • Epiploic appendagitis • Omental infarction Normal • Peritoneal carcinomatosis • Peritonitis/abscess 35-year-old male who complained of Clinical Evaluation Abdominal Tenderness, Elevated Serum Amylase abdominal pain and collapsed and Lipase 4
  • 5. 35-year-old male who complained of Acute Pancreatitis abdominal pain and collapsed Normal Normal Normal Pancreas Normal Pancreas Acute Pancreatitis Acute Pancreatitis • Metabolic  Alcohol, hyperlipidemia, hypercalcemia, hereditary Alcohol, hypercalcemia, pancreatitis, kwashiorkor • Mechanical  Gallstones, post-operative, trauma, duct anomalies, Gallstones, iatrogenic, neoplasm, gastric ulcers • Vascular  Vasculitis, atherosclerotic embolism • Drugs  Steroids, aspirin, sulfonamides, tetracycline, opiates, cholinergics Normal • Infection  Mumps, measles, HIV, CMV 5
  • 6. Acute Pancreatitis Why Order Imaging Studies? • Clinical • Confirm clinical diagnosis  Abdominal pain, nausea, vomiting, abdominal • Evaluate the etiology of pancreatitis distension, shock • Evaluate extent of pancreatic injury and  Flank ecchymosis (Grey Turner’s sign), periumbilical Turner’ inflammation hematoma (Cullen’s sign) (Cullen’ • Evaluate for complications • Laboratory Evaluation  Pseudocyst, abscess, intestinal obstruction, vascular  Amylase, lipase complication • Radiologic Evaluation • Exclude other abdominal disorders that may mimic pancreatitis Acute Pancreatitis with Peripancreatic Acute Pancreatitis Fluid Normal Normal 9-year-old female with abdominal pain, Acute Pancreatitis with Pseudocyst vomiting, diarrhea, and abdominal distension 6
  • 7. E.Coli O157:H7 Colitis Inflammatory Conditions of the Colon • Clinical  Diarrhea, nausea, vomiting, fever, malaise • Laboratory evaluation  Stool culture, WBC count • Radiologic evaluation  Abdominal radiographs, computed tomography Inflammatory Conditions of the Colon Why Order Imaging Studies? • Bacterial Infections • Exclude other intra-abdominal processes  Salmonella, shigella, campylobacter, yersinia, E. coli, tuberculosis, shigella, yersinia, actinomycosis • Evaluate for complications • Viral Infections  Toxic megacolon  CMV  Pneumatosis • Parasitic Infections  Amebiasis, schistosomiasis, trichuriasis schistosomiasis,  Perforation • Fungal Infections  Abscess formation  Histoplasmosis, mucormycosis Histoplasmosis, • Noninfectious colitis  Ulcerative colitis, Crohn's disease, ischemia • Exogenous Causes  Radiation, drug-induced, pseudomembranous colitis 7
  • 8. Toxic Megacolon Toxic Megacolon • Inflammation  Transmural  Serosal • Vasculitis • Destruction of neural plexuses • Disintegration of normal tissue cohesiveness  “Wet tissue paper” paper” Normal Colon Toxic Megacolon Toxic Megacolon Ulcerative Colitis with Toxic Megacolon • Correct clinical setting • Diagnosis by abdominal radiograph  Transverse colon  Dilatation >5cm  Colonic wall thickening  Loss of haustral pattern  Fluid levels  Ileus 65-year-old female with abdominal pain Ulcerative Colitis with Toxic Megacolon and rigidity of the abdominal wall 8
  • 9. Pneumoperitoneum Intestinal Perforation • Gastric or duodenal ulcer • Intestinal obstruction  Adhesions  Neoplasm  Inflammation • Tumor • Severe inflammation  Diverticulitis, appendicitis • Severe colitis  Ischemia, infection, ulcerative colitis 9
  • 10. Armed Forces Institute of Pathology Summary • Clinical signs and symptoms of an acute abdomen  Pain, collapse, vomiting, muscular rigidity, abdominal distension • Why order radiological studies? • Common disorders causing an acute abdomen  Appendicitis, pancreatitis, severe gastroenteritis/colitis, intestinal perforation www.radpath.org 10