Acute abdomen
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Acute abdomen Presentation Transcript

  • 1. Acute Abdomen Radiological Approach Prof Dr. Haney A Sami
  • 2. Acute Abdomen
    • Bowel
      • Gastric
      • Small
      • Large
    • Visceral
      • GB
      • Pancreas
      • Kidney
    • Vascular
      • Aorta
      • Mesenteric
  • 3. Definition
    • Acute 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
  • 4.
      • Acute appendicitis
      • Acute cholecystitis
      • Bowel obstruction
      • Urinary colic
      • Perforated peptic ulcer
      • Acute pancreatitis
      • Acute diventricular disease
    Causes
  • 5. Imaging techniques
    • Clinical assessment is often difficult and laboratory investigations are often non specific.
    • Plain X-ray
    • Ultra sonography
    • CT examinations
    • Contrast studies
  • 6. 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
  • 7.  
  • 8.
    • 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
  • 9.  
  • 10.  
  • 11. 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.
  • 12. Common causes of acute pain in an abdominal quadrant
    • Left upper quadrant:
    • Splenic infarction.
    • Splenic abscess.
    • Gastritis.
    • Gastric ulcer.
  • 13. 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.
  • 14. Common causes of acute pain in an abdominal quadrant
    • Left lower quadrant :
    • Diverticulitis.
    • Epiploic appendagitis.
  • 15. Pancreatitis Ulcer Diverticulitis Cholecystitis Appendicitis
  • 16. What to Examine by Plain X-ray
    • Gas pattern
    • Extraluminal air
    • Soft tissue masses
    • Calcifications
    • Skeletal pathology
  • 17. 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.
  • 18. 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
  • 19. Gas in stomach Gas in a few loops of small bowel Gas in rectum or sigmoid Normal Gas Pattern
  • 20. Normal Fluid Levels
    • Stomach
      • Always (except supine film)
    • Small Bowel
      • Two or three levels possible
    • Large Bowel
      • None normally
  • 21. Erect Abdomen Always air/fluid level in stomach A few air/fluid levels in small bowel
  • 22. Large vs. Small Bowel
    • Large Bowel
      • Peripheral
      • Haustral markings don't extend from wall to wall
    • Small Bowel
      • Central
      • Valvulae extend across lumen
  • 23. Haustra films Faecal mottling
  • 24. Complete Abdomen Obstruction Series
    • Supine
    • Erect or left decubitus
    • Chest - erect or supine
    • Prone or lateral rectum
  • 25. Complete Abdomen Supine
    • Looking for
      • Scout film for gas pattern
      • Calcifications
      • Soft tissue masses
    • Substitute – none
  • 26. Complete Abdomen Erect
    • Looking for
      • Free air
      • Air-fluid levels
    • Substitute – left lateral decubitus
  • 27. Complete Abdomen Erect Chest
    • Looking for
      • Free air
      • Pneumonia at bases
      • Pleural effusions
    • Substitute – supine chest
  • 28. Complete Abdomen Prone
    • Looking for
      • Gas in rectum/sigmoid
      • Gas in ascending and descending colon
    • Substitute – lateral rectum
  • 29. Abnormal Gas Patterns
    • Functional Ileus
      • Localized (Sentinel Loops)
      • Generalized adynamic ileus
    • Mechanical Obstruction
      • SBO
      • LBO
  • 30.
    • One or two persistently dilated loops of large or small bowel
    • Gas in rectum or sigmoid
    Localized Ileus Key Features Sentinel Loops Supine Prone
  • 31. Localized Ileus Pancreatitis Ulcer Diverticulitis Cholecystitis Appendicitis Sentinel Loops
  • 32. Localized Ileus Pitfalls
    • May resemble early mechanical SBO
      • Clinical course
      • Get follow-up
  • 33.
    • 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 Ileus Key Features
  • 34. Generalized Adynamic Ileus Supine Erect
  • 35. Is It An Ileus?
    • Is the patient immediately post-op?
    • Are the bowel sounds absent or hypoactive?
  • 36. Mechanical SBO Key Features
    • Dilated small bowel
    • Fighting loops
    • Little gas in colon, especially rectum
    • Key: disproportionate dilatation of SB
    SBO
  • 37. Mechanical SBO Causes
    • Adhesions
    • Hernia*
    • Volvulus
    • Gallstone ileus*
    • Intussusception
    *Cause may be visible on plain film
  • 38. Mechanical SBO Pitfalls
    • Early SBO may resemble localized ileus -get F/O
  • 39. Differentiation between SBO & ILEUS
    • Obstruction transition of dilated loops
    • Degree of dilatation is greater with obstruction
    • Spacing between the bowel loops
  • 40. Mechanical LBO Key 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
  • 41. LBO
  • 42. LBO Supine Prone
  • 43. Mechanical LBO Causes
    • Tumor
    • Volvulus
    • Hernia
    • Diverticulitis
    • Intussusception
  • 44.  
  • 45. Mechanical LBO Pitfalls
    • Incompetent ileocecal valve
      • Large bowel decompresses into small bowel
      • May look like SBO
      • Get BE or follow-up
  • 46. Carcinoma of Sigmoid – LBO – Decompressed into SB Prone Supine
  • 47.  
  • 48.  
  • 49.
    • The goals of imaging in a patient with suspected intestinal obstruction have been defined and are as follows:
    • To confirm that it is a true obstruction and to differentiate it from an ileus.
    • To determine the level of obstruction.
    • To determine the cause of the obstruction.
    • To look for findings of strangulation.
    • To allow a good management either medically or surgically by laparoscopy or laparoscopy).
  • 50.  
  • 51. Air in biliary tree Gallstone Gallstone Ileus
  • 52. Post-op C-section Adynamic Ileus
  • 53. Mesenteric Occlusion
  • 54. Abnormal Gas Patterns Ileus and Obstruction
    • Localized ileus
    • Generalized ileus
    • Mechanical SBO
    • Mechanical LBO
  • 55. Conditions causing extraluminal air
    • Perforated abdominal viscus
    • Abscesses (subphrenic and other)
    • Biliary fistula
    • Cholangitis
    • Pneumatosis coli
    • Necrotising enterocolitis
    • Portal pyaemia
  • 56. 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.
  • 57. Extraluminal Air Free Intraperitoneal Air
  • 58. Signs of Free Air
    • Air beneath diaphragm
    • Both sides of bowel wall
    • Falciform ligament sign
    • In the biliary system
    Crescent sign Free Intraperitoneal Air
  • 59. Free Air Causes
    • Rupture of a hollow viscus
      • Perforated ulcer
      • Perforated diverticulitis
      • Perforated carcinoma
      • Trauma or instrumentation
    • Post-op 5–7 days
    • NOT perforated appendix
  • 60. Extraperitoneal Air
  • 61. Soft Tissue Masses
  • 62. Soft Tissue Masses
    • Hepatosplenomegaly
      • Plain films poor for judging liver size
    • Tumor or cyst
      • Bowel displacement
  • 63. Splenomegaly
  • 64. Myomatous Uterus
  • 65. Bladder Outlet Obstruction – pre- and post- cath Hours later
  • 66. Right Renal Cyst
  • 67. RLQ Abscess
  • 68. Abdominal Calcifications
  • 69. Normal structures that calcify
    • ● Costal cartilage
    • ● Mesenteric lymph nodes
    • ● Pelvic vein clots (phlebolith)
    • ● Prostate gland
  • 70. Abnormal structures that contain calcium
    • Calcium indicates pathology
    • ● Pancreas
    • ● Renal parenchymal tissue
    • ● Blood vessels and vascular aneurysms
    • ● Gallbladder fibroids (leiomyoma)
  • 71. Abnormal structures that contain calcium
    • Calcium is pathology
    • ● Biliary calculi
    • ● Renal calculi
    • ● Appendicolith
    • ● Bladder calculi
    • ● Teratoma
  • 72. Abdominal Calcifications Patterns
    • Rimlike
    • Linear or track-like
    • Lamellar
    • Cloudlike
  • 73. Rimlike Calcification
    • Wall of a hollow viscus
      • Cysts
        • Renal cyst
      • Aneurysms
        • Aortic aneurysm
      • Saccular organs e.g. GB
        • Porcelain Gallbladder
    Renal Cyst Gallbladder Wall
  • 74. Linear or Track-like
    • Walls of a tube
      • Ureters
      • Arterial walls
    Atherosclerosis Calcification Vas Deferens
  • 75. Lamellar or Laminar
    • Formed in lumen of a hollow viscus
      • Renal stones
      • Gallstones
      • Bladder stones
    Stone in Ureterocoele Staghorn Calculi
  • 76. Cloudlike, Amorphous, Popcorn
    • Formed in a solid organ or tumor
      • Leiomyomas of uterus
      • Ovarian cystadenomas
    Nephrocalcinosis Myomatous Uterus
  • 77. Visceral Inflammation Colitis Appendicitis Diverticulitis Bowel Inflammation Cholecystitis Pancreatitis
  • 78. 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 . Cholelithiasis 2 . Gallbladder wall thickening 3 . Pericholecystic fluid . Complicated cases may reveal perforation or hepatic abscess formation .
  • 79.
    • 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.
  • 80. Thickening of gallbladder wall Cholelithiasis .
  • 81.  
  • 82.  
  • 83.  
  • 84. 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 fat 2 . Peripancreatic fluid collections can often be seen 3 . Pseudocysts, ( encapsulated fluid collections containing pancreatic secretions, are later complications of pancreatitis )
  • 85. Notice the peripancreatic stranding ( bars ) as well as the fluid thickening of the interfascial space
  • 86.
    • 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% .
  • 87. Pancreatic necrosis
  • 88. Pancreatic pseudocyst
  • 89.  
  • 90. 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
  • 91. This image of an acute abdomen ( arrow ) displays periappendicial stranding and dilattion of its terminal portion .
  • 92. For comparison, this image of a normal appendix can be visualized at the ileocecal junction . Also notethe fat ventralcontaining heria
  • 93. 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 ).
  • 94.  
  • 95. This example of colitis shows thickening of the colon and pericolonic stranding typical of inflammation .
  • 96. Thickening of sigmoid colon due to pseudomembranous colitis
  • 97. A case of diverticulitis showing a thickened sigmoid colon and a diverticulum
  • 98. Diverticulitis
  • 99. Distal ureteral stone lead ing to right hyrdronephrosis in above image Ureteral junctional stone Renal Colic
  • 100. Renal stone right sided hydronephrosis Renal Colic
  • 101. Aortic aneurysms
  • 102. Case give a diagnosis
  • 103.  
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  • 118.  
  • 119. The End