Acute abdomen


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Acute abdomen

  1. 1. Acute Abdomen Radiological Approach Prof Dr. Haney A Sami
  2. 2. Acute Abdomen <ul><li>Bowel </li></ul><ul><ul><li>Gastric </li></ul></ul><ul><ul><li>Small </li></ul></ul><ul><ul><li>Large </li></ul></ul><ul><li>Visceral </li></ul><ul><ul><li>GB </li></ul></ul><ul><ul><li>Pancreas </li></ul></ul><ul><ul><li>Kidney </li></ul></ul><ul><li>Vascular </li></ul><ul><ul><li>Aorta </li></ul></ul><ul><ul><li>Mesenteric </li></ul></ul>
  3. 3. Definition <ul><li>Acute abdominal pain Is Pain unrelated to trauma </li></ul><ul><li>It is one of the most common conditions in patients presenting to the hospital emergency department. </li></ul><ul><li>It is a syndrome characterized by the sudden onset of severe abdominal pain, requiring early medical or surgical treatment </li></ul>
  4. 4. <ul><ul><li>Acute appendicitis </li></ul></ul><ul><ul><li>Acute cholecystitis </li></ul></ul><ul><ul><li>Bowel obstruction </li></ul></ul><ul><ul><li>Urinary colic </li></ul></ul><ul><ul><li>Perforated peptic ulcer </li></ul></ul><ul><ul><li>Acute pancreatitis </li></ul></ul><ul><ul><li>Acute diventricular disease </li></ul></ul>Causes
  5. 5. Imaging techniques <ul><li>Clinical assessment is often difficult and laboratory investigations are often non specific. </li></ul><ul><li>Plain X-ray </li></ul><ul><li>Ultra sonography </li></ul><ul><li>CT examinations </li></ul><ul><li>Contrast studies </li></ul>
  6. 6. Imaging techniques <ul><li>Plain radiographs of the abdomen, is of significant diagnostic limitations, It is the initial radiological approach. </li></ul><ul><li>Two views are usually taken a </li></ul><ul><li>supine and an erect. </li></ul><ul><li>If the patient is unable to stand, a decubitus view </li></ul>
  7. 8. <ul><li>CT is clearly superior to plain radiography :- </li></ul><ul><li>Confirming the diagnosis (site and level) </li></ul><ul><li>Revealing the cause of bowel obstruction </li></ul><ul><li>Detecting pneumoperitoneum </li></ul><ul><li>Identifying ureteric stones . </li></ul><ul><li>Examining solid organs. </li></ul><ul><li>The major obstacle to replace plain abdominal radiography with unenhanced CT appears to be its cost, availability, and radiation dose. </li></ul>Value of CT
  8. 11. Common causes of acute pain in an abdominal quadrant <ul><li>Right upper quadrant: </li></ul><ul><li>Acute calculous / non calculous Cholecystitis. </li></ul><ul><li>Amebic liver abscess. </li></ul><ul><li>Spontaneous rupture of hepatic neoplasm. </li></ul><ul><li>Myocardial infarction. </li></ul>
  9. 12. Common causes of acute pain in an abdominal quadrant <ul><li>Left upper quadrant: </li></ul><ul><li>Splenic infarction. </li></ul><ul><li>Splenic abscess. </li></ul><ul><li>Gastritis. </li></ul><ul><li>Gastric ulcer. </li></ul>
  10. 13. Common causes of acute pain in an abdominal quadrant <ul><li>Right lower quadrant : </li></ul><ul><li>Acute appendicitis. </li></ul><ul><li>Acute terminal ileitis. </li></ul><ul><li>Acute typhlitis. </li></ul><ul><li>Pelvic inflammatory disease. </li></ul><ul><li>Complications of overian cyst. Endometriosis. Ectopic pregnancy. </li></ul>
  11. 14. Common causes of acute pain in an abdominal quadrant <ul><li>Left lower quadrant : </li></ul><ul><li>Diverticulitis. </li></ul><ul><li>Epiploic appendagitis. </li></ul>
  12. 15. Pancreatitis Ulcer Diverticulitis Cholecystitis Appendicitis
  13. 16. What to Examine by Plain X-ray <ul><li>Gas pattern </li></ul><ul><li>Extraluminal air </li></ul><ul><li>Soft tissue masses </li></ul><ul><li>Calcifications </li></ul><ul><li>Skeletal pathology </li></ul>
  14. 17. Key to densities in AXRs <ul><li>● Black—gas </li></ul><ul><li>● White—calcified structures </li></ul><ul><li>● Gray—soft tissues </li></ul><ul><li>● Darker gray—fat </li></ul><ul><li>● Intense white—metallic objects </li></ul><ul><li>The clarity of outlines of structures depends, on the differences between these densities. </li></ul>
  15. 18. Normal Gas Pattern <ul><li>Stomach </li></ul><ul><ul><li>Always </li></ul></ul><ul><li>Small Bowel </li></ul><ul><ul><li>Two or three loops of non-distended bowel </li></ul></ul><ul><ul><li>Normal diameter = 2.5 cm </li></ul></ul><ul><li>Large Bowel </li></ul><ul><ul><li>In rectum or sigmoid – almost always </li></ul></ul>
  16. 19. Gas in stomach Gas in a few loops of small bowel Gas in rectum or sigmoid Normal Gas Pattern
  17. 20. Normal Fluid Levels <ul><li>Stomach </li></ul><ul><ul><li>Always (except supine film) </li></ul></ul><ul><li>Small Bowel </li></ul><ul><ul><li>Two or three levels possible </li></ul></ul><ul><li>Large Bowel </li></ul><ul><ul><li>None normally </li></ul></ul>
  18. 21. Erect Abdomen Always air/fluid level in stomach A few air/fluid levels in small bowel
  19. 22. Large vs. Small Bowel <ul><li>Large Bowel </li></ul><ul><ul><li>Peripheral </li></ul></ul><ul><ul><li>Haustral markings don't extend from wall to wall </li></ul></ul><ul><li>Small Bowel </li></ul><ul><ul><li>Central </li></ul></ul><ul><ul><li>Valvulae extend across lumen </li></ul></ul>
  20. 23. Haustra films Faecal mottling
  21. 24. Complete Abdomen Obstruction Series <ul><li>Supine </li></ul><ul><li>Erect or left decubitus </li></ul><ul><li>Chest - erect or supine </li></ul><ul><li>Prone or lateral rectum </li></ul>
  22. 25. Complete Abdomen Supine <ul><li>Looking for </li></ul><ul><ul><li>Scout film for gas pattern </li></ul></ul><ul><ul><li>Calcifications </li></ul></ul><ul><ul><li>Soft tissue masses </li></ul></ul><ul><li>Substitute – none </li></ul>
  23. 26. Complete Abdomen Erect <ul><li>Looking for </li></ul><ul><ul><li>Free air </li></ul></ul><ul><ul><li>Air-fluid levels </li></ul></ul><ul><li>Substitute – left lateral decubitus </li></ul>
  24. 27. Complete Abdomen Erect Chest <ul><li>Looking for </li></ul><ul><ul><li>Free air </li></ul></ul><ul><ul><li>Pneumonia at bases </li></ul></ul><ul><ul><li>Pleural effusions </li></ul></ul><ul><li>Substitute – supine chest </li></ul>
  25. 28. Complete Abdomen Prone <ul><li>Looking for </li></ul><ul><ul><li>Gas in rectum/sigmoid </li></ul></ul><ul><ul><li>Gas in ascending and descending colon </li></ul></ul><ul><li>Substitute – lateral rectum </li></ul>
  26. 29. Abnormal Gas Patterns <ul><li>Functional Ileus </li></ul><ul><ul><li>Localized (Sentinel Loops) </li></ul></ul><ul><ul><li>Generalized adynamic ileus </li></ul></ul><ul><li>Mechanical Obstruction </li></ul><ul><ul><li>SBO </li></ul></ul><ul><ul><li>LBO </li></ul></ul>
  27. 30. <ul><li>One or two persistently dilated loops of large or small bowel </li></ul><ul><li>Gas in rectum or sigmoid </li></ul>Localized Ileus Key Features Sentinel Loops Supine Prone
  28. 31. Localized Ileus Pancreatitis Ulcer Diverticulitis Cholecystitis Appendicitis Sentinel Loops
  29. 32. Localized Ileus Pitfalls <ul><li>May resemble early mechanical SBO </li></ul><ul><ul><li>Clinical course </li></ul></ul><ul><ul><li>Get follow-up </li></ul></ul>
  30. 33. <ul><li>Gas in dilated small bowel and large bowel to rectum </li></ul><ul><li>Long air-fluid levels </li></ul><ul><li>Only post-op patients have generalized ileus </li></ul><ul><li>Other causes:- </li></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>Metabolic disorder as hypothyroidism </li></ul></ul><ul><ul><li>Vascular occlusion </li></ul></ul>Generalized Ileus Key Features
  31. 34. Generalized Adynamic Ileus Supine Erect
  32. 35. Is It An Ileus? <ul><li>Is the patient immediately post-op? </li></ul><ul><li>Are the bowel sounds absent or hypoactive? </li></ul>
  33. 36. Mechanical SBO Key Features <ul><li>Dilated small bowel </li></ul><ul><li>Fighting loops </li></ul><ul><li>Little gas in colon, especially rectum </li></ul><ul><li>Key: disproportionate dilatation of SB </li></ul>SBO
  34. 37. Mechanical SBO Causes <ul><li>Adhesions </li></ul><ul><li>Hernia* </li></ul><ul><li>Volvulus </li></ul><ul><li>Gallstone ileus* </li></ul><ul><li>Intussusception </li></ul>*Cause may be visible on plain film
  35. 38. Mechanical SBO Pitfalls <ul><li>Early SBO may resemble localized ileus -get F/O </li></ul>
  36. 39. Differentiation between SBO & ILEUS <ul><li>Obstruction transition of dilated loops </li></ul><ul><li>Degree of dilatation is greater with obstruction </li></ul><ul><li>Spacing between the bowel loops </li></ul>
  37. 40. Mechanical LBO Key Features <ul><li>Dilated colon to point of obstruction </li></ul><ul><li>Little or no air in rectum/sigmoid </li></ul><ul><li>Little or no gas in small bowel, if… </li></ul><ul><ul><li>Ileocecal valve remains competent </li></ul></ul>
  38. 41. LBO
  39. 42. LBO Supine Prone
  40. 43. Mechanical LBO Causes <ul><li>Tumor </li></ul><ul><li>Volvulus </li></ul><ul><li>Hernia </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Intussusception </li></ul>
  41. 45. Mechanical LBO Pitfalls <ul><li>Incompetent ileocecal valve </li></ul><ul><ul><li>Large bowel decompresses into small bowel </li></ul></ul><ul><ul><li>May look like SBO </li></ul></ul><ul><ul><li>Get BE or follow-up </li></ul></ul>
  42. 46. Carcinoma of Sigmoid – LBO – Decompressed into SB Prone Supine
  43. 49. <ul><li>The goals of imaging in a patient with suspected intestinal obstruction have been defined and are as follows: </li></ul><ul><li>To confirm that it is a true obstruction and to differentiate it from an ileus. </li></ul><ul><li>To determine the level of obstruction. </li></ul><ul><li>To determine the cause of the obstruction. </li></ul><ul><li>To look for findings of strangulation. </li></ul><ul><li>To allow a good management either medically or surgically by laparoscopy or laparoscopy). </li></ul>
  44. 51. Air in biliary tree Gallstone Gallstone Ileus
  45. 52. Post-op C-section Adynamic Ileus
  46. 53. Mesenteric Occlusion
  47. 54. Abnormal Gas Patterns Ileus and Obstruction <ul><li>Localized ileus </li></ul><ul><li>Generalized ileus </li></ul><ul><li>Mechanical SBO </li></ul><ul><li>Mechanical LBO </li></ul>
  48. 55. Conditions causing extraluminal air <ul><li>Perforated abdominal viscus </li></ul><ul><li>Abscesses (subphrenic and other) </li></ul><ul><li>Biliary fistula </li></ul><ul><li>Cholangitis </li></ul><ul><li>Pneumatosis coli </li></ul><ul><li>Necrotising enterocolitis </li></ul><ul><li>Portal pyaemia </li></ul>
  49. 56. Chilaiditi’s syndrome <ul><li>Chilaiditi’s syndrome is an important normal variant on the erect chest radiograph, </li></ul><ul><li>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. </li></ul>
  50. 57. Extraluminal Air Free Intraperitoneal Air
  51. 58. Signs of Free Air <ul><li>Air beneath diaphragm </li></ul><ul><li>Both sides of bowel wall </li></ul><ul><li>Falciform ligament sign </li></ul><ul><li>In the biliary system </li></ul>Crescent sign Free Intraperitoneal Air
  52. 59. Free Air Causes <ul><li>Rupture of a hollow viscus </li></ul><ul><ul><li>Perforated ulcer </li></ul></ul><ul><ul><li>Perforated diverticulitis </li></ul></ul><ul><ul><li>Perforated carcinoma </li></ul></ul><ul><ul><li>Trauma or instrumentation </li></ul></ul><ul><li>Post-op 5–7 days </li></ul><ul><li>NOT perforated appendix </li></ul>
  53. 60. Extraperitoneal Air
  54. 61. Soft Tissue Masses
  55. 62. Soft Tissue Masses <ul><li>Hepatosplenomegaly </li></ul><ul><ul><li>Plain films poor for judging liver size </li></ul></ul><ul><li>Tumor or cyst </li></ul><ul><ul><li>Bowel displacement </li></ul></ul>
  56. 63. Splenomegaly
  57. 64. Myomatous Uterus
  58. 65. Bladder Outlet Obstruction – pre- and post- cath Hours later
  59. 66. Right Renal Cyst
  60. 67. RLQ Abscess
  61. 68. Abdominal Calcifications
  62. 69. Normal structures that calcify <ul><li>● Costal cartilage </li></ul><ul><li>● Mesenteric lymph nodes </li></ul><ul><li>● Pelvic vein clots (phlebolith) </li></ul><ul><li>● Prostate gland </li></ul>
  63. 70. Abnormal structures that contain calcium <ul><li>Calcium indicates pathology </li></ul><ul><li>● Pancreas </li></ul><ul><li>● Renal parenchymal tissue </li></ul><ul><li>● Blood vessels and vascular aneurysms </li></ul><ul><li>● Gallbladder fibroids (leiomyoma) </li></ul>
  64. 71. Abnormal structures that contain calcium <ul><li>Calcium is pathology </li></ul><ul><li>● Biliary calculi </li></ul><ul><li>● Renal calculi </li></ul><ul><li>● Appendicolith </li></ul><ul><li>● Bladder calculi </li></ul><ul><li>● Teratoma </li></ul>
  65. 72. Abdominal Calcifications Patterns <ul><li>Rimlike </li></ul><ul><li>Linear or track-like </li></ul><ul><li>Lamellar </li></ul><ul><li>Cloudlike </li></ul>
  66. 73. Rimlike Calcification <ul><li>Wall of a hollow viscus </li></ul><ul><ul><li>Cysts </li></ul></ul><ul><ul><ul><li>Renal cyst </li></ul></ul></ul><ul><ul><li>Aneurysms </li></ul></ul><ul><ul><ul><li>Aortic aneurysm </li></ul></ul></ul><ul><ul><li>Saccular organs e.g. GB </li></ul></ul><ul><ul><ul><li>Porcelain Gallbladder </li></ul></ul></ul>Renal Cyst Gallbladder Wall
  67. 74. Linear or Track-like <ul><li>Walls of a tube </li></ul><ul><ul><li>Ureters </li></ul></ul><ul><ul><li>Arterial walls </li></ul></ul>Atherosclerosis Calcification Vas Deferens
  68. 75. Lamellar or Laminar <ul><li>Formed in lumen of a hollow viscus </li></ul><ul><ul><li>Renal stones </li></ul></ul><ul><ul><li>Gallstones </li></ul></ul><ul><ul><li>Bladder stones </li></ul></ul>Stone in Ureterocoele Staghorn Calculi
  69. 76. Cloudlike, Amorphous, Popcorn <ul><li>Formed in a solid organ or tumor </li></ul><ul><ul><li>Leiomyomas of uterus </li></ul></ul><ul><ul><li>Ovarian cystadenomas </li></ul></ul>Nephrocalcinosis Myomatous Uterus
  70. 77. Visceral Inflammation Colitis Appendicitis Diverticulitis Bowel Inflammation Cholecystitis Pancreatitis
  71. 78. Inflammation - Cholecystitis <ul><li>Acute cholecystitis is inflammation of the gallbladder </li></ul><ul><li>usually from impaction of a gallstone within the cystic or common bile duct . </li></ul><ul><li>Ultrasound is the preferred imaging method to confirm cholecystitis in the appropriate clinical setting . </li></ul><ul><li>CT findings of cholecystitis include : 1 . Cholelithiasis 2 . Gallbladder wall thickening 3 . Pericholecystic fluid . Complicated cases may reveal perforation or hepatic abscess formation . </li></ul>
  72. 79. <ul><li>Acute calculous cholecystitis: </li></ul><ul><li>Calculus obstructs the cystic duct </li></ul><ul><li>The trapped concentrated bile irritates the gallbladder wall, causing increased secretion, which in turn leads to distention and edema of the wall. </li></ul><ul><li>Rising intra luminal pressure compresses the vessels, resulting in thrombosis, ischemia, and subsequent necrosis and perforation of the wall. </li></ul>
  73. 80. Thickening of gallbladder wall Cholelithiasis .
  74. 84. Pancreatitis <ul><li>Acute pancreatitis is most often secondary to alcohol abuse or gallstone impaction in the distal common bile duct . </li></ul><ul><li>Other causes include trauma, cryptogenic, tumor, infection, hyperlipidemia, and ERCP . CT Findings typical of pancreatitis include : </li></ul><ul><li>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 ) </li></ul>
  75. 85. Notice the peripancreatic stranding ( bars ) as well as the fluid thickening of the interfascial space
  76. 86. <ul><li>A common complication of pancreatitis is the development of pancreatic necrosis . </li></ul><ul><li>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% . </li></ul>
  77. 87. Pancreatic necrosis
  78. 88. Pancreatic pseudocyst
  79. 90. Appendicitis <ul><li>Right lower quadrant pain, fever and leukocytosis are the classical clinical findings . </li></ul><ul><li>CT and US are being used more often to confirm clinical suspicions and reduce the number of unnecessary laporotomies . </li></ul><ul><li>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 </li></ul>
  80. 91. This image of an acute abdomen ( arrow ) displays periappendicial stranding and dilattion of its terminal portion .
  81. 92. For comparison, this image of a normal appendix can be visualized at the ileocecal junction . Also notethe fat ventralcontaining heria
  82. 93. Inflammation - Colitis <ul><li>Colitis, or inflammation of the colon, is a frequent cause of abdominal pain . </li></ul><ul><li>Specific entities which produce inflammatory thickening of the colon include:- </li></ul><ul><li>Diverticulitis, inflammatory bowel disease, pseudomembranous colitis, and other bacterial infections ( i . e . typhlitis ). </li></ul>
  83. 95. This example of colitis shows thickening of the colon and pericolonic stranding typical of inflammation .
  84. 96. Thickening of sigmoid colon due to pseudomembranous colitis
  85. 97. A case of diverticulitis showing a thickened sigmoid colon and a diverticulum
  86. 98. Diverticulitis
  87. 99. Distal ureteral stone lead ing to right hyrdronephrosis in above image Ureteral junctional stone Renal Colic
  88. 100. Renal stone right sided hydronephrosis Renal Colic
  89. 101. Aortic aneurysms
  90. 102. Case give a diagnosis
  91. 119. The End
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