DAVID SUTTON PICTURES THE ACUTE ABDOMEN ONLY FOR STUDY PURPOSE

1. 22
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 22.1 Air swallowing.
There is slight gaseous
distension of both small
and large bowel, but this
extends down to the
rectum. A 7-year-old girl
admitted to hospital with
abdominal pain and
distension following a single
episode of vomiting. At the
time of admission she was
distressed and crying.
Shortly after admission her
bowels were opened
normally and the abdominal
distension and pain
disappeared.

4. • Fig. 22.2 Pneumoperitoneum. Erect chest film. Free intra-abdominal
gas is clearly demonstrated under the right hemidiaphragm. Under the
left hemidiaphragm a small triangular collection of free gas can be
identified between loops of gas-filled bowel (arrow).

5. • Fig. 22.3 Pneumoperitoneum. Abdomen, supine. A triangular
collection of free gas is demonstrated in the subhepatic region
(arrows). The falciform ligament is also outlined (arrowheads).

6. • Fig. 22.4 Pneumoperitoneum. Abdomen, supine.
Visualisation of both sides of the bowel wall
(Rigler's sign). Both the inside and outside wall of
multiple loops of small bowel can be clearly
identified.

7. • Fig. 22.5 Free intraperitoneal gas. (A) On
abdominal windows the free gas is not well
seen anteriorly. (B) On wide window settings,
the free gas is much more obvious.

8. • Fig. 22.6 Pseudopneumoperitoneum. A band of curvilinear
pulmonary collapse (arrows) with a crescent of normal lung
beneath it simulates a pneumoperitoneum almost exactly.

9. • Fig. 22.7 Pneumoperitoneum without peritonitis.
Small-bowel pneumatosis. Free gas is readily identified
under the left hemidiaphragm and there is a thin
crescent of gas under the right hemidiaphragm. The
typical cysts of pneumatosis can be identified in the
small bowel under the right hemidiaphragm. A 69-
year-old man admitted with haematemesis. (Courtesy
of Dr A. R. Carter.)

10. • Fig. 22.8 Acute gastric dilatation. Abdomen,
supine. A 38-year-old woman admitted in
diabetic precoma.

11. • Fig. 22.9 Small-bowel obstruction: (A) supine; (B) erect. Multiple dilated
loops of both gas-filled and fluid-filled small bowel are readily identified.
There is little or no gas in the large bowel. Multiple fluid levels are noted
on erect film. A 77-year-old woman with a past history of several
abdominal operations. The small-bowel obstruction was presumed to be
due to adhesions and resolved with conservative management.

12. • Fig. 22.10 Small-bowel obstruction, 'string of beads' sign.
Erect film. The dilated proximal small bowel is predominantly
gas filled with a few long fluid levels. More distally, the small
bowel is fluid filled and bubbles of gas are trapped between
the valvulae conniventes, producing a chain of bubbles.

13. • Fig. 22.11 Small-bowel obstruction due to a
metastatic deposit. Very dilated small bowel
leads into the mass at the point of transition
to collapsed small bowel.

14. • Fig. 22.12 Small-bowel obstruction due to left
femoral hernia. (A) Dilated small-bowel loops
in the midabdomen. (B) There is a left
femoral hernia containing a bowel loop.

15. • Fig. 22.13 Strangulated small bowel loop.
There is whorled mesenteric thickening with
an adjacent loop of small bowel with a
thickened wall.

16. • Fig. 22.14 Small-bowel obstruction due to an
incisional hernia in an obese patient. (A) CT scout
image showing dilated small bowel, and
illustrating the degree of obesity. (B) CT
demonstrating the midline incisional hernia
containing a bowel loop.

17. • Fig. 22.15 Appendix abscess causing small-bowel
obstruction. A small gas bubble which lies within the
abscess (arrow) is seen in the right iliac fossa. Age 11
years, vomiting with some diarrhoea for 1 week.

18. • Fig. 22.16 Gallstone ileus. Supine film. Multiple
dilated loops of small bowel are seen. A band of
gas in the right hypochondrium (arrowheads) lies
within the common bile duct. The obstructing
gallstone cannot be identified.

19. • Fig. 22.17 Small-bowel obstruction due to an
ileal faecolith. (A) Dilated small bowel loops.
The gallbladder appeared normal. (B) Image
through the pelvis. At the transition from
dilated to collapsed bowel is a large densely
calcified intraluminal faecolith.

20. • Fig. 22.18 Intussusception. Supine film. There
are multiple gas-filled loops of slightly dilated
small bowel. In addition, there is a soft-tissue
mass in the right iliac fossa (arrow). A 5-month-
old child with mesenteric adenitis.

21. • Fig. 22.19 Small-bowel obstruction due to a
small-bowel melanoma metastasis which has
caused jejunal intussusception. The grossly
dilated loop of jejunum contains oral contrast
medium, and leads into the intussusception,
which contains the characteristic central
mesenteric fat (arrow).

22. • Fig. 22.20 Large-bowel obstruction: the different types (after Love). Type
IA: Competent ileocaecal valve. Distended large bowel, particularly
ascending colon and caecum. No distension of small bowel. Type I B:
Competent ileocaecal valve. Caecal distension and small-bowel distension.
Type II: Incompetent ileocaecal valve. No distension of caecum and
ascending colon but distension of small bowel. Caecal perforation is much
more likely to occur in type I large-bowel obstruction.

23. • Fig. 22.21 Large-bowel obstruction type IA
(competent ileocaecal valve). Supine film. There is
gaseous distension of the large bowel from the sigmoid
backward, including the ascending colon and caecum.
The dilated caecum lies in the pelvis. There is no visible
small-bowel distension. (Carcinoma of the sigmoid.)

24. • Fig. 22.22 Pseudo-obstruction: (A) supine abdomen; (B) barium enema.
On the plain film, gas-filled loops of both small and large bowel can be
identified, with gas extending down to the rectum. The barium
examination demonstrates diverticular disease in the sigmoid but this is
not obstructing, and barium flows freely into the dilated descending colon.
Conservative management, using a flatus tube, failed and a laparotomy
had to be undertaken. Dilated small and large bowel were found but there
was no obstructing lesion. A caecostomy was performed.

25. • Fig. 22.23 Caecal
volvulus. Supine.
The considerably
distended caecum
with its haustral
markings is readily
identified lying low
in the central
abdomen. There is
no significant small-
bowel distension.

26. • Fig. 22.24 Sigmoid
volvulus. Supine film.
The hugely dilated
ahaustral loop of
sigmoid can be seen
rising out of the pelvis
in the shape of an
inverted U. Haustrated
ascending and
descending colon can
be identified separate
from the volved
sigmoid loop.

27. • Fig. 22.25 Paralytic
ileus. Supine film.
There is generalised
dilatation of both
small and large
bowel. An 84-year-old
woman with
generalised
peritonitis following
perforation of a
gastric ulcer.

28. • Fig. 22.26 Acute
inflammatory bowel
disease. Supine film. Loss
of haustration and irregular
mucosa, with mucosal
island formation, are most
readily identified in the
transverse colon. A 35-
year-old man with
progressive severe bloody
diarrhoea, subsequently
proven to have ulcerative
colitis.

29. • Fig. 22.27 Toxic
megacolon. Supine film. A
37-year-old woman with
progressively severe
diarrhoea over a period of
3 weeks, which failed to
respond to medical
treatment, subsequently
requiring a total
colectomy. Final diagnosis:
Crohn's disease.

30. • Fig. 22.28 Postoperative right subphrenic
abscess. (A) Chest X-ray showing a raised right
hemidiaphragm and small pleural effusion. (B)
CT demonstrates the subphrenic collection
(arrow).

31. • Fig. 22.29 (A,B) CT scans of prone patient showing a
large right subhepatic abscess secondary to gallbladder
surgery. Electronic cursors are used to measure (A)
distance from midline to avoid kidney, and (B) distance
to centre of abscess. (C) Prone X-ray, showing catheter
in situ after insertion from posterior approach. A small
amount of contrast medium has been injected.
(Courtesy of Dr David Sutton.)

32. • Fig. 22.29 (A,B) CT scans of prone patient showing a large right subhepatic abscess
secondary to gallbladder surgery. Electronic cursors are used to measure (A) distance
from midline to avoid kidney, and (B) distance to centre of abscess. (C) Prone X-ray,
showing catheter in situ after insertion from posterior approach. A small amount of
contrast medium has been injected. (Courtesy of Dr David Sutton.)

33. • Fig. 22.30 Intra-abdominal abscess. "In-leucocyte scan, 24 h
film. Postoperative repair of aortic aneurysm. No localising
clinical signs. Accumulation of isotope in the right iliac
fossa, with isotope in the right side of the colon indicating
enteric communication. (Courtesy of Dr A. I. Coakley.)

34. • Fig. 22.31 Acute appendicitis. Ultrasound in the right
iliac fossa demonstrating a hypoechoic non-
compressible tubular structure measuring more than 6
cm in diameter, with surrounding hyperechoic fat.

35. • Fig. 22.32 Acute
appendicitis. Ultrasound in
the right iliac fossa
demonstrating a non-
compressible thickened
appendix in transverse
section, with surrounding
hyperechoic fat.

36. • F19.22.33 Acute appendicitis. CT showing an
appendix which contains a dense
appendicolith, with surrounding inflammatory
changes.

37. • Fig. 22.34 Appendix inflammatory mass. CT
shows soft-tissue density in the right iliac
fossa containing an appendicolith. Abscess
formation was seen on adjacent images.

38. • Fig. 22.35 Acute cholecystitis. (A) Ultrasound
examination. (B) Diagram. A distended
gallbladder has been identified, with a
considerably thickened gallbladder wall. Markers
placed across the gallbladder wall indicate a
thickness of 9 mm. No gallstones have been
identified. (Courtesy of Dr M. 0. Downes.)

39. • Fig. 22.36 Acute pancreatitis-pancreatic
pseudocyst. (A) Ultrasound. (B) Diagram. A large
transonic area is demonstrated in the region of
the head of the pancreas, and, within it, irregular
echoes represent pancreatic debris. Ten days
following an attack of acute pancreatitis.
(Courtesy of Dr M. 0. Downes.)

40. • Fig. 22.37 Leaking aortic aneurysm. Supine film. The faintly
calcified rim of an aortic aneurysm is identified (arrowheads). In
addition, there is a large soft-tissue mass outside the aneurysm,
indicating a retroperitoneal haematoma. The outlines of the psoas
and renal margins on the left are lost.