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Plain picture in acute abdomen
The document discusses using plain radiography to evaluate patients presenting with an acute abdomen. It describes the basic radiographic views that should be obtained, including supine and erect abdominal views. Key findings on plain films that can help diagnose conditions causing acute abdomen are discussed, such as pneumoperitoneum, intestinal obstruction, and gastric dilatation. The document provides examples of radiographic signs and mimics for various acute abdominal pathologies.
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Plain picture in acute abdomen
- 1. Plain picture inacute abdomen Moderator- Dr (Prof). R. K. Gogoi Presenter: Dr. Sarbesh Tiwari
- 2. INTRODUCTION • Acute abdomenrefers to presence of severe abdominal pain developing suddenly or over a period of several hours. • Most frequent reasons for presentation at the emergency department (ED). • It requires a clinician to make an urgent therapeutic decision. 2
- 3. Plain Radiography • Plainabdominal radiography is traditionally the first radiological investigation in acute abdomen • Interpretation of plain films presents with formidable challenge because though specific diagnosis can be made, not infrequently the appearance are non specific and misleading. 3
- 4. Basic radiographs A supineAbdomen radiograph & Basic standard radiographs Erect Chest x ray Erect abdomen Left lateral decubitus (right side raised) are taken to add information Patient to remain in given position – 10 minutes 4
- 5. Erect chest radiograph: oSmall pneumoperitoneum can be detected o Various chest conditions may mimic an acute abdomen. o Acute abdominal conditions may be complicated by chest pathology o Even a normal chest radiograph acts as a baseline and helps in detection of post operative complication. 5
- 6. Chest Conditions thatmimic acute abdomen 1. Pneumonia 2. Myocardial Infarction 3. Pulmonary Infarction 4. Congestive cardiac failure 5. Pericarditis 6. Leaking or dessecting thoracic aortic aneurysm 7. Pneumothorax 8. Pleurisy 6
- 7. Abdominal radiographs:(kv:60-65, short exposure time) o Supine abdominal radiograph- Distribution of gas Calibre of bowel Displacement of bowel Obliteration of fat lines o Erect abdominal radiograph- fluid level and free gas o Horizontal-ray films( erect or lateral decubitus)- free intra- abdominal air, fluid levels 7
- 8. TECHNIQUE standard projection • supine with knee Anteroposterior supine slightly flexed. • centered at iliac crest. • Exposure during expiration • Low kV (60-75 kV) • Short exposure time to avoid motion • Both the lung bases and the pubic symphysis included. 8
- 9. Supplemental projections Abdomen AP erect • Ideally, tilting x ray table with potter Bucky diaphragm used to reduce distress to patient • 14”- 17” film, high mA, short exposure time, increased 7-10 kVp over supine. • Centered just above umbilicus in midline 9
- 10. ADDITIONAL PROJECTIONS • Prone,Oblique, Lateral • For better definition and localization of • mass lesions • calcifications • herniations • A prone radiograph is useful when distal colonic obstruction is suspected. 10
- 11. RADIATION EXPOSURE • OnePP abdomen exposes a patient to 0.7 mSv of radiation, equivalent to 35 chest radiograph. • Gonadal shielding should be used if gonads lie within 5 cm of the primary beam, if clinical objective is not compromised 11
- 12.
- 13. NORMAL GAS PATTERN •Stomach - always • Small bowel - 2 or 3 loops of non-distended bowel - normal diameter = 2.5 cm • Larger bowel - in rectum or sigmoid colon - always
- 15. NORMAL FLUID LEVELS • Stomach - always (except supine film) • Small bowel - 2 or 3 levels possible • Large bowel - none normally
- 17. DISEASE ENTITY PNEUMOPERITONEUM 17
- 18. • Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity • Almost always caused by perforation of hollow viscus. • Perforated duodenal ulcer is the most frequent cause 18
- 19. CAUSES 1. Perforation • Pepticulcer disease • Inflammation- Diverticulitis, toxic megacolon,necrotizing enterocolitis • Infraction • Pneumatosis coli- The cyst may rupture • Maliganacy. • Mechanical perforation following trauma 2. Iatrogenic • Abdominal surgery • Peritoneal dialysis 3. Pneumothorax- due to congenital pleuroperitoneal fistula. 19 4.Introduction per vaginum- e.g. douching
- 20. RADIOGRAPHY • Optimal radiographictechnique is important. • At least 2 radiographs, • a supine abdominal radiograph and • either an erect chest image or a left lateral decubitus image. • The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired. • As minimal as 1ml of free gas could be detected by proper technique. 20
- 21. Signs in pneumoperitoneum Erect chest radiograph reveals free gas between the liver and both does of diaphragm. 21
- 22. Left lateral decubitusfilm showing gas between the liver and abdominal wall. 22
- 23. Signs of pneumoperitoneumof supine radiograph • Right upper quadrant gas Peri hepatic Sub hepatic Morrison’s pouch • Fissure for ligament teres • Rigler’s (double wall sign) • Ligament visualization Falciform Umbilical inverted ‘V’ sign • Triangular air • The cupola sign • Football or air dome • Scrotal air in children 23
- 24. Gas in subhepaticspace Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space 24
- 25. Doges cap sign •Doges Cap sign refers to free air in Morrison's pouch. • Morrison's pouch is normally a potential space between the right kidney and the liver 25
- 26. Triangular gas shadowsuperior to kidney and postero- inferior to 11th rib 26
- 27. Rigler’s sign Rigler's signrefers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air .The extra luminal air is free peritoneal gas 27
- 28. Falciform ligament visualization Visualizationof Falciform ligament by free gas on either side of 28 the ligament
- 29. Football sign • Thefootball sign likens the massively air- filled peritoneum to an American football • In the supine position, free air collects anterior to the abdominal viscera, producing a sharp interface with the parietal peritoneum and thereby creating the football outline 29
- 30.
- 31. Double Bubble Sign Twocollections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of 31 the stomach
- 32. The Cupola Sign Anarcuate collection of free intraperitoneal air beneath the central tendon of diaphragm. The superior border is well defined (arrows) 32 compared with the inferior extent of the collection.
- 33. The Triangle Sign Thetriangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow) 33
- 34. CONDITIONS SIMULATING PNEUMOPERITONEUM 1. Chilaiditi’s syndrome-intestine between liver and diaphragm 2. Subphrenic abscess 3. Curvilinear supradiaphragmatic pulmonary collapse 4. Subdiaphragmatic fat 5. Cyst in pneumatosis intestinalis 6. Sub pulmonary pneumothorax 34
- 35. CONDITIONS SIMULATING PNEUMOPERITONEUM Chilaiditi‟s syndrome- intestine between liver and diaphragm 35
- 36. CONDITIONS SIMULATING PNEUMOPERITONEUM Rightsided subphrenic abscess 36
- 37. CONDITIONS SIMULATING PNEUMOPERITONEUM Large bulla at the base of the right lung mimics a large pneumoperitoneum 37
- 38.
- 39. GASTRIC DILATATION Causes 1. Mechanicalgastric outlet obstruction. 2. Paralytic ileus 3. Gastric volvulus 4. Air swallowing. 39
- 40. GASTRIC VOLVULUS o Twistingof the stomach around its longitudinal or mesenteric axis o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed, with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen 40
- 41. • Mesenteroaxial volvulus--less common , occurs when the stomach rotates along its short axis, with resultant displacement of the antrum above the gastroesophageal junction 41
- 42. SMALL BOWEL OBSTRUCTION •Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed • The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions) • A small bowel diameter on plain film greater than 30mm is considered dilated 42
- 43. Clinical Presentation ofSBO Abdominal pain Rapid onset of nausea and vomiting Belching Abdominal swelling Constipation and obstipation. Squealing bowel sounds (early obstruction) No bowel sounds (bowel wall muscular exhaustion) 43
- 44. SMALL BOWEL OBSTRUCTION •Extrinsic causes - adhesions( most common) - hernias - masses - congenital malrotations • Intramural causes - inflammatory strictures - ischaemia - primary small bowel tumours • Intraluminal causes - gall stones -foreign bodies 44
- 45. PLAIN RADIOGRAPH • Plainfilm Signs appear after 3-5 hours marked after 12 hours • Supine abdominal X-rays- dilated gas filled bowel loops (more than 2.5 cm) with little or no gas in colon • Erect films shows- multiple fluid level assuming a „„step-ladder apperance‟‟ • „„String of pearls sign‟‟- - Seen in decubitus or upright film and is virtually diagnostic of SBO 45
- 46. markedly distended loopsof small bowel, with effacement Step ladder pattern of the Valvulae in the mid produced by air fluid abdomen levels in erect film 46
- 47. STRING OF PEARLSIGN Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows), which represents air trapped between the Valvulae Conniventes. 47
- 48. The coiled springappearance only occurs in the dilated air- filled small bowel. It is most noticeable in the jejunum where the valvulae conniventes are closely spaced 48
- 49. GASLESS SMALL BOWELOBSTRUCTION Gasless fluid filled dilated small bowel All the air is absorbed Difficult to differentiate with normal bowel loops 49
- 50. PARALYTIC ILEUS • lleusoccurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction. • Causes- 1. Post operative ileus 2. Electrolyte imbalance 3. Sepsis 4. Generalised peritonoitis 5. Blunt abdominal trauma 6. Infiltration of mesentry by tumor 50
- 51. PARALYTIC ILEUS • Difficultto distinguish adynamic ileus from mechanical obstruction based on single radiograph • Degree of distension varies and features are not specific • Generalized distension- difficult to distinguish from low large bowel obstruction 51
- 52.
- 53. Differentiating SBO fromParalytic Ileus SBO Ileus Patient with prior Recent (hours) post- Etiology surgery weeks to years operative patient prior Pain Colicky Not a prominent feature Abdominal Frequently prominent May not be apparent distension Bowel sounds Usually increased Usually absent Small bowel Present Present dilatation Large bowel Absent Present dilatation 53
- 54. STRANGULATING OBSTRUCTION • Occurswhen two limbs of a loop are incarcerated by a band or in a hernia, compromising the blood supply • Plain radiograph - soft tissue mass or pseudotumour -gas filled loops separated by thickened walls may resemble a large coffee bean - if gangrene occurs, lines of gas seen in the wall of the small bowel 54
- 55. Dilated small bowel loopswith an obstructed bowel in the right inguinal canal. 55
- 56. GALLSTONE ILEUS • Mechanicalintestinal obstruction due to impaction of gall stones in the intestine • Comprises about 2% of small bowel obstruction • Unusual complication of chronic cholecystitis • Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula • Average age of diagnosis is 70 years. 56
- 57. • The classic radiographic signs, described by Rigler • Rigler’s traid:- 1. Incomplete or complete SBO 2. Gas within gall bladder/bile duct 3. Ectopic location of gall stone 57
- 58. INTUSSUSCEPTION • It isthe invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens) • Commonly seen in children below 2 years • Ileocolic segment involved in 90% cases • Colocolic and ileoileal intussusception may occur • Common in the ileum due to inflammation of the lymphoid tissue in Peyer’s patches 58
- 59. INTUSSUSCEPTION • In adultsusually secondary to tumor of the bowel. • Results in small bowel obstruction • Crescent sign-Soft tissue mass, sometimes surrounded by a crescent of gas, most commonly in Rt.hypochondrium. • Target sign- two concentric circles of fat density lying to the rt. of spine. • Target sign twice as common as crescent sign 59
- 60. There is aprominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant. 60
- 61. Intussusceptions in theleft upper quadrant on this plain film of an infant with pain vomiting 61
- 62. SMALL INTESTINAL INFARCTION •Thrombosis or embolism of superior mesentric artery • FEATURES 1. Gas filled dilated loops with multiple fluid levels. 2. Thickened bowel loops owing to submucosal edema or hemorrhage. 3. Linear gas in wall streaks suggest gangrene. 4. Free gas if perforation. 5. Intra luminal gas in mesentric veins or portal vein in advanced cases. 62
- 63. Intramural gas with positiverigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction. 63
- 64. • LARGE BOWELOBSTRUCTION 64
- 65. Large Bowel Obstruction •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 65
- 66. Etiology • Mechanical obstruction 1. Carcinoma of colon (60%) 2. Diverticulitis (second most common) 3. Volvulus 4. Extrinsic compression • Paralytic ileus. AKA acute colonic psudo- obstruction, was first described by Ogilvie 66
- 67. LARGE BOWEL OBSTRUCTION-types • TYPE 1 A • Large bowel distension only- • Owing to competent ileocaecal valve. • Caecum at risk of perforation 67
- 68. LARGE BOWEL OBSTRUCTION-types • TYPE 1 B • Competent ileocaecal valve leading to caecal distension but also as a mechanical obstruction to small bowel • Caecum at risk of perforation. 68
- 69. LARGE BOWEL OBSTRUCTION-types • TYPE II • Large and small bowel distension • Incompetent valve 69
- 70. Large bowel Volvulus •Sigmoid colon and caecum - most common sites • If twist greater than 360 degrees, unlikely to resolve spontaneously. • The risk of vascular compromise more important than mechanical effects • Compound volvulus, involving interwining of two loops of bowel is rare, such as ileosigmoid knot. 70
- 71. CAECAL VOLVULUS • Torsionof the bowel around its own mesentery and often results in a closed-loop obstruction • Occurs due to development failure of peritoneal fixation. • Accounts for 2-3% case of intestinal obstruction and 11% cases of colonic volvulus. 71
- 72. The cecum twistsin the axial plane, rotating clockwise or counterclockwise around its long axis. At times caecum twists and inverts and occupy left upper quadrant. 72
- 73. PLAIN RADIOGRAPH • Plainfilm diagnostic in about 75%. • Dilated air filled caecum in an ectopic location, usually with the caecal apex in left upper quadrant • Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation. • Little gas in distal colon, and usually collapsed. • Refluxed gas may erroneously suggest a small bowel obstruction. 73
- 74. Even though thereis considerable distension of the caecum,one or two haustral markings can be usually seen,unlike sigmoid volvulus Identification of attached gas filled appendix confirms diagnosis. 74
- 75. SIGMOID VOLVULUS • Accountsfor 60-70% of colonic volvulus • Classically occur in old age, psychiatrically disturbed, mentally retarded or institutionalised people. • Twists around mesenteric axis, rarely with axial torsion. 75
- 76. SIGMOID VOLVULUS-findings • Dilatedloop of sigmoid colon that has a inverted U configuration with absent haustral margin is an important diagnostic point • Left flank overlap sign • Liver overlap sign • Apex under left hemidiaphram • Apex above 10th thoracic vertebra • Inferior convergence on left 76
- 77.
- 78.
- 79. COLONIC PSEUDO OBSTRUCTION •Also known as OGILVIE syndrome • Due to autonomic imbalance • Acute abd distension within10 days of precipitating pathology • Contrast enema/ CT required to exclude mechanical obstruction. 79
- 80. DISTINCTION BETWEEN SMALLAND LARGE BOWEL OBSTRUCTION Small bowel Large bowel Valvulae Present in Absent Conniventes jejunum Number of loops Many Few Distribution of Central Peripheral loops Haustra Absent Present Diameter 3-5 cm >5cm Radius of small large curvature Solid faeces Absent Present 80
- 81. Acute colitis • Anassessment of the extent of colitis, state of mucosa,depth of ulceration,presence or absence of toxic megacolon and perforation can be made. • The extent of faecal residue related to the extent of colitis. • ‘Empty abdomen’-no faecal residue or gas s/o active total colitis • Intra luminal gas tend to accumulate as colitis progress. 81
- 82. Acute ulcerative colitis- descending colonwith irregular outline, absent haustrations, absent faecal residue 82
- 83. TOXIC MEGACOLON • Fulminatingform of colitis with trans mural inflammation. • Perforation and peritonitis common • Radiologically-dilatation and nodular mucosa. • Dilatation >55mm- significant and sufficient, • Changes most frequent in transverse colon. • Gaseous distension of small bowel- severe colitis – poor prognosis 83
- 84. TOXIC MEGACOLON • Plainabdominal radiograph shows distention of the transverse colon associated with mucosal edema. • The maximum transverse diameter of the transverse colon is 6 cm 84
- 85. • ISCHAEMIC COLITIS oDisorder caused by vascular insufficiency and bleeding into the wall of the colon o Preferentially involves the splenic flexure and the proximal descending colon. o Radiographically, difficult to identify unless some intra luminal gas present. o Submucosal thickening with cresentic margins (thumb- printing). o Involved area acts as a functional obstruction, so proximal parts frequently distended 85
- 86.
- 87. PSEUDOMEMBRANOUS COLITIS • Commoncause of antibiotic associated diarrohea • Clostridium difficile is usually involved • 1/3 rd cases shows positive findings on plain films. • Colonic dilatation (32 %) • Thumb printing, thickened haustra, abnormal mucosa (18 %) • Untreated cases develops toxic megacolon and subsequent perforation. • Associated small bowel dilation(20 %), ascites (7 %) may be seen. 87
- 88. extensive haustral thickening (arrows)in a patient with pseudomembranous colitis 88
- 89.
- 90. ACUTE APPENDICITIS o Commonestacute surgical condition in the developing country o Radiological signs- Appendix calculus(0.5-0.6)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening / blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix 90
- 91. Appendicoliths are foundin 10% of cases. Its presence with pain in rt lower abdomen is highly suggestive of diagnosis.91
- 92. ACUTE CHOLECYSTITIS • Gallstones- in 20% only • Porcelein GB • Right hypochondrial mass due to enlarged gall bladder. • Duodenal ileus • Ileus of hepatic flexure of colon • Gas within biliary system 92
- 93.
- 94. ACUTE PANCREATITIS • Acutepancreatitis refers to acute inflammation of the pancreas. • Causes • Gallstones (most common) • Alcohol abuse, usually chronic • Trauma, more often penetrating • Drug-induced • Anatomic abnormality • ERCP-induced • Infectious, especially post-viral in children • Vasculitis • Idiopathic 94
- 95. ACUTE PANCREATITIS • Pathologicalchanges are edema, hemorrhege,lnfarction,fat necrosis followed by acute suppuration • Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space. • Lot of radiological signs described, but many are of little value in diagnosing individual cases. 95
- 96. Plain film changes- Chest x-ray- o Left sided pleural effusion o Splinting of left hemidiaphragm o Basal atelactasis Abdominal film- o Duodenal ileus o Gasless abdomen o “colon cut off” sign o Renal “halo” sign o Absent left psoas shadow o Indistinct mottled shadowing o Sentinel loop o Intrapancreatic gas-abscess/ enteric fistula 96
- 97. The abrupt terminationof gas within the proximal colon at the level of the radiographic splenic flexure, usually with decompression of the distal colon 97
- 98. A sentinel loopis a focal area of adynamic ileus close to an intra- abdominal inflammatory process. The sentinel loop sign may aid in localizing the source of inflammation 98
- 99. • Later stages-pancreatic pseudocyst visible on plain film as large soft tissue mass • Pleural effusions, mainly left sided. 99
- 100. INTRA-ABDOMINAL ABSCESS • Abscessesare collections of pus that may displace adjacent structures following their involvement by inflammatory process • Usually of soft tissue density on plain films,but frequently contain gas. • Recognition of small gas bubbles outside bowel lumen,unchanged in position on sequential films, strongly s/o abscess. 100
- 101. SUBPHRENIC ABSCESS • Nearlyalways occurs as a result of surgery • Chest X-ray - raised hemidiaphragm - basal consolidation - pleural effusion Abdominal radiographs - gas/fluid level - Irregular gas pocket - Scoliosis towards the lesion - localised paralytic ileus Fluoroscopy- decrease diaphragmatic movement - locates small gas-fluid level/ irregular gas pockets 101
- 102. INTRA-ABDOMINAL ABSCESS Subhepatic abscess •A gas/fluid level is seen beneath the right hemidiaphragm. Note also the pleural effusion. The abscess developed in a 45-year- old woman following a cholecystectomy. 102
- 103. PARACOLIC ABSCESS Lies closeto the site of causative lesion Diverticulosis and appendicitis are the commonest causative lesions Soft tissue mass, often containing gas bubbles, and displacing colon – m.c radiographic presentation 103
- 104. INTRAMURAL GAS • Gaswithin walls of hollow viscus • Classification Cystic pneumatosis Interstitial emphysema Gas-forming infections 104
- 105. Cystic pneumatosis (Pneumatosis cystoides intestinalis) • Cyst like collections of gas in the walls of the hollow viscera • Left half of colon most frequently involved- pneumatosis coli • Plain abdominal radiographs- Gas containing cyst Pneumoperitoneum 105
- 106. INTERSTITIAL EMPHYSEMA • Linear gas, in single or double streaks, is found in the bowel wall • Common site- stomach & colon • Associated with toxic megacolon Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen Emphysematous cholecystitis -occurs in absence of gallstones 106
- 107. Necrotizing enterocolitis- in premature babies - generalised bowel distension - bowel wall thickening - pneumatosis - associated with gas in the portal vein Emphysematous cystitis- - linear gas streaks and gas cysts within the wall of the urinary bladder & within the lumen of the bladder 107
- 108. Linear or curvilinear lucenciesare seen in the walls of the bowel 108
- 109. Emphysematous gastritis Emphysematous cysytitis09 1
- 110.
- 111. OTHER CONDITIONS 111
- 112. RENAL COLIC • Ahigh proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen • About 90% of renal stones are radio-opaque. Uric acid stones especially may be missed • Plain abdominal radiograph- Calculi (90%) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines 112
- 113.
- 114. Emphysematous Pyelonephritis •Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule • Occurs in uncontrolled Diabetes or Obstructive uropathy 114
- 115. ACUTE GYNAECOLOGICAL DISORDERS •Torsion of an ovarian cyst- pelvic mass • Dermoid cyst- contains calcification, teeth or fat • Ruptured ectopic pregnancy- - pelvic mass - paralytic ileus - free intrapeitoneal fluid 115
- 116. Ovarian teratoma Pop cornlike / cauliflower – uterine leiomyoma 116
- 117. Abdominal Aortic Aneurysm •Presents as acute abdomen with shock and simulated renal colic • Curvilinear calcification seen on AP radiograph but is best detected on a lateral view • Calcified walls of aorta can allow measurement of lumen • AAA if over 3 cm AP diameter • Ultrasound and CT are much more sensitive 117
- 118.
- 119. ASCITES • Only largeamount of Ascites can be recognized on abdominal radiograph • Signs: 1.Obliteration of the inferior edge of the liver 2.Widening of the distance between the flank stripe and ascending colon. Normal is 2-3 mm 3. Fluid accumulation in the pelvis 4. centrally located bowel loops with bulging flanks 5. Ground glass appearnace_ requires large amount of fluid. 119
- 120. Supine view ofthe abdomen shows central displacement of the loops of bowel,a uniform grayness to the abdomen, loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of 120 the pelvis, all suggestive of ascites
- 121. Hydatid cyst inthe Liver 121
- 122. FOREIGN BODY IRON TABLETS BUTTON BATTERIES 122
- 123. • PAEDIATRICS 123
- 124. DUODENAL ATRESIA JEJUNAL ATRESIA 124
- 125.
- 126. Conclusion • Following thehistory and clinical examination, plain film radiographs have been one of the first and most useful methods of further investigation. • Plain picture continues to be initial imaging modility in acute abdomen, particularly in perforation and intestinal obstruction. • In cases where definite diagnosis cannot be reached, further evaluation with USG and CT scan is required. 126
- 127.
Editor's Notes
- #13 Subcostal plane : a plane corresponding to a line drawn joining the lowermost bony point of the rib cage - usually 10th costal cartilageThis corresponds the level of the body of the L3 vertebra. The origin of the superior mesentericartery and 3rd part of the duodenum lie on this planeTrans-tubercular plane : a plane corresponding to a line uniting the two tubercles of the iliac crests.The upper border of the L5 vertebra corresponds to this plane long with the confluence of the common iliac veins (i.e. commencement of the Inferior Vena Cava).
- #21 Pneumoperitoneum is detected in 76% of cases in erect film, but when a left lateral decubitus film is added the sensitivity is raised to 90%.
- #26 Triangular in shape, concave lateral border, positioned inferior to the right 11th rib, positioned superior to the right kidney
- #28 Coined by leorigler,american radiologist. Air is present on both sides of the intestine, i.e. when there is air on both the luminal and peritoneal side of the bowel wall.
- #31 The oval radiolucency seen in the football sign (Figure) represents massive pneumoperitoneum, which distends the peritoneal cavity. In the supine position, free air collects anterior to the abdominal viscera, producing a sharp interface with the parietal peritoneum and thereby creating the football outline. The pneumoperitoneum may outline the falciform ligament, which is seen as a faint linear opacity situated longitudinally within the right upper abdomen
- #33 Cupola is an inverted cup or a “dome”.. Seen in erect film.
- #35 Subdiaphragmatic fat is an extension of posterior pararenal fat, a normal finding.
- #36 Bowel loop, usually the transverse colon is interposed between the liver and the hemidiaphragm resulting in pain. Features that suggest a Chilaiditi syndrome (termed the Chilaiditi sign) include:1.gas between liver and diaphragm,2.rugal folds within the gas suggesting that it is within bowel and not free
- #40 Mechanical as a complication to peptic ulcer disease, antral carcinoma, extrensic compression over duodenum.Paralytic ileus – commonly post-operative, electolyte disturbance due to metabolic conditions like hepatic or diabetic coma,,, Inflamamtion like pancreatitis, cholecystitis or trauma.Drugs.
- #45 Post-surgical adhesions account for 60% of cases of acute SBO, can occur within 4wks of surgery.Or may present as chronic obstruction decades latter.
- #46 Factors affecting radiographic appearance_- 1. Duration of obstruction,2. Frequency of emesis 3. Use of nasogastric tube.
- #47 Three or more small bowel fluid levels longer than 2.5 cm are abnormal and indicates dilated small bowel, usually with stasis.
- #48 The obliquely oriented row of air bubbles represents small amounts of air trapped between the valvulaeconniventes along the superior wall of predominantly fluid-filled, dilated small-bowel loops. The meniscal effect of the surrounding fluid gives the trapped air an ovoid or rounded appearance.
- #51 Ileus means disruption of the normal propulsive activity of gastrointestinal tract.
- #52 Presence of gas in colon with decreased dilatation may give clue to diagnosis of paralytic ileus.
- #53 The appearance of generalisedadynamicileus is quite characteristic. The large and small bowel are extensively air filled but not dilated. That is the large and small bowel "looking the same“.
- #58 duodenum / stomach : leading to gastric outlet obstruction (Bouveret's syndrome)
- #63 Usually an elderly patient presents with acute onset abdominal pain with bloody diarrhoea.
- #75 Caecal Volvulus-Dilated loop of large bowel (cecum) in the left upper quadrant with little gas is seen distal part
- #77 The ahaustral margin can often be indentified overlapping respectively the lower border of the liver shadow(the liver overlap sign), the haustrated, dilated descending colon (the left flank overlap sign) and the left side of the pelvis (the pelvic overlap sign).The top the volvulus reaches very high in the abdomen (above 10th rib) with the apex on left side.
- #89 The classic findings are colonic dilation, nodular haustral thickening, and thumb printing. In this radiograph the thickening is most pronounced in the transverse colon.
- #98 Inflammatory exudate in acute pancreatitis that extends intothe phrenicocolic ligament. Infiltration of the phrenicocolic ligament results in functional spasm and/or mechanical narrowing of the splenicflexure at the level where the colon returns to the retroperitoneum. This transition point, or cutoff, is further accentuated bydistention of the intraperitoneal transverse colon from thefocal adynamicileus, which is also a result of the underlyinginflammatory process. This appearance can mimic a truecolonic obstruction
- #111 Air in the wall (blue arrows) of the gallbladder. There is also a lucency within the lumen of the gallbladder suggesting air inside the lumen. Just superior to the gallbladder is another collection of air (red arrow) that represents a pericholecystic abscess. The yellow arrow points to PEG tube in the stomach.
- #114 The severe pain which accompanies renal colic frequently leads to air swallowing and this, together with an associated paralytic ileus, frequently results in gas filled small and large bowel loops.
- #115 Emphysematous pyelonephritis. Patient with diabetes mellitus and sepsis. The left renal collecting system and ureterare distended and gas filled. There are also multiple dense gallstones in the gallbladder.
- #119 The mere presence of of an aortic aneurysm does not indicate dissection or leak. However, a soft tissue mass identified outside the calcified wall of an aneurysm or bowel gas displaced anteriorly or obscured psoas or renal outline suggests a leak.