ACUTE ABDOMEN ABNORMAL GAS COLLECTIONS

TERRENCE C. DEMOS, MDDEPARTMENT OF RADIOLOGY

OR

GAZ

• RADIOGRAPHS– LEFT LATERAL DECUBITUS ABDOMEN – UPRIGHT ABDOMENT– UPRIGHT CHEST– SUPINE ABDOMEN

ACUTE ABDOMEN EXAMINATION

PNEUMOPERITONEUM

FREE AIR SENSITIVITY OF IMAGING STUDIES

• COMPUTED TOMOGRAPHY 99%

• LATERAL UPRIGHT CHEST RADIOGRAPH 98%

• AP UPRIGHT CHEST RADIOGRAPH 80 - 90%

• LEFT DECUBITUS ABDOMEN RADIOGRAPH 80- 90%

• SUPINE ABDOMEN RADIOGRAPH ?

PNEUMOPERITONEUM SENSITIVITY OF IMAGING STUDIES

• RADIOLOGIC DEMONSTRATION DEPENDS ON:– VOLUME OF FREE AIR

– TIME INTERVAL BEFORE IMAGING

– TYPE OF IMAGING

– CONDUCT OF IMAGING EXAMINATION

• AS LITTLE AS ONE CC CAN BE DEMONSTRATED

• 10% OF PATIENTS WITH PERFORATED ULCERS DO NOT DEMONSTRATE PNEUMOPERITONEUM

UPRIGHT CHEST

PNEUMOPERITONEUMUPRIGHT RADIOGRAPHS

UNDER RIGHT HEMIDIAPHRAGMUPRIGHT ABD CENTRAL TENDON

AND HEMIDIAPHRAGM

FREE AIR…….DECUBITUS VIEWGAS BETWEEN LIVER AND BODY WALL

BUT MAY ALSO BE IN OR ONLY IN THE PELVIS

ACUTE ABDOMINAL PAINUPRIGHT AP CHEST & LEFT LATERAL DECUB NEGATIVE

PNEUMOPERITONEUM

SUPINE RADIOGRAPHS

GAS BUBBLE ON LIVER SURFACE

FREE AIRCENTRAL TENDON

FREE AIRCENTRAL TENDON

RIGLER’S SIGNBOTH SIDES OF BOWEL WALL VISIBLE

DOUBLE WALL SIGN

MASSIVE PNEUMOPERITONEUMFOOTBALL SIGN

FALCIFORM LIGAMENTGAS BUBBLE OVER LIVER

FALCIFORM LIGAMENT

PNEUMOPERITONEUMSUBHEPATIC GAS BUBBLE

DIVERTICULITIS PNEUMOPERITONEUM

ANTERIOR ABDOMINAL WALLANATOMIC FOLDS

FREE AIRINFERIOR EPIGASTRIC VESSELS

(LATERAL UMBILICAL LIGAMENTS)

FREE AIR 2 DAYS AFTER OHT

CT 3 DAYS LATER: DIVERTICULITIS

PNEUMOPERITONEUMWITH PERITONITIS

• PERFORATED VISCUS– ULCER– NEOPLASM– BOWEL OBSTRUCTION– ISCHEMIC BOWEL– TRAUMA

• TRAUMA

• PERITONITIS– GAS FORMING ORGANISM

PSEUDO-PNEUMOPERITONEUM

CENTRAL TENDON GAS

YES, BUT JUST THE STOMACH

GAS UNDER THE RIGHT HEMIDIAPHRAGM

HEPATIC FLEXURE ANTERIOR-SUPERIOR TO LIVER

SUBDIAPHRAGMATIC FATSIMULATING FREE AIR

FREE AIR OR NOT FREE AIR?THAT IS THE QUESTION

PNEUMOTHORAX SIMULATES FREE AIR

GAS IN SUBPHRENIC ABSCESS SIMULATES FREE AIR

RETROPERITONEAL GASSIMULATES FREE AIR

RETROPERITONEAL GAS

• LITTLE CHANGE IN POSITION OR SHAPE WHEN COMPARING SUPINE, UPRIGHT, DECUB RADIOGRAPHS

• BUT FREE INTRAPERITONEAL GAS IS FREELY MOBILE

• TENDS TO STAY IN ONE RETROPERITONEAL COMPARTMENT• DUODENAL PERFORATION…..RUQ ANTERIOR PARARENAL SPACE

• SIGMOID DIVERTICULITIS….. LLQ

• PERIRENAL ABSCESS…………. PERINEPHRIC SPACE

• OFTEN FORMS LINEAR, CURVILINEAR GAS COLLECTIONS

RETROPERITONEAL GAS IMAGING

49-YEAR-OLD MAN WITH FEVER AND DIARRHEA FOR 2 WEEKS. HE HAS INFECTED URINE

• BENEATH DIAPHRAGM CAN SIMULATE PNEUMOTHORAX• BUT MEDIAL, LATERAL, LOW NOT DIRECTLY UNDER APEX AS FREE AIR

– DIFFERENTIATE BY OBTAINING UPRIGHT OR DECUBITUS VIEWS

• LARGE VOLUME OF GAS CAN OUTLINE RETROPERITONEAL STRUCTURES

• KIDNEY, LIVER MARGIN, PSOAS, FLANK STRIPE

• RETROPERITONEAL GAS CAN EXTEND• CEPHALAD TO MEDIASTINUM

• FASCIAL PLANES OF BODY WALL AND EXTREMITIES

• INTO PERITONEAL CAVITY

RETROPERITONEAL GAS IMAGING

RETROPERITONEAL GAS

13-YEAR-OLD GIRL WITH CROHN’S DISEASE

HAS SUBACUTE FEVER AND ABD PAIN

RETROPERITONEAL GASEXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT

ABDOMINAL PAIN 4 HOURS AFTER COLONOSCOPY AND BIOPSY

EXTENSIVE RETROPERITONEAL GAS

BAROTRAUMAMEDIASTINUM – RETROPERITONEUM – FREE AIR

• IATROGENIC– SURGERY– DIAGNOSTIC PROCEDURE

• TRAUMA– PENETRATING– RUPTURED VISCUS

• RETROPERITONEAL DUODENUM, COLON, RECTUM

• PERFORATED BOWEL• SECONDARY TO TUMOR, INFECTION, OBSTRUCTION, NECROSIS

• CAUDAL EXTENSION OF PNEUMOMEDIASTINUM

• GAS WITHIN ABSCESS

RETROPERITONEAL GASCAUSES

BOWEL WALL GAS

PNEUMATOSIS OF COLON INFANT ADULT

NECROTIZING ENTEROCOLITIS

ISCHEMIC COLITIS

WHAT IS THE ABNORMALITY HERE?

USE LUNG WINDOWS TO LOOK FOR GAS

72-YEAR-OLD WOMAN WITH DIARREHA FOR 2 DAYS

NORMAL PHYSICAL EXAMINATION

58-YEAR-OLD WOMANMILD ABDOMINAL PAIN FOR 2 DAYS

DIFFERENTIAL DIAGNOSIS?

SCLERODERMA, GAS IN COLON WALL

PNEUMATOSIS 2 DAYS AFTER SEGMENTAL SB RESECTION

RESOLVED SPONTANEOUSLY, DISCHARGED AFTER 1 WEEK

BOWEL WALL GAS MAY BE INNOCUOUS

ASYMPTOMATIC 40-YEAR-OLD MAN

BENIGN STEADY STATE PNEUMATOSIS

ISCHEMIC BOWEL

ISCHEMIC BOWELIMAGING SIGNS

– DILATION • PSEUDOOBSTRUCTION

– BOWEL WALL• THICKENED• PNEUMATOSIS• UNENHANCING

– GAS IN VESSELS• MESENTERIC, SMV, PORTAL VEINS

– OBSTRUCTED VESSELS• SMA, SMV

– HIGH DENSITY CLOT ON UNENHANCED CT– FILLING DEFECTS ON CT WITH IV CONTRAST

– ASCITES, FREE AIR AFTER PERFORATION

ACUTE ONSET OF ABDOMINAL PAIN

SMA EMBOLIS

ISCHEMIC COLITIS IN TWO PATIENTS

ISCHEMIC SB AND COLONTHICKENED MUCOSAL FOLDS

SBOISCHEMIC BOWEL

AT SURGERY: SB TWISTED UNDERADHESION WITH OBSTRUCTI0N & SEGMENT OF DEAD BOWEL

61-YEAR-OLD MAN WITH PROSTHETIC AORTIC VALVE HAS ACUTE GI BLEEDING

ISCHEMIC COLITIS

ISCHEMIC SMALL BOWELETIOLOGY ?

SMV CLOT

47-YEAR-OLD WOMAN 2 WEEKS AFTER MI ACUTE ABDOMINAL PAINOCCULT BLOOD + STOOL

SMA EMBOLIS FROM MURAL THROMBUS

BILE DUCT GAS

BILE DUCT GAS• IATROGENIC

– BILE DUCT SURGERY– SPHINCTEROTOMY

• BILIARY FISTULA– GALLSTONE ERODING INTO BOWEL– DUODENAL ULCER– UPPER ABDOMINAL MALIGNANCY– TRAUMA

• CHOLANGITIS– GAS FORMING ORGANISM

BILE DUCT GAS

BILE DUCT GAS CHUNKY AND CENTRAL

59-YEAR-OLD MANHISTORY OF DUODENAL ULCER

BILE DUCT GAS AND SBO

SBO GALLSTONE ILEUS

GALLSTONE ILEUS

GALLSTONE ILEUS

GALLSTONE ILEUSBILE DUCT GAS, SBO, STONE

GALLSTONE ILEUS

86-YEAR-OLD MAN ABD PAIN, VOMITING X 2 DAYSNO HISTORY OF PRIOR SURGERY AND NO HERNIAS

82-YEAR-OLD MAN COMES TO ER ABDOMINAL PAIN AFEBRILE, NORMAL WBC

ABD 1 DAY LATER

THE 82-YEAR-OLD MAN NOW HAS THE DIAGNOSIS OF SBO AND A CT STUDY IS DONE

73-YEAR OLD MAN

SIGNED OUT AMA AFTER UGI

ONE YEAR LATERADMITTED WITH

ABD PAIN, VOMITING

75-YEAR-OLD WOMAN NAUSEA AND VOMITING X 1 DAY

GALLBLADDER COLON FISTULA

49-YEAR-OLD MAN WITH INTRACTABLE DIARRHEA

RADIOGRAPH 2YEARS EARLIER

GALLBLADDER GAS

GALLBLADDER GAS

• GALLBLADDER LUMEN– GALLBLADDER-BOWEL FISTULA– GALLSTONE ILEUS– EMPHYSEMATOUS CHOLECYSTITIS

• GALLBLADDER WALL GAS– EMPHYSEMATOUS CHOLECYSTITIS

EMPHYSEMATOUS CHOLECYSTITIS

EMPHYSEMATOUS CHOLECYSTITIS

EMPHYSEMATOUS CHOLECYSTITIS

38 Emph Chole

53-YEAR-OLD WOMAN

RUQ PAIN AND FEVER

SUPINE

UPRIGHT

LEFT LAT. DECUBITUS

2 WEEKS POST HEART TRANSPLANTFEVER AND ABDOMINAL PAIN

PREOPERATIVE RADIOGRAPH

PORTAL VEIN GAS

SMALL BOWEL ISCHEMIAGAS IN MESENTERIC AND PORTAL VEINS

48 SubPhrenic Abs CT

65-YEAR-OLD MANABDOMINAL PAIN, NORMAL PX

PORTAL VEIN GAS DELICATE AND PERIPHERAL

36-YEAR-OLD MANMULTIPLE CONGENITAL ANOMALIES

FEVER , WBC 17.8, 15 BANDS

ISCHEMIA OF SB AND STOMACH

ISCHEMIC BOWELMESENTERIC VEIN GAS

ABSCESS

ABSCESS

• SUSPECT AN ABSCESS WHEN RADIOGRAPHS SHOW A GAS COLLECTION THAT IS ABNORMAL BECAUSE OF PERSISTENCE ON MULTIPLE VIEWS

• GET HISTORY, PX, LAB DATA BY CONSULTATION WITH ORDERING MD AND BY LOOKING IN EMR

• CONFIRM WITH CROSS-SECTIONAL IMAGING

APPENDICEAL ABSCESSRETROCECAL APPENDIX

ABNORMAL GAS… UNCHANGED ON MULTIPLE VIEWS

SIGMOID DIVERTICULITISGAS FILLED “DIVERTICULUM

GIANT ABSCESS 2 WEEKS AFTER ANEURYSM SURGERY

8 DAYS POST LEFT HEMICOLECTOMY TEMP 39.1, WBC 16,OOO 15 BANDS

PERIHEPATIC ABSCESS.

CONNECTION TO BOWEL SHOWN BY UGI

SUBPHRENIC ABSCESS

FEVER 10 DAYS AFTER ABDOMINAL SURGERY

CROHN’S DISEASE WITH ABSCESS

54-YEAR-OLD WOMAN TRANSFERRED WITH PERSISTENT FEVER AND ELEVATED WBC

POST DIVERTICULAR ABSCESS DRAINAGE

47-YEAR-OLD WOMAN HAS FEVER, WBC 29.6

7 DAYS POST HEMICOLECTOMY

PERCUTANEOUS DRAINAGE OF ABSCESS

ABSCESS WITH FISTULA TO SMALL BOWEL SHOWN BY DELAYED SCANNING

PERITONITISTHICKENED, ENHANCING PERITONEUM

PANCREATIC ABSCESS

PANCREATIC GAS

• GAS IN PANCREATIC BED– ABSCESS

– POST PANCREATIC DRAINAGE PROCEDURE• PERCUTANEOUS OR SURGICAL

– PUESTOW PROCEDURE

– PSEUDOCYST

– PANCREATIC FISTULA

PANCREATITIS WITH ABSCESS

LESSER SAC ABSCESS

GAS IN PANCREATIC ABSCESS

PANCREAS-COLON FISTULA

POST PUESTOW PROCEDURE

PANCREAS-GAS BUT NO ABSCESS

LESSER SAC

LESSER SAC

GASTRIC ULCER PERFORATION INTO LESSER SAC

GALLBLADDER IN LESSER SAC

GAS IN LESSER SACPERFORATED GASTRIC ULCER

CULTURE

HISTORY OF RADIOLOGY

INTERMITTENT ABDOMINAL PAIN FOR 3 WEEKSTAKING NSAIDS FOR 2 MONTHS

68-YEAR –OLD MANSUDDEN ONSET OF SEVERE ABDOMINAL PAIN