Acute Abdomen Clinical, Laboratory and plain film or CT confirm or exclude most of the common disease

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Plain film is useful for: Kidney stone detection Pneumoperitoneum Other indications: CT or Ultrasound

Acute abdomen

Plain film : Shows no abnormalities

Follow up CT :

Shows distended fluid filled loops of small bowel.

Does not show on plain films if there is no intraluminal air.

Ileus.

Pneumothorax

Free air in the abdomen Lucency beneath the diaphragm

Radiologic Work up

•Confirm or exclude the most common disease •RLQ : Appendicitis •LLQ : Diverticulitis •RUQ : Cholecystitis

• Differential Diagnosis • Mesenteric lymphadenitis • Bacterial ileocecitis • Urolithiasis • Ruptured Aneurysm • Salphingitis • Pancreatitis • Epiploic appendagitis

Screening for general signs of pathology • Inflamed fat • Bowel wall thickening • Ileus • Ascites • Free air Small bowel - 4% –Dilated loops > 3cm in diameter Obstruction –adhesions -60 - 80% Closed loop obstruction Fluid or inflammation in the retroperotineum Perirenal or peri-ureteral fat stranding Calculi in the kidneys or gall bladder

Urolithiasis –Flank pain

CT –without oral or IV contrast CT is the modality of choice

.Urolithiasis often causes flank pain but clinically may simulate appendicitis, cholecystitis or diverticulitis.

Differential

Appendicitis may cause hematuria, pyuria and albinuria in upto 25% of patients because of ureteral inflammation

Normal No wall thickening or wall edema No inflamed fat Compressible

Appendicitis Wall thickening Surrounding hyperechoic fat Often not compressible Wall to wall > 6 mm

Appendicitis CT or Ultrasound

RLQ pain - Normal CT

Normal appendix: CT shows an air-containing non-distended appendix (arrowheads), with homogeneous low-density periappendiceal fat

Appendicitis

CT with Oral and IV contrast

Peri cecal - appendcial fat stranding

Wall thickening

Contrast enhancement of wall

Free air not common

May see appendicolith

Left Lower quadrant pain -

Sigmoid diverticulitis – most common

Fat stranding

Abscess

Free air

Wall thickening

Normal loops of small bowel

Abdominal Aneurysm 3 cms diameter

Ruptured Aneurysm

Classic triad of hypotension, pulsating mass and back pain.

May simulate sigmoid diverticulitis or renal colic due to impingement of hematoma on the adjacent structures

Small bowel obstruction

Small bowel obstruction

SBO -Dilated loops of small bowel

Small bowel feces sign- point of obstruction

Air fluid levels – if without normal sized small bowel loops then may suggest ileus

Closed loop obstruction

Figure B; two points of narrowing – point of obstruction in closed loop obstruction

The bowel wall thickening, ascites and mesenteric edema indicate the presence of bowel ischemia

Ileus Intussusception

Obstructive

Distended lops of small bowel with loops of small bowel that are non distended

Wall enhancement patterns

Ischemia -

Thrombus in the superior mesenteric vein, venous congestion of mesentery Ischemia due to closed loop obstruction

Ischemia. Pneumatosis intestinalis

Portal Venous gas – an ominous radiologic sign

High mortality rate

Gas in the mesenteric veins or portal vein

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So the most important question to answer is: Is there a closed loop obstruction?

Because if there is, this patient is at risk for bowel infarction and surgery is the best option.

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Patient with mild left flank pain. Thought to have diverticulitis, with a sentinel loop inflammation of adjacent small bowel. Small bowel strangulation

Repeat Ct three days later. Shows dilated loops of small bowel. Contrast enhancement of bowel wall. Inflammation of mesentery fat

Volvulus: Can be cecal or sigmoid Sigmoid: Goes to right upper quadrant.

Cecal: Can be RUQ, LUQ or Pelvic

Volvulus: cecal or sigmoid colon

Plain abdominal film is shown of a 57 year old man with a two day history of increasing abdominal pain and distension.

Dilated loops of bowel.

Large amount of air in the pelvis.

Sigmoid Volvulus.

Coffee bean sign

CT is very helpful in this case and demonstrates the twist at the transition point (arrow).

CT demonstrating the transition point of the volvulus.

Pancreatitis

CT shows fat-stranding around the pancreas

Acute

Chronic -

Calcification

Pseudocysts

Right Upper Quadrant pain

• Gallbladder pathology.

• Cholecystitis:

• Acute or chronic

• Calculus or Acalculus

• Initial modality of choice is Ultrasound –Sludge or stones

• Some stones may not show on CT

• Then CT or MRI

• MRCP

• Nuclear mebrofenin

LEFT: US of a normal gallbladder after an overnight

fast shows the wall as a pencil-thin echogenic line

(arrow).

Normal gallbladder Ultrasound

RIGHT: US in the postprandial state shows

pseudothickening of the gallbladder

RUQ ultrasound Radiographic signs of Cholecystitis

- Gall bladder wall thickening

- Edema

- Non compressible gall bladder

- Positive murphy’s sign

CT : cholecystitis Gall bladder wall thickening and enhancement.

Fat inflamation

Pitfalls: Wall thickening seen in

Pancreatitis

Hepatitis

Right Heart failure

Ascites

Acute cholecystitis is the fourth most common cause of hospital admissions for patients presenting with an acute abdomen

Diffuse gallbladder wall thickening can result from a broad spectrum of pathological conditions, including surgical and non-surgical diseases. The cause can be determined by correlation of the associated imaging findings with the clinical presentation.

On the left images of a 62-year-old man with acute calculous cholecystitis. Transverse sonogram at the spot of maximum tenderness shows a non-compressible hydropically distended thick-walled gallbladder (arrowheads), with an intraluminal stone and sludge or debris. Contrast-enhanced CT depicts extensive fat inflammation (arrowheads) surrounding the gallbladder (arrow).

Chronic cholecystitis Chronic cholecystitis is a term used clinically to refer to symptomatic gallbladder stones that cause transient obstruction, leading to a low-grade inflammation with fibrosis [1]. Correlation of the imaging finding of a stone-containing slightly thick-walled gallbladder with the clinical history is critical.

1.Rumack CM, Wilson SR, Charboneau JW. Diagnostic Ultrasound, 2nd ed. St.Louis: Mosby, 1998:175-200 2.Zissin R, Osadchy A, Shapiro M, Gayer G. CT of a thickened-wall gallbladder. Br J Radiol 2003; 76:137-143 3.Jung SE, Lee JM, Lee K, et al. Gallbladder wall thickening: MR imaging and pathologic correlation with emphasis on layered pattern. Eur Radiol 2005; 15:694-701 4.Gore RM, Yaghmai V, Newmark GM, Berlin JW, Miller FH. Imaging of benign and malignant disease of the gallbladder. Radiol Clin N Am 2002; 40:1307-1323 5.Boland GWL, Slater G, Lu DSK, Eisenberg P, Lee MJ, Mueller PR. Prevalence and significance of gallbladder abnormalities seen on sonography in intensive care unit patients. AJR 2000; 174:973-977 6.Levy AD, Murakat LA, Abbott RM, Rohrmann CA. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. RadioGraphics 2002; 22:387-413 7.Yoshimitsu K, Honda H, Jimi M, et al. MR diagnosis of adenomyomatosis of the gallbladder and differentiation from gallbladder carcinoma: importance of showing Rokitansky-Aschoff sinuses. AJR 1999;172:1535-1540 8.Kaftori JK, Pery M, Green J, Gaitini D. Thickness of the gallbladder wall in patients with hypoalbuminemia: a sonographic study of patients on peritoneal dialysis. AJR 1987; 148:1117-1118 9.Yamada K, Yamada H. Gallbladder wall thickening in mononucleosis syndromes. J Clin Ultrasound 2001; 29:322-325 Adriaan C. van Breda Vriesman, Robin Smithuis, Dries van Engelen and Julien B.C.M. Puylaert Radiology Department of the Rijnland Hospital, Leiderdorp; the Groene Hart Hospital, Gouda and the Medical Centre Haaglanden, the Hague, the Netherlands Radiology Assistant The Netherlands http://www.radiologyassistant.nl/en/p43a0746accc5d/gallbladder-wall-thickening.html