Slide 1

Aid of Imaging in diagnosis of Acute AbdomenDr. Sharan Khan & Dr. Tanvir KabirIntern DoctorDepartment of Surgery Enam Medical College Hospital

IntroductionAn acute abdomen denotes any sudden, spontaneous, nontraumatic, severe abdominal pain, typically of less than 24 hours duration

Common causes of acute abdomen that we encountered generallyA. Gastrointestinal Tract DisordersAppendicitisSmall and large bowel obstructionPerforated peptic ulcerAcute gastritisMesenteric adenitis

Common causes of acute abdomen that we encountered generally contd.B. Liver, Spleen, and Biliary Tract Disorders:Acute cholecystitisAcute cholangitisHepatic abscessRuptured hepatic tumorSpontaneous rupture of the spleenBiliary colic

Common causes of acute abdomen that we encountered generally contd.C. Pancreatic DisordersAcute pancreatitisD. Urinary Tract DisordersUreteral or renal colicAcute pyelonephritisAcute cystitisE. Vascular disorderRuptured aortic and visceral aneurysmsAcute ischemic colitisMesenteric thrombosis

Imaging help in Diagnosing acute abdomen:

Abdominal X RayChest X rayUltrasonographyComputed tomography scanAngiographyGIT Contrast x ray studyRadionuclide scan

Abdominal X RayCommon DisorderFindingSmall bowel obstructionCentrally placed Multiple air fluid level(Stepladder pattern)Valvulae conniventConcertina effectDiameter > 3 cm of the bowel wallRiglers triad, comprising: small bowel obstruction, pneumobilia and an atypical mineral shadow on radiographs of the abdomen. In Gallstone ileus

Abdominal X RayCommon DisorderFindingLarge bowel obstructionPeripherally placed multiple air fluid level except for the caecum, shows haustral folds

unlike valvulae conniventes, they are spaced irregularly,

Caecum a distended caecum is shown by a rounded gasshadow in the right iliac fossa

Diameter > 6 cm for colon and > 9 cm for caecum

Abdominal X RayCommon DisorderFinding

Perforation of gas containing viscusSubdiaphragmatic cresentic air shadowMultiple air fluid levelGround glass appearnace(Due to free intraperitonela fluid)The presence of free intraperitoneal air outlines the bowel so that both sides of the bowel wall can be seen(Riglers sign).

Abdominal X RayCommon DisorderFindingAcute pancreatitisGall stone(10%)Pancreatic calcinosisPleural effusionSentinel loopColon cut off signRenal haloGround Glass AppearanceLoss of psoas shadow(if retroperitoneal He)Acute appendicitisCalcified appendicolith in the right iliac fossa

Abdominal X RayCommon disorderFindingGall bladder disease and biliary treeGall stone 10%(Sea-gul or Mercedes Benz sign)Porceline gallbladderEmphysematous cholecystitisPneumobilia( After ERCP, Gallstone ileus, bilio-enteric anastomosis)Ischemic colitisThumbprint signRenal colicDemonstrate all calculi with site except uric acid stone

Chest X rayCommon DisorderFindingPerforation of gas containing viscusSubdiaphragmatic cresentic air shadowPleural effusionElevated hemidiaphragm.Acute pancreatitisPleural effusion

Ultrasonography:

Common disorderFindingAcute appendicitis(Retrocaecalappendicitis can readily escape detection with ultrasound)Periappendiceal collectionThickened appendix (>7 mm) in pt who are lean and thin and childrenInflammatory mass(Appendicular lump)Acute PancreatitisEnlarged pancreasPeripancreatic fluid and inflammatory changesPancreatic calcinosisPancreatic duct dilatationFree fluidPancreatic pseudocystIt can be used to guide percutaneous drainage of inflammatory fluid collections

Ultrasonography:

Common disorderFinding

Perforation of hollow viscusThickened edematous bowel wallAperistaltic intestine(Ileus)Free intraperitoneal fluidBowel obstructionDilated thickened bowel wallMass lesion if presentAscitic fluidAbdominal aortic aneurysmextent and exact size of aneurysm for surveillance and for treatment planRenal colicdemonstrate all calculiSite of calculidemonstrate hydronephrosis and hydroureterRenal parenchymal change

Ultrasonography:

Common disorderFinding

Acute cholecystitis with biliary pathologyPericholecystic fluidThickened(>3mm), distension or fibrosed gall bladder wallGall stone, size site of impactionCommon bile duct dilatation or stoneUltrasonographic Murphys sign(Tenderness on application of probe)Gall bladder perforation with subhepatic collection

Computed tomography scan

Common disorderFindingAcute appendicitisPeriappendiceal collectionThickened appendix (>7 mm) in pt who are lean and thin and childrenInflammatory mass(Appendicular lump) thickening of the caecal pole, possible localised small bowel ileus and right iliac fossa lymphadenopathy.Acute pancreatitisenlarged oedematous glandperipancreatic fluid collectionsvascular complications such as arterial pseudoaneurysm formation or venous thrombosis and necrosis either of the gland itself or of the surrounding fat.CT can be used to guide percutaneous drainage of inflammatory fluid collections.

Computed tomography scan

Common disorderFindingsAcute cholecystitis/biliary colic/jaundicegangrenous cholecystitis, gallbladder perforation and emphysematous cholecystitisto look for common causes including stones, cholangiocarcinoma and pancreatic carcinoma.CBD stone, diameter other pathologyIntestinal ObstructionDilated thickened bowel wallMass lesion, origin and extensionFree intraperitoneal fluid

Computed tomography scanCommon DisorderFindingsRenal Colic CT UrogramStone(Site, size, number)Hydroureter, hydronephrosisExcretory functionRenal parenchymal changePerforation of hollow viscusshow tiny quantities of free air and also identify causeIschemic colitisbowel wall thickening, submucosal oedema and freefluid between the folds of the mesentery (particularly if haemorrhagic).

Angiogram:

CT angiography (CTA), percutaneous invasive angiographic studies, or magnetic resonance angiography (MRA), are indicated if intestinal ischemia or ongoing hemorrhage are suspected It confirm a ruptured liver adenoma or carcinoma or an aneurysm of the splenic artery or other visceral artery.

it can be used for therapeutic purpose i.e embolization

MRA(Magnetic resonance angiogram) is useful when a patient is unable to undergo IV contrast administration (due to either renal impairment or contrast dye allergy).

GIT Contrast x ray study with Urinary system

For suspected perforations of the esophagus or gastroduodenal area without pneumoperitoneum, a water-soluble contrast medium (eg, meglumine diatrizoate [Gastrografin]) is preferred.If there is no clinical evidence of bowel perforation, a barium enema may identify the level of a large bowel obstruction or even reduce a sigmoid volvulus(Pneumatic tire like shadow arises from pelvis, coffee bean sign) or intussusceptions(Claw sign).IVU- Space occupying lesion, filling defect, stone, hydroureter, hydronephrosis, excretory function are assessed.

Radionuclide scanRBC Scan for occult, slow or intermittent GIT BleedingTechnetium scan for Ectopic gastric mucosa in Meckels diverticulitisGalium 67 to detect occult intrabdominal abscess or infectionHIDA scan for acute cholecystitis or bile leakage.

Figure 1 : Erect chest radiograph showing marked bilateral elevation of the hemidiaphragms with a large volume of subdiaphragmatic free gas.

Figure 2 : Pneumoperitoneum. The presence of free intraperitoneal air outlines the bowel so that both sides of the bowel wall can be seen (Riglers sign).

Figure 3: LEFT: Plain abdominal film in a patient with an acute abdomen, showing no abnormalities. RIGHT: Subsequent CT shows distended small bowel loops (arrowheads)

Figure 4 : Multiple air fluid level in Small bowel obstruction

Figure 5 : subdiaphragmatic free gas(PGCHV)

Figure 6: Gall bladder stone

Figure 7: Colon cut off sign in acute pancreatitis

Figure 8 Plain X Ray KUB Showing Bilateral renal stone

Figure 9 CT-scan 10 days after admission: Necrotic pancreatic tissue and peripancreatic fluid collections.

Figure 10 IVU Showing Renal stone

Figure 11: USG showing gall stone

Figure 12: CT scan of perforation of gas containing hollow viscus

Figure 13: CT Urogram showing filling defect

Figure 14: Plain X ray Showing sigmoid volvulus

Figure 15: Barium enema

Figure: 16 HIDA Scan

Figure 17 : Isotope scan for Meckels Diverticlum

KasperThis four and half year old boy well known as a trekker and also named choto Vhoot(little ghost).Suddenly developed per rectal bleeding and first operated in Chittagong but failed to identify the cause of Hge.The condition of Kasper worsed day by day.no Doctor/Surgeon identify the causeFinally Kasper Landed in Dhaka.In BSMMU second Exploratory laparotomy done and that time they identify Meckels Diverticulum

In BSMMU They did excision of the meckels diverticulum.But post operatively suddenly He developed ARDS and shifted To ICU then leave the world..