PLAIN ABDOMINAL FILMS

PLAIN ABDOMINAL FILMSThe supine abdominal filmThe erect chest filmThe horizontal-ray abdominal film: - Erect - Left lateral decubitus1The supine abdomen film

Include the diaphragm & the hernial orificesAsses:- The preperitoneal fat line: Blurring of the preperitoneal fat line e.g. inflammatoryThe psoas outlines: Obliteration of psoas outlines e.g. fluid/inflammatory exudateDistribution of gasThe calibre of bowel : N: Calibre of small bowel is 2.5 cm & colon is 5 cm.- The thickened of bowel wallDisplacement of bowel by soft-tissue masses.Calculus2Normal Gas PatternStomachAlwaysSmall BowelTwo or three loops of non-distended bowelNormal diameter = 2.5 cm Large BowelIn rectum or sigmoid almost always3

Gas in stomachGas in a few loops of small bowelGas in rectum or sigmoidNormal Gas Pattern4Normal Fluid LevelsStomachAlways (except supine film)Small BowelTwo or three levels possibleLarge BowelNone normally5

Erect AbdomenAlways air/fluid level in stomachA few air/fluid levels in small bowel6Large vs. Small BowelLarge BowelPeripheralHaustral markings don't extend from wall to wallSmall BowelCentralValvulae extend across lumen

78The erect chest filmThe erect chest film can assess :Small pneumoperitoneum.Chest conditions may mimic an acute abdomen. Acute abdominal conditions may be complicated by chest pathology, e.g. pleural effusion frequently complicate acute pancreatitis, etc.The erect chest filmErectThe patients should be in position for 10 min before the film is taken.Radiological findings: - free gas beneath the diaphragm - chest abnormality

9The horizontal-ray abdominal filmErect & left lateral decubitus.The patients should be in position for 10 min before the film is taken.Radiological findings: fluid levels & free gas 10ACUTE ABDOMENPerforationIntestinal obstructionParalytic ileusAcute colitisIntraperitoneal fluidInflammatory conditionsCalcification associated with acute abdominal conditions11Abnormal Gas PatternsFunctional IleusLocalized (Sentinel Loops)Generalized adynamic ileusMechanical ObstructionSBOLBO12

13Localized IleusKey FeaturesOne or two persistently dilated loops of large or small bowelGas in rectum or sigmoid14Sentinel Loops/Localized ileus

Supine

Prone15

PancreatitisUlcerDiverticulitisCholecystitisAppendicitisUlcerUreteral calculusSentinel Loops16Localized IleusPitfallsMay resemble early mechanical SBOClinical courseGet follow-up

17Generalized IleusKey FeaturesGas in dilated small bowel and large bowel to rectumBowel wall ThickeningLong air-fluid levelsOnly post-op patients have generalized ileus18

Generalized Adynamic IleusSupineErect19Ileus Paralitik

20Is It An Ileus?Is the patient immediately post-op?Are the bowel sounds absent or hypoactive?If no, then it isnt an ileus

21Mechanical SBOKey FeaturesDilated small bowelBowel wall ThickeningLittle gas in colon, especially rectumKey: disproportionate dilatation of SB22SBO

23Mechanical SBOCausesAdhesionsHernia*VolvulusGallstone ileus*Intussusception24Mechanical SBOPitfallsEarly SBO may resemble localized ileus

25Mechanical LBOKey FeaturesDilated colon to point of obstructionMultiple air fluid level=Step LadderHerring Bone appearancesLittle or no air in rectum/sigmoidLittle or no gas in small bowel, Ileocecal valve remains competent26Gambaran Step Ladder

27 Ileus Obstruksi

28

Large Bowel Obstruction

SupineProne29Mechanical LBOCausesTumorVolvulusHerniaDiverticulitisIntussusception30Mechanical LBOPitfallsIncompetent ileocecal valveLarge bowel decompresses into small bowelMay look like SBOFollow-up31Carcinoma of Sigmoid : Large Bowel Decompressed into Small Bowel

Prone

Supine32

33

Air in biliary treeSBOGallstoneGallstone Ileus34

Sigmoid Volvulus35Extraluminal AirFree Intraperitoneal Air36Signs of Free AirAir beneath diaphragmBoth sides of bowel wallFalciform ligament sign37

Crescent signFree Intraperitoneal Air38

Free Intraperitoneal AirAir on both sides of bowel wall Riglers Sign39Free Intraperitoneal Air

Football sign

40Free AirCausesRupture of a hollow viscusPerforated ulcerPerforated diverticulitisPerforated carcinomaTrauma or instrumentationPost-op 57 daysNOT perforated appendix41

Extraperitoneal Air42PERFORATION PNEUMOPERITONEUM

Require emergency surgery!

Small pneumoperitoneum (I ml of free gas) erect chest/LLD abdominal films. 43Small pneumoperitoneum

44Pneumoperitoneum

45Pneumoperitoneum

46INTESTINAL OBSTRUCTION= Dilated loops of bowel proximally with non-dilated/collapsed bowel distal to the presumed point of obstruction.

Gastric Dilatation:Etiology:Mechanical gastric outlet obstructionParalytic ileusGastric volvulusAir swallowing47Gastric Dilatation

48Small-Bowel Obstruction:

Etiology: - Adhesions due to previous surgery - Strangulated hernias - Volvulus - Gallstone ileus - Intussusception - Neoplastic, etc.

49 Radiological appearances: Plain film changes appear after 3-5 h (marked after 12 h) (complete obstruction).

Supine film: - Small-bowel dilatation with accumulation of both gas & fluid. - A reduction in calibre of the large bowel.

50Small-Bowel Obstructiondue to adhesion

51Multiple dilated loops of small bowelMultiple fluid levels on erect filmSmall-Bowel Obstructiondue to gallstone ileus

52Multiple dilated loops of small bowel are seen. A band of gas in the right hypochondrium lies within the common bile duct.Small-Bowel Obstructiondue to Intussusception

53A crescent of air at the apex of an intussusception

Erect film: - Multiple fluid levels (Stepladder pattern). - String of beads sign = small bubbles of gas may be trapped in rows between the valvulae conniventes.

54Stepladder pattern in mechanical obstruction of the small bowel

55Small-Bowel Obstruction:String of beads sign

56 Ultrasound: - Dilated fluid-filled loops of small-bowel obstruction. - Assessment of the peristaltic activity.

57

CT: * CT should be performed whenever there is a history of previous abd. malignancy.

* Radiological appearances: - Bowel calibre change - Fluid-filled loops - The level of obstruction - Peritoneal adhesions

58LARGE-BOWEL OBSTRUCTIONEtiology: - Neoplastic (benign & malignant) - Volvulus (caecal & sigmoid), etc. Radiological appearances: Depends on the state of competence of the ileocaecal valve:

59LARGE-BOWEL OBSTRUCTION due to Sigmoid Volvulus

60The hugely dilated ahaustral loop of sigmoid can be seen rising out of the pelvis in the shape of an inverted U. Haustrated ascending & descending colon separate from the volved sigmoid loop.LARGE-BOWEL OBSTRUCTION due to Caecal Volvulus

61Distended caecum with its haustral markings is lying low in the central abdomen. There is no significant small-bowel distention.PARALYTIC ILEUSGeneralised paralytic ileus:Etiology: - Peritonitis - Post-operative - Hypokalaemia - General debility or infection - Drugs: morphine - Congestive cardiac failure, renal colic, etc.

Radiological appearances: - Both small & large-bowel dilatation - Horizontal-ray films: multiple fluid levels62PARALYTIC ILEUS

63There is generalised dilatation of both small & large bowel.

Localised ileus: Etiology: - Local inflammatory processes: pancreatitis, cholecystitis, appendicitis, salpingitis - Trauma: spine, ribs, hip, retroperitoneum - Renal colic, etc.

Radiological appearances: - Non specific (Mimic small/large-bowel obstruction). - Dilatation of one/two adjacent loops of bowel.

64Toxic megacolonA fulminating form of colitis with transmural inflammation, extensive & deep ulceration & neuromuscular degeneration.Involve the transverse colonRo. Findings: Mucosal islands (=pseudopolyps) & dilatation (8 cm)Common complication: Perforation in the sigmoid & peritonitis65Toxic megacolon

66INFLAMMATORY CONDITIONSAppendicitisAcute cholecystitisEmphysematous cholecystitisAcute pancreatitis67AppendicitisSigns of acute appendicitis: - Appendix calculus (0.5-6cm) - Localised paralytic ileus in RLQ - Sentinel loop-dilated atonic ileum containing a fluid level - Widening of the preperitoneal fat line - Blurring of the preperitoneal fat line - Blurring of the right psoas outline-unreliable cont 68Appendicitis - Scoliosis concave to the right - Dilated caecum - Right lower quadrant (RLQ) mass identing the caecum on its medial border (abscess formation) - RLQ haze due to fluid & oedema - Gas in the appendix-rare, unreliable.69Small bowel obstruction due to Appendix abscess

70Appendix abscess causing small-bowel obstruction. A small gas bubble which lies within the abscess is seen in the right iliac fossa. Ultrasound signs of acute appendicitis : - Blind-ending tubular structure at the point of tenderness: Non-compressible Diameter 7 mm No peristalsis - Appendicolith casting acoustic shadow - Surrounding fluid/abscess 71Acute appendicitis

72Acute appendicitis

73 Acute appendicitis with appendicolith. Abscess formation & appendicolith.Acute cholecystitisPlain abdominal film: - Gallstones seen in 20% - Duodenal ileus - Ileus of hepatic flexure of colon - Right hypochondrial mass due to enlarged gallbladder - Gas within the biliary system - Normal plain films in two-thirds of cases

74 Ultrasound imaging: - A circumferential halo of low echogenicity with thickening of the gallbladder wall (8-10mm) in fasting state. - Indistinct contour to the gallbladder wall - Fluid around the fundus of the gallbladder - Gallstones casting acoustic shadow - A distended gallbladder (a stone obstructing the cystic duct) - Echogenic sediment in the lumen - Positive sonographic Murphy sign

75Acute cholecystitis

76CHRONIC CHOLECYSTITISUltrasound imaging: - A contracted gallbladder - Sometimes, obliteration of the lumen - Thickening of the gallbladder wall & strongly reflective - Cholelithiasis

77CHRONIC CHOLECYSTITIS

78Acute pancreatitis Plain chest film: - A left side pleural effusion - Basal parenchymal shadowing - Elevated left hemidiaphragm-unreliable

Plain abdominal film: - Normal plain films in two-thirds of cases - Duodenal ileus Gas in a dilated duodenal loop in the LLD - A gasless abdomen due to vomiting cont

79Acute pancreatitis - Generalised paralytic ileus - Dilated loops of bowel (small bowel, terminal ileum, ascending & transverse colon) - Loss of the psoas outline - Multiple small bubbles within the pancreas (pancreatic abscess) - Pancreatic calcification-unreliable

80 Ultrasound signs of acute pancreatitis: - Contours: smooth & well delineated - Enlargement - Echotexture: heterogeneous, hypoechoic to anechoic & less echogenic than the liver - Associated signs: venous compression, pleural effusion, ascites, duodenal atony

81ACUTE PANCREATITIS

82 CT signs of acute pancreatitis: - Necrosis, haemorrhage, & solid parenchyma that enhances with i.v.contrast medium - Abscess - Pancreatic pseudocyst - Extrapancreatic fluid collection - Ascites83Air in Rectum or sigmoidAir in Small BowelAir in Large Bowel

LocalizedIleusYes2-3 distended loopsAir in rectum or sigmoid

GeneralizedIleusYesMultiple distended loopsYes-

Distended

SBONoMultiple dilated loopsNo

LBONoNone-unless ileocecal valve incompetentYes-

Dilated