Imaging in Pain Abdomen

Dr.Runal Shah3rd year Resident,

Masters in Emergency MedicineKDAH.

Introduction

Acute Abdomen : Clinical syndrome characterized by

the sudden onset of severe abdominal pain requiring emergency medical or surgical treatment.

Need for immediate surgical exploration can be identified by history and physical examination.

Establishing an accurate working diagnosis is often difficult because the clinical presentation of many entities overlap and physical and laboratory examinations are often non-specific.

8 common causes for 90% patients –

1) Acute Appendicitis2) Acute Cholecystitis3) Acute Pancreatitis4) Small Bowel Obstruction5) Acute Gynecological diseases6) Renal Colic7) Perforated peptic ulcer8) Acute Diverticulitis

Objectives Cases Scenarios

Abdominal quadrants

Imaging modalities

Case 1 67/ Male, pain in abdomen with bloating & nausea since 3

days.

Past h/o Ca.GB operated by Open cholecystectomy 7 years ago

O/E : Abd distended, Tenderness diffuse, Tympanic on percussion, Bowel sounds Not heard !

Case 2 30/ Female, pain in lower abdomen with per vaginal spotting,

? last period 15 days ago

H/O – i-pill taken 1 month ago.

O/E – Suprapubic tenderness, forniceal tenderness on PV

Case 3 72/ Female, pain in abdomen since 2 days

Past H/O – Chronic Afib on Amiodarone, HT on Telmisartan, DM on OHAs

O/E – Soft, diffuse abdominal tenderness with voluntary guarding, Bowel sounds sluggish

Abdominal Quadrants Right Upper Quadrant

Acute cholecystitis Choledocholithiasis Pancreatitis

Liver Abscess Hepatitis

Cecal diverticulitis Retrocecal appendicitis

Peptic ulcer disease Pneumonia (RLL) / PE

Left Upper Quadrant Splenic infarction Splenic abscess Sickle cell disease

Gastritis Gastric ulcer

Pneumonia (LLL) / PE

Abdominal Quadrants Right Lower Quadrant

Appendicitis Diverticulitis Mesenteric adenitis

Inguinal hernia (incarcerated/strangulated)

Testicular Torsion

Ureteric Colic

Ovarian torsion Ectopic Pregnancy Ovarian cyst (ruptured)

Left Lower Quadrant Diverticulitis (Sigmoid) Ischemic Colitis Regional Enteritis

Inguinal hernia (incarcerated/strangulated)

Testicular Torsion

Ureteric Colic

Ovarian torsion Ectopic Pregnancy Ovarian cyst (ruptured)

Abdominal Quadrants Diffuse Pain

Aortic Aneurysm (Leaking / Ruptured)

Aortic Dissection

Bowel Obstruction Volvulus Perforated bowel Acute Gastro-enteritis Mesenteric Ischemia Peritonitis

Pancreatitis

Metabolic causes Diabetic Keto Acidosis Alcoholic Keto Acidosis Uremia Addisonian crisis

Sickle cell anemia

X Ray Abdomen Supine vs. Erect Supine – Dilated bowel loops Erect – Air under diaphragm (Sn~30%), air-fluid levels

+ CXR to add To include inguinal region – to look for incarcerated hernia

To screen for Obstruction Severe constipation Sigmoid volvulus Perforation of bowel

X Ray Abdomen

String of pearls

X Ray Abdomen

Air under diaphragm – 80% Sensitive for perforation – in an erect film

X Ray Abdomen vs. Chest

X Ray Abdomen

• Coffee bean sign

Sigmoid Volvulus

Ultrasonography For RUQ pain

(Hepatobiliary)

Population in whom radiation exposure is major concern –

Children Women of child bearing age

group.

Pros : Dynamic Real time imaging Readily available in ER

Cons : Operator dependent Need for a proper acoustic

window Disturbance by gas, bone

and obesity ed time consumption

Ultrasonography

Gall stones with acoustic shadow

There is a thin layer of pericholecysticfluid (arrow), a sign of acute cholecystitis.

Ultrasonography

UltrasonographyWomen with lower abdominal pain ± PV bleed &UPT Negative heralds strong suspicion of Hemorrhagic Ovarian cyst – corpus luteal or functional cyst with free fluid in pelvis.

Ultrasonography AAA (Abdominal Aortic Aneurysm)

Transverse image Saggital image

Ultrasonography Renal calculi

Young children and Women of child bearing age.

Kidneys and Bladder (VUJ) are visualized well. Kidney – Stones : filling defects, Pyonephrosis, Hydronephrosis Bladder – Debris : cystitis changes

Ureteric stones are poorly localized as obscured by bowel shadows..!! CT should be done.

Ultrasonography Bedside USG

For Bladder screening in acute retention of urine

FAST (Focused Abdominal Sonography in Trauma)

CT Scan CT scan is a sensitive and specific tool in acute abdomen. Radiation dose is 10x of plain abdomen X ray.

Non contrast CT is the diagnostic modality of choice for kidney and ureteric calculi.

IV contrast CT provides superior visualization of bowel mucosa, visceral organs and vascular structures.

It can identify small and large bowel obstruction and the transition point.

It is the initial test of choice for suspected abdominal aortic aneurysm rupture or mesenteric ischemia.

CT Scan Contrast scan has the risk of Nephrotoxicity and Allergic

reactions.

If the S.Creatinine is >1.5 or the GFR is <60, the use of IV contrast is generally not recommended except in life threatening situations.

Patients receiving IV contrast should be hydrated with 1 to 2 L of normal saline as long as there are no contraindications to vigorous hydration.

Adjunct Laboratory Tests CBC Random Blood Sugar

Metabolic profile – Electrolytes Serum Creatinine ±

BUN Venous Blood Gas

Amylase & Lipase

Liver function test Coagulation profile

Blood group & cross-match

Don’t forgetECG, Chest X ray

Reference1) Tintinalli’s Emergency Medicine, 8th edition2) Emergency Radiology – case studies by David T. Schwartz3) Emergency Radiology – Imaging and Intervention by Borut Marincek ,

Robert F. Dondelinger (Eds.)4) Radiology – The oral boards primer