Prof. András Palkó MD, PhD - u-szeged.hu abd... · acute abdomen Prof. András Palkó MD, PhD...

Department of Radiology 1

Role of imaging in the evaluation of the acute abdomen

Prof. András Palkó MD, PhD

Department of Radiology

Faculty of General Medicine

University of Szeged

Hungary


Definition

• Sudden onset of severe symptoms requiring emergency

medical or surgical treatment,

– typically characterized by intensive abdominal pain

– may be associated with:

• muscular defense

• paralytic ileus or hyper- (retro-) –peristalsis

• nausea, vomiting, meteorism, hiccups

• fever, collapse, shock


Potential causes

• perforation

• obstruction

• ischemia

• bleeding

• infection

peritoneal irritation

GI paralysis & defanse musculaire


Acute abdomen – top 8

1. Acute appendicitis

2. Acute cholecystitis

3. Small bowel obstruction (SBO)

4. Acute gynecological disease

5. Acute pancreatitis

6. Renal colic

7. Perforated peptic ulcer

8. Acute diverticulitis

account for 90 % of patients referred to hospital


Role of imaging

• After stabilizing the patient’s condition rapid diagnosis

and therapeutic decision is essential to minimize

progression and reduce mortality.

• Clinical presentation, history, and lab test results are too

often non-specific.

• Imaging examinations are of utmost importance to

establish diagnosis.


What’s wrong? – clinical findings


• Intestinal – Acute appendicitis

– IBD

– Mesenteric adenitis

– Perforated carcinoma

– Epiploic appendagitis

– Omental infarction

– Cecal diverticulitis

– Infectious ileocolitis

– Sigmoid diverticulitis

– Obstructive sigmoid carcinoma

• Urological – Urinary tract obstruction

• Gynecological – PID

– Ovarian vein thrombosis

– Hemorrhagic ovarian cyst

– Rupture of ovarian dermoid

– Ovarian torsion

– Rupture of ectopic pregnancy

– Endometriosis

– Necrotic uterine leiomyoma

• Cholecystitis – Calculous

– Acalculous

– Emphysematous

• Hepatitis

• Liver abscess

• Spontaneous rupture

of a hepatic neoplasm

• Right-sided LB diverticulitis

• Retrocecal appendicitis

• Acute pancreatitis • Duodenal ulcer • Bowel obstruction • Abdominal aortic

aneurysm

• Bowel obstruction – SBO

• Adhesion

• Crohn’s

• Neoplasm

• Hernia

• Radiation

• Miscellaneous

– LBO

• Carcinoma

• Volvulus

• Diverticulitis

• Perforation • Peptic ulcer

• Diverticulitis

• Iatrogenic

• Bowel ischemia – Mesenteric artery

• Thromboembolism

• Atherosclerosis

• Dissection

– Mesenteric vein

• Hypercoagulable

• Neoplastic

• Strangulation, volvulus

• Infectious • Gastroenterocoliti

s

• Pseudomembranous colitis

• IBD • Ulcerative colitis

• Crohn’s disease


• (history, physical examination and lab tests)

• plain X-ray examination – abdomen

• erect or decubitus

• supine

– chest

• ultrasound

• computed tomography

Diagnostic algorithm


What’s wrong? – imaging findings

• Pathological gas accumulation

• Localized/diffuse fluid accumulation

• Diffuse/segmental gas/fluid levels

• Extravasation, leakage

• Pathological circulation

• Wall thickening (bull’s eye)

• Foreign body


Pathological gas accumulation

• Pneumoperitoneum – perforation

– iatrogenic

– per vaginam

• Pneumoretroperitoneum – perforation

– iatrogenic

• Bowel wall – pneumatosis

– infarction

– necrosis




– iatrogenic

– per vaginam


– iatrogenic


– infarction

– necrosis

Note: Ogilvie-sy!




– iatrogenic

– per vaginam


– iatrogenic


– infarction

– necrosis




– iatrogenic

– per vaginam


– iatrogenic


– infarction

– necrosis

Gellett LR et al: Emerg Med J 2002;19:480-481



• Biliary system – sphincter Oddi incompetence

– postoperative

– spontaneous fistula

– emphysematous cholecystitis

• Portal vein – mesenteric infarction

– air embolus

– necrotizing enterocolitis

• Abscess




– postoperative




– air embolus


• Abscess


Pathological gas accumulation – gasless abdomen

• Normal abdomen

• Small bowel

obstruction/ischemia

• Ascites

• Surgery (e.g. total

colectomy)

• Gastroenteritis

• Large abdominal mass

Thompson WM: AJR, 191:1093–1099, 2008


Localized/diffuse fluid accumulation

• Ascites – cirrhosis

– tumor

– hypoalbuminaemia

– portal hypertension

– lymphatic obstruction

• Inflammation

• Perforation

• Abscess





– tumor




• Inflammation

• Perforation

• Abscess


Diffuse/segmental gas/fluid levels

• Paralytic ileus

– Diffuse

• peritonitis

• gastroenteritis

• abdominal pain

• other (postoperative, drug effect,

electrolyte imbalance, pneumonia,

retroperitoneal hemorrhage, etc.)

– Segmental (sentinel loop) • pancreatitis

• cholecystitis

• appendicitis,

• diverticulitis

• etc.



• Paralytic ileus

– Diffuse

• peritonitis

• gastroenteritis

• abdominal pain

• other (postoperative, drug effect,

electrolyte imbalance, pneumonia,

retroperitoneal hemorrhage, etc.)

– Segmental (sentinel loop) • pancreatitis

• cholecystitis

• appendicitis,

• diverticulitis

• etc.



Paulsen SR, RadioGraphics, 26:641, 2006

• Obstruction

– Small bowel

• Adhesion

• Crohn’s

• Neoplasm

• Hernia

• Radiation

• Miscellaneous

– Large bowel • Carcinoma

• Volvulus

• Diverticulitis

http://radiographics.rsna.org/content/26/3/641/F11.large.jpg



• Obstruction

– Small bowel

• Adhesion

• Crohn’s

• Neoplasm

• Hernia

• Radiation

• Miscellaneous


• Volvulus

• Diverticulitis



Takeyama,et al: RadioGraphics 2005; 25:997–1015

• Obstruction

– Small bowel

• Adhesion

• Crohn’s

• Neoplasm

• Hernia

• Radiation

• Miscellaneous


• Volvulus

• Diverticulitis



E M Anderson, Imaging 2006;18:198

• Obstruction

– Small bowel

• Adhesion

• Crohn’s

• Neoplasm

• Hernia

• Radiation

• Miscellaneous


• Volvulus

• Diverticulitis



www.nypemergency.org

• Obstruction

– Small bowel

• Adhesion

• Crohn’s

• Neoplasm

• Hernia

• Radiation

• Miscellaneous


• Volvulus

• Diverticulitis



• Obstruction

– Small bowel

• Adhesion

• Crohn’s

• Neoplasm

• Hernia

• Radiation

• Miscellaneous


• Volvulus

• Diverticulitis


Extravasation, leakage

• Perforation (see also pathologic gas/fluid accumulation)

• Bleeding

– Endoluminal

(ulcer, tumor, inflammation, iatrogenic, etc)

– Extraluminal

(aneurysm, tumor, iatrogenic, etc)

– Parenchymal organ

(tumor, iatrogenic, etc)




• Bleeding

– Endoluminal


– Extraluminal




Yoon W et al: Radiology 239:16-167, 2006

Detectable rate (arteriography): 0.5 – 1.5 mL/min

http://radiology.rsna.org/content/239/1/160/F1.large.jpg






• Bleeding

– Endoluminal


– Extraluminal





Pathological circulation

• Arterial – thromboembolism (MI, rheumatic

heart disease, atrial fibrillation,

etc.)

– arteriosclerosis

– dissection

– heart failure

– others (iatrogenic, idiopathic, strangulation/volvulus, septicemia,

extrinsic mass, etc.)

• Venous – thrombosis

– others (extrinsic mass, iatrogenic, – strangulation/volvulus, etc.)

Kirkpatrick IDC et al: Radiology, 229:91-98, 2003






etc.)


– dissection

– heart failure





Shih MCP et al AJR 2007; 188:462-471

http://www.ajronline.org/content/vol188/issue2/images/large/02_05_1168_15a_cmyk.jpeg

http://www.ajronline.org/content/vol188/issue2/images/large/02_05_1168_05a_cmyk.jpeg





etc.)


– dissection

– heart failure





McMahon MA et al: Radiographics, 30:445-460, 2010

http://api.ning.com/files/py5E2iOfdI-Or5itqW*YJrmM7zkEPihOmTRkgOIT53viKRsAvOoKhZHybxknwByYduznK1ldufAB9fNxJxkAkeJSCRn3G9MM/RadswikiAortic_dissection_type_B_005.jpg





etc.)


– dissection

– heart failure









etc.)


– dissection

– heart failure





Okino Y et al: Radiographics, 21:1475-1490, 2001



Wall thickening

• Infarction, ischemia

• Intramural hematoma

• Inflammation

– epiploic appendagitis

– Groove pancreatitis

• Infection

– appendicitis

– sigmoiditis

– typhlitis (neutropenic colitis)

– pseudomembranous colitis

(clostridium difficile)

– others (TBC, amebiasis, campylobacter,

shigella, etc.)

• Neoplasm

Rha SE et al: RadioGraphics, 20:29-42, 2000




Wall thickening

Dibbad R et al: The Internet Journal of Radiology, 12/1, 2010



• Inflammation



• Infection

– appendicitis

– sigmoiditis





shigella, etc.)

• Neoplasm


Wall thickening

Noah Gudel, DO; Lisa M. Rock, MD, Medscape 2008



• Inflammation



• Infection

– appendicitis

– sigmoiditis





shigella, etc.)

• Neoplasm




• Inflammation



• Infection

– appendicitis

– sigmoiditis





shigella, etc.)

• Neoplasm

Wall thickening


Wall thickening



• Inflammation



• Infection

– appendicitis

– sigmoiditis





shigella, etc.)

• Neoplasm


Wall thickening

Poletti PA et al, AJR 2004; 182:1159-1165



• Inflammation



• Infection

– appendicitis

– sigmoiditis





shigella, etc.)

• Neoplasm

http://www.ajronline.org/content/vol182/issue5/images/large/AD0981_02.jpeg


Wall thickening



• Inflammation



• Infection

– appendicitis

– sigmoiditis





shigella, etc.)

• Neoplasm


Foreign body

• Accidental/intentional/iatrogenic

• Endoluminal/extraluminal

• W./w.o. perforation

Maglinte DDT: Radiology, 236:763-767, 2005



Acute abdomen - algorithm




• supine

– chest

• ultrasound






• supine

– chest

• ultrasound


?

Acute abdomen - algorithm

Prof. András Palkó MD, PhD - u-szeged.hu abd... · acute abdomen Prof. András Palkó MD, PhD...

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