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
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