Acute Abdomen

Radiological
Approach

Prof Dr. Haney A Sami

 Acute Abdomen
● Bowel
■ Gastric
■ Small
■ Large
● Visceral
■ GB
■ Pancreas
■ Kidney
● Vascular
■ Aorta
■ Mesenteric
 Definition
●Acute abdominal pain Is Pain unrelated to
trauma

●It is one of the most common conditions in

patients presenting to the hospital emergency
department.

●It is a syndrome characterized by the sudden

onset of severe abdominal pain, requiring
early medical or surgical treatment
 Causes

■ Acute appendicitis
■ Acute cholecystitis
■ Bowel obstruction
■ Urinary colic
■ Perforated peptic ulcer
■ Acute pancreatitis
■ Acute diventricular disease
 Imaging techniques
Clinical assessment is often difficult and
laboratory investigations are often non
specific.

Plain X-ray
Ultra sonography
CT examinations
Contrast studies
 Imaging techniques
Plain radiographs of the abdomen, is of
significant diagnostic limitations, It is the
initial radiological approach.

Two views are usually taken a

supine and an erect.
If the patient is unable to stand, a decubitus
view
 Value of CT
CT is clearly superior to plain radiography :-
● Confirming the diagnosis (site and level)

● Revealing the cause of bowel obstruction

● Detecting pneumoperitoneum

● Identifying ureteric stones.

● Examining solid organs.

The major obstacle to replace plain abdominal

radiography with unenhanced CT appears to be
its cost, availability, and radiation dose.
Common causes of acute pain
in an abdominal quadrant

Right upper quadrant:

● Acute calculous / non calculous

Cholecystitis.
● Amebic liver abscess.
● Spontaneous rupture of hepatic
neoplasm.
● Myocardial infarction.
Common causes of acute pain
in an abdominal quadrant
Left upper quadrant:

● Splenic infarction.
● Splenic abscess.

● Gastritis.
● Gastric ulcer.
 Common causes of acute pain
in an abdominal quadrant

Right lower quadrant :

● Acute appendicitis.
● Acute terminal ileitis.
● Acute typhlitis.
● Pelvic inflammatory disease.
● Complications of overian cyst.
Endometriosis.
Ectopic pregnancy.
 Common causes of acute pain
in an abdominal quadrant

Left lower quadrant :

● Diverticulitis.
● Epiploic appendagitis.
Cholecystitis Pancreatitis
Ulcer

Appendicitis Diverticulitis
 What to Examine by
Plain X-ray

● Gas pattern
● Extraluminal air
● Soft tissue masses
● Calcifications
● Skeletal pathology
 Key to densities in AXRs
● Black—gas
● White—calcified structures
● Gray—soft tissues
● Darker gray—fat
● Intense white—metallic objects

● The clarity of outlines of structures

depends, on the differences between
these densities.
 Normal Gas Pattern

● Stomach
■ Always
● Small Bowel
■ Two or three loops of non-distended bowel
■ Normal diameter = 2.5 cm
● Large Bowel
■ In rectum or sigmoid – almost always
 Gas in
stomach

Gas in a few
loops of
small bowel

Gas in
rectum or
sigmoid

Normal Gas Pattern

Normal Fluid Levels

● Stomach
■ Always (except supine film)
● Small Bowel
■ Two or three levels possible
● Large Bowel
■ None normally
 Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen
 Large vs. Small Bowel
● Large Bowel
■ Peripheral
■ Haustral markings don't extend
from wall to wall

● Small Bowel
■ Central
■ Valvulae extend across lumen
Haustra films Faecal mottling
Complete Abdomen
Obstruction Series

● Supine
● Erect or left decubitus
● Chest - erect or supine
● Prone or lateral rectum
 Complete Abdomen
Supine

● Looking for
■ Scout film for gas
pattern
■ Calcifications
■ Soft tissue masses
● Substitute – none
 Complete Abdomen
Erect

● Looking for
■ Free air
■ Air-fluid levels
● Substitute – left
lateral decubitus
 Complete Abdomen
Erect Chest

● Looking for
■ Free air
■ Pneumonia at bases
■ Pleural effusions
● Substitute – supine
chest
 Complete Abdomen
Prone

● Looking for
■ Gas in rectum/sigmoid
■ Gas in ascending and
descending colon
● Substitute – lateral
rectum
Abnormal Gas Patterns

1. Functional Ileus
■ Localized (Sentinel Loops)
■ Generalized adynamic ileus
2. Mechanical Obstruction
■ SBO
■ LBO
Localized Ileus Key Features

● One or two persistently dilated

loops of large or small bowel
Supine Prone
● Gas in rectum or sigmoid
Sentinel Loops
Localized Ileus Sentinel Loops
Cholecystitis Pancreatitis
Ulcer

Appendicitis Diverticulitis
 Localized Ileus
Pitfalls

● May resemble early

mechanical SBO
■ Clinical course
■ Get follow-up
 Generalized Ileus
Key Features
● Gas in dilated small bowel and large bowel to
rectum
● Long air-fluid levels
● Only post-op patients have generalized ileus
● Other causes:-
■ Peritonitis
■ Hypokalemia
■ Metabolic disorder as hypothyroidism
■ Vascular occlusion
 Supine Erect

Generalized Adynamic Ileus

 Is It An Ileus?

● Is the patient immediately post-op?

● Are the bowel sounds absent or hypoactive?
 Mechanical SBO
Key Features

● Dilated small bowel

● Fighting loops
● Little gas in colon,
especially rectum
● Key: disproportionate
dilatation of SB

SBO
 Mechanical SBO
Causes

● Adhesions
● Hernia*
● Volvulus
● Gallstone ileus*
● Intussusception

*Cause may be visible on plain film

 Mechanical SBO
Pitfalls

● Early SBO may

resemble localized
ileus -get F/O
 Differentiation between
SBO & ILEUS
● Obstruction transition of dilated
loops
● Degree of dilatation is greater with
obstruction
● Spacing between the bowel loops
 Mechanical LBO
Key Features

● Dilated colon to point of obstruction

● Little or no air in rectum/sigmoid
● Little or no gas in small bowel, if…
■ Ileocecal valve remains competent
LBO
 Prone
Supine

LBO
Mechanical LBO
Causes

● Tumor
● Volvulus
● Hernia
● Diverticulitis
● Intussusception
 Mechanical LBO
Pitfalls

● Incompetent ileocecal valve

■ Large bowel decompresses into small bowel
■ May look like SBO
■ Get BE or follow-up
 Supine Prone

Carcinoma of Sigmoid – LBO –

Decompressed into SB
The goals of imaging in a patient with suspected
intestinal obstruction have been defined and
are as follows:

3. To confirm that it is a true obstruction and to

differentiate it from an ileus.
4. To determine the level of obstruction.
5. To determine the cause of the obstruction.
6. To look for findings of strangulation.
7. To allow a good management either medically
or surgically by laparoscopy or laparoscopy).
 Air in
biliary
tree

Gallstone Gallstone Ileus

Post-op C-section
Adynamic Ileus
Mesenteric Occlusion
Abnormal Gas Patterns
Ileus and Obstruction

● Localized ileus
● Generalized ileus
● Mechanical SBO
● Mechanical LBO
 Conditions causing
extraluminal
air
● Perforated abdominal viscus
● Abscesses (subphrenic and other)
● Biliary fistula
● Cholangitis
● Pneumatosis coli
● Necrotising enterocolitis
● Portal pyaemia
 Chilaiditi’s syndrome

Chilaiditi’s syndrome is an
important normal variant on the
erect chest radiograph,
which must be distinguished from
pathological free gas under the
diaphragm. (apparent, as
haustra are seen within the gas
filled structure). This gas is still
contained in the bowel loop.
Extraluminal Air
Free Intraperitoneal Air
 Signs of Free Air
Crescent
sign

● Air beneath diaphragm

● Both sides of bowel wall
● Falciform ligament sign
● In the biliary system

Free Intraperitoneal Air

 Free Air
Causes

● Rupture of a hollow viscus

■ Perforated ulcer
■ Perforated diverticulitis
■ Perforated carcinoma
■ Trauma or instrumentation
● Post-op 5–7 days
● NOT perforated appendix
Extraperitoneal Air
Soft Tissue Masses
 Soft Tissue Masses

● Hepatosplenomegaly
■ Plain films poor for judging liver size

● Tumor or cyst
■ Bowel displacement
Splenomegaly
Myomatous Uterus
 Hours
later

Bladder Outlet Obstruction – pre- and post- cath

Right Renal Cyst
RLQ Abscess
 Abdominal
Calcifications
 Normal structures that
calcify

● Costal cartilage
● Mesenteric lymph nodes
● Pelvic vein clots (phlebolith)
● Prostate gland
 Abnormal structures that
contain calcium

Calcium indicates pathology

● Pancreas
● Renal parenchymal tissue
● Blood vessels and vascular
aneurysms
● Gallbladder fibroids (leiomyoma)
Abnormal structures that
contain calcium

Calcium is pathology
● Biliary calculi
● Renal calculi
● Appendicolith
● Bladder calculi
● Teratoma
Abdominal Calcifications
Patterns

● Rimlike
● Linear or track-like
● Lamellar
● Cloudlike
 Rimlike Calcification
● Wall of a hollow viscus
■ Cysts
● Renal cyst
■ Aneurysms
● Aortic aneurysm
■ Saccular organs e.g. GB
● Porcelain Gallbladder

Renal Cyst Gallbladder Wall

Linear or Track-like
● Walls of a tube
■ Ureters
■ Arterial walls

Atherosclerosis Calcification Vas Deferens

 Lamellar or Laminar
● Formed in lumen of a hollow viscus
■ Renal stones
■ Gallstones
■ Bladder stones

Stone in Ureterocoele
Staghorn Calculi
Cloudlike, Amorphous,
Popcorn

● Formed in a solid organ or

tumor
■ Leiomyomas of uterus
■ Ovarian cystadenomas

Nephrocalcinosis Myomatous Uterus

Visceral Inflammation
Cholecystitis
Pancreatitis

Bowel Inflammation
Colitis
Appendicitis
Diverticulitis
 Inflammation- Cholecystitis
Acute cholecystitis is inflammation of the
gallbladder

usually from impaction of a gallstone within the

cystic or common bile duct.

Ultrasound is the preferred imaging method to

confirm cholecystitis in the appropriate
clinical setting.

CT findings of cholecystitis include:

1. Cholelithiasis
2. Gallbladder wall thickening
3. Pericholecystic fluid.
Complicated cases may reveal perforation or
hepatic abscess formation.
 Acute calculous cholecystitis:

Calculus obstructs the cystic duct

The trapped concentrated bile irritates the

gallbladder wall, causing increased secretion,
which in turn leads to distention and edema of
the wall.

Rising intra luminal pressure compresses the

vessels, resulting in thrombosis, ischemia, and
subsequent necrosis and perforation of the wall.
Thickening of gallbladder wall
.Cholelithiasis
 Pancreatitis

Acute pancreatitis is most often secondary to alcohol

abuse or gallstone impaction in the distal common bile
duct.

Other causes include trauma, cryptogenic, tumor,

infection, hyperlipidemia, and ERCP.
CT Findings typical of pancreatitis include:

1. An enlarged pancreas with infiltration of the

surrounding fat
2. Peripancreatic fluid collections can often be seen
3. Pseudocysts, (encapsulated fluid collections
containing pancreatic secretions, are later complications
of pancreatitis)
Notice the peripancreatic stranding)bars ( as well
as the fluid thickening of the interfascial space
A common complication
of pancreatitis is the
development of
pancreatic necrosis.

Lack of gland
enhancement following
IV contrast
administration is
diagnostic. When over
half the pancreas
becomes necrosed, the
mortality rate may
reach as high as 30%.
Pancreatic necrosis
Pancreatic pseudocyst
 Appendicitis

Right lower quadrant pain, fever and leukocytosis are the classical
clinical findings.

CT and US are being used more often to confirm clinical

suspicions and reduce the number of unnecessary laporotomies.

General CT findings for acute appendicitis include:

1. Dilated appendix greater than 6 mm or visualization of an
appendicolith with an appendix of any size
2. Peri-appendicial fat stranding
This image of an acute abdomen )arrow( displays
periappendicial stranding and dilattion of its
terminal portion.
For comparison, this image of a normal appendix can be visualized at the
ileocecal junction. Also notethe fat ventralcontaining heria
Inflammation- Colitis

Colitis, or inflammation of the colon, is a

frequent cause of abdominal pain.
Specific entities which produce
inflammatory thickening of the colon
include:-

Diverticulitis, inflammatory bowel disease,

pseudomembranous colitis, and other
bacterial infections (i.e. typhlitis).
This example of colitis shows thickening of the colon
.and pericolonic stranding typical of inflammation
Thickening of sigmoid colon due to pseudomembranous colitis
A case of diverticulitis showing a thickened sigmoid colon and a diverticulum
Diverticulitis
 Renal Colic

Distal ureteral stone lead ing to right

hyrdronephrosis in above image

Ureteral junctional stone

 Renal Colic

Renal stone right sided hydronephrosis

 Aortic
aneurysms
Case give a diagnosis
The End