Imaging in Abdominal

Radiograph with Cross

Sectional Imaging Correlation
Taufik Agung Wibowo, MD
Abdominal Imaging Division
Department of Radiology
FKUI-RSCM
Introduction
 How Are Radiographic Images Produced

Perry Sprawls. The physical principles of medical imaging. Available in www.sprawls.org/resources/

 Abdominal X-ray Projection

Dr Graham Lloyd-Jones BA MBBS MRCP FRCR. Abdominal x-ray – System and anatomy. Available in
www.radiologymasterclass.co.uk/tutorials
 Dr Jeremy Jones. Normal abdominal X-ray. Available at www.radiopaedia.org/cases/normal-abdominal-x-ray
Dr Graham Lloyd-Jones BA MBBS
MRCP FRCR. Abdominal x-ray –
System and anatomy. Available in
www.radiologymasterclass.co.uk/t
utorials
 INTERPRETATION

James B, Kelly B. The abdominal radiograph. Ulster Med J. 2013;82(3):179-187.

Acute Abdomen
 Acute Abdomen
• Acute abdominal pain :
• common in the outpatient setting
• represent benign to life-threatening surgical
emergencies conditions.

• If the clinical examination hard to identify the

cause of pain & if serious pathology remains a
clinical concern, diagnostic imaging is
indicated.

Jaap Stoker, Adrienne van Randen, Wytze Laméris, and Marja A. Boermeester. Imaging Patients with Acute Abdominal Pain.
 Modality
Conventional Abdominal US Examination
Radiography
• Provided useful information
• Used to exclude major illness for 56-65% of patients with
such as bowel obstruction acute abdominal pain.
and perforated viscus.
• Correct diagnosis after clinical
• Some study investigators evaluation increased from
have reported an accuracy of 70% to 83% after evaluation
53%. with US.
• Treatment management • US findings led to an
changes 🡪 only 4% of alteration in treatment
patients. management for 22% of
patients
• In select cases, such as those
of patients suspected of
having bowel obstruction,
perforated viscus, urinary
tract calculi, or foreign bodies
has been reported to have
good accuracy.

Jaap Stoker, Adrienne van Randen, Wytze Laméris, and Marja A. Boermeester. Imaging Patients with Acute Abdominal Pain.
 Modality
CT Examination MR Imaging
• CT was significantly • MR imaging is used in
more sensitive than US only select cases at
(89% vs 70%) many institutions,
• Two RCT in which primarily after US yields
standard practice was nondiagnostic findings
compared with early CT) in pregnant women.
🡪 early CT group had
shorter hospital stays
• Overall sensitivity of CT
is reportedly 96%
compared with 30% for
conventional
radiography

Jaap Stoker, Adrienne van Randen, Wytze Laméris, and Marja A. Boermeester. Imaging Patients with Acute Abdominal Pain.
 Case 1
Female elderly with
acute abdominal pain
 Bowel Gas Pattern

Musson RE, Bickle I, Vijay RKP. Gas patterns on plain abdominal radiographs: a pictorial review. Postgrad Med J 2011;87:274–87.
Pneumoperitoneum
 Pneumo-retroperitoneum

Musson RE, Bickle I, Vijay RKP. Gas patterns on plain abdominal radiographs: a pictorial review. Postgrad Med J 2011;87:274–87.
Case 2
Male 54 years old. Vague abdominal pain, not passing or little flatus or
stool for 3 days. Had surgery 4 days prior for ruptured appendix
 General adynamic ileus
• Generalized, uniform
dilatation of small and
large intestine with no
transition point

• There are a number of

causes,
• postoperative states
• Drugs
• metabolic cause
• intra-abdominal
inflammation

Musson RE, Bickle I, Vijay RKP. Gas patterns on plain abdominal radiographs: a pictorial review. Postgrad Med J 2011;87:274–87.
 Case 3

Male 65 years old with

abdominal pain.
History of bloody stool
since 3 months ago

James B, Kelly B. The abdominal radiograph. Ulster Med J. 2013;82(3):179-187.

 Case 4
Male 34 years old with abdominal pain and bloating,
no flatus or bowel movement for 24 hours. Vomiting
watery green fluid for 12 hours.

Dr. Brent Burbridge MD, FRCPC, University Medical Imaging Consultants, College of Medicine, University of
Feature of Gas Pattern
SBO vs LBO
 Role of Cross Sectional Imaging in
SBO and LBO

Musson RE, Bickle I, Vijay RKP. Gas patterns on plain abdominal radiographs: a pictorial review. Postgrad Med J 2011;87:274–87.
Complicated Bowel Obstruction
 Schematic Drawing of Large
Bowel Volvulus

Vandendries, C et al. “Diagnosis of colonic volvulus: findings on multidetector CT with three-dimensional reconstructions.” The British journal of radiology vol.
83,995 (2010): 983-90. doi:10.1259/bjr/35714052
Journal of Clinical Imaging
Science

Figure 5 Sigmoid volvulus: (a) Erect plain abdominal radiograph in a 58-year-old man presenting with abdominal distension and severe lower
abdominal pain demonstrates marked distension of the sigmoid colon with a typical coffee-bean sign (arrows) which is highly characteristic of
sigmoid volvulus. A rubber tube has been placed for decompression. Axial contrast-enhanced computed tomography images (b and c) in another
patient with similar presentation demonstrates the whirl pattern (arrow in b) and the characteristic bird beak appearance (arrow in c). The
redundant and dilated sigmoid colon (asterisk) is better depicted on the coronal image (d) with characteristic beak appearance (arrow).

Reproduced with permission from: Ramanathan S, Ojili V, Vassa R, Nagar A. Large Bowel Obstruction in the Emergency Department: Imaging
Spectrum of Common and Uncommon Causes. Available from: https://dx.doi.org/10.4103/jcis.JCIS_6_17
 Journal of Clinical Imaging
Science

Figure 6 Cecal volvulus: (a) Erect plain radiograph of the abdomen in a 65-year-old male patient presenting with severe abdominal pain
demonstrates mildly dilated loops of small bowel (short arrows) in the right hemi abdomen and a markedly dilated gas filled structure in the left
upper quadrant (long arrow) which is compressing the stomach which contains nasogastric tube. Axial contrast enhanced computed tomography
images (b and c) demonstrate a large air and fluid filled structure in the left abdomen (asterisk) with absence of cecum in its normal location. A small
amount of fluid (arrow) is noted secondary to early ischemia. The enteric contrast is noted to opacify only the small bowel. Imaging findings are
concerning for cecal volvulus which was subsequently confirmed at surgery.

Reproduced with permission from: Ramanathan S, Ojili V, Vassa R, Nagar A. Large Bowel Obstruction in the Emergency Department: Imaging
Spectrum of Common and Uncommon Causes. Available from: https://dx.doi.org/10.4103/jcis.JCIS_6_17
 Role of Cross-Sectional Imaging in
Volvulus

Vandendries, C et al. “Diagnosis of colonic volvulus: findings on multidetector CT with three-dimensional reconstructions.” The British journal of radiology vol.
83,995 (2010): 983-90. doi:10.1259/bjr/35714052
Focal Ileus (Sentinel
Loop)
 Case 5
Male 25 years old
complains abdominal
pain with constipation,
suspected bowel
obstruction

  Dr Henry Knipe. Available at www.radiopaedia.org

Acute appendicitis with
appendicoliths
Focal paralytic ileus (sentinel
loop)
• Focal dilated small intestine
(>2,5 cm) or colon (>6 cm)
• Central position of intestine
& kerckring folds (small
intestine)
• Peripheral position &
haustral appearance (large
intestine)
 Acute Appendicitis
Ultrasound
• Aperistaltic, non-compressible,
dilated appendix (>6 mm outer
diameter)
• hyperechoic appendicolith
with posterior acoustic shadow
• echogenic prominent
pericaecal and periappendiceal
fat
• wall thickening (3 mm or
above)
• periappendiceal fluid
collection
• echogenic prominent
pericaecal and periappendiceal
fat

Ian Bickle, Koshy Jacob et al. Appendicitis. Available at radiopaedia.org

 Acute Appendicitis
CT Scan

• Sign of Perforation
• Appendiceal abscess
• Extraluminal air
• Defect in the enhancing appendiceal wall

Ian Bickle, Koshy Jacob et al. Appendicitis. Available at radiopaedia.org

Nuno Pinto Leite, José M. Pereira, Rui Cunha, Pedro Pinto, and Claude Sirlin. CT Evaluation of Appendicitis and Its Complications: Imaging Techniques
and Key Diagnostic Findings. American Journal of Roentgenology 2005 185:2, 406-417
 Case 6
Female 47 years old with
history of gallstone.
Acute onset of severe
epigastric pain. Elevated
amylase and lipase.
 Interstitial Edematous
Pancreatitis

Gonzalez et al. Acute pancreatitis structured radiology report: the importance for the patients´s management. DOI:
10.1594/ecr2017/C-1474
 Colon Cut off Sign

N Engl J Med 2018; 378:1621. DOI: 10.1056/NEJMicm1714270

 Acute Pancreatitis
Interstitial Edematous Necrotizing Pancreatitis
Pancreatitis • High incidence of local
• Majority of case (90%) complication & high
• Difuse (rarely focal) mortality rate
enlarged normal enhancing • Necrotizing pancreatitis is
pancreas subdivided into
• Loss of normal fatty • Pancreatic parenchymal
lobulation necrosis alone
• Peripancreatic necrosis
• Peripancreatic fat stranding, • Pancreatic and
edema and free fluid peripancreatic necrosis
• Mild (early) pancreatitis can
appear normal on imaging

Gonzalez et al. Acute pancreatitis structured radiology report: the importance for the patients´s management. DOI:
10.1594/ecr2017/C-1474
 Pancreatic fluid collections
(Revised Atlanta
Classification)

Trikudanathan G, et al. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. DOI:
https://doi.org/10.1053/j.gastro.2019.01.269
 Acute Peri-pancreatic
Fluid Collection

Acute Necrotic Collection

Xiao B. Acute pancreatitis: A pictorial review of early pancreatic fluid collections. Artif Intell Med Imaging 2020; 1(1): 40-49
Xiao B. Acute pancreatitis: A pictorial review of early pancreatic fluid collections. Artif Intell Med Imaging 2020; 1(1): 40-49
Xiao B. Acute pancreatitis: A pictorial review of early pancreatic fluid collections. Artif Intell Med Imaging 2020; 1(1): 40-49
 Other Focal Acute Abdominal
Pain
Diverticulitis

Jaap Stoker, Adrienne van Randen, Wytze Laméris, and Marja A. Boermeester. Imaging Patients with Acute Abdominal Pain.
Radiology 2009 253:1, 31-46
 Other Focal Acute Abdominal
Pain
Cholecystitis

Jaap Stoker, Adrienne van Randen, Wytze Laméris, and Marja A. Boermeester. Imaging Patients with Acute Abdominal Pain.
Radiology 2009 253:1, 31-46
Chawla, Ashish et al. “Imaging of acute cholecystitis and cholecystitis-associated complications in the emergency setting.” Singapore medical
journal vol. 56,8 (2015): 438-43; quiz 444. doi:10.11622/smedj.2015120
Dr Mohammad Taghi Niknejad. Acute calcular cholecystitis. Available at radiopaedia.org
Abdominal Traumatic
Emergencies
Focused Assesment with
Sonography for Trauma (FAST)
• Bed side screening to detect free fluid in abdomen
and thorax
• Sensitivity 80-90% and specificity 95-100% for
detecting free fluid
Holmes EJ, Misra RR. A-z of emergency radiology. Cambridge university press. 2004
Holmes EJ, Misra RR. A-z of emergency radiology. Cambridge university press. 2004
 Extended FAST
• Screening for hemothorax and pneumothorax

Holmes EJ, Misra RR. A-z of emergency radiology. Cambridge university press. 2004
Holmes EJ, Misra RR. A-z of emergency radiology. Cambridge university press. 2004
Thank You