Dr Majid Al-Homiedan Department of Radiology and Diagnostic Imaging King Khaled University Hospital

What is an acute abdomen?

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A clinical syndrome characterized by the sudden onset of severe abdominal pain requiring emergency medical or surgical treatment. 

³CT performed in the ER department increases the physicians level of certainty, reduces hospital admission rates by 24%, leads to more timely surgical intervention, ruled out significant disorders in 26% of cases and provided an alternative diagnosis for the patients symptoms in 26% of patients.´
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Rosen MP et al. AJR 2000 

Clinical Parameters
Patient age and sex € Past medical history € Current medications € Clinical presentation € Findings on physical examination € Abnormal laboratory findings € Prior radiological examinations
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Scanning protocols
Oral contrast € Positive or neutral contrast € 750-1000 ml of oral contrast
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IV contrast: € 120 ml of omnipaque 350 € Rate of 3-4 ml/sec € Occasionaly rectal contrast
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Life-threatening

Self-limiting

Aortic aneurythem rupture Pancreatitis Bowel Ischemia Perforated peptic ulcer Perforated diverticulitis

Appendicitis Cholecystitis Sigmoid diverticulitis Salpingitis

Gastroenteritis Lymphadenitis Epiploic appendagitis Omental infarction Cecal diverticulitis 

A Four Quadrant Approach
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Many disorders may cause an acute abdomen, but fortunately only a few of these are common and clinically important. Focus on confirming or excluding these frequent disorders

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Four Quadrant Approach
Cholecystitis Usually gastric pathology

Diverticulitis
Appendicitis 

Screen for General Signs of Pathology

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Look for:
y Inflamed fat y Bowel wall thickening y Ileus y Free fluids y Free air 

Case 1
History: Young male patient with abdominal pain, fever and leukocystosis. Patient has no significant past medical history
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Appendicitis
Acute appendicitis is one of the most common conditions requiring emergency abdominal surgery. € CT is currently an effective tool for the diagnosis of appendicitis. However, there are concerns for radiation exposure from multislice CT technology in children, adolescents, and young women. € Graded compression technique in US
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Normal Appendix 

Inflamed Appendix 

Appendicitis 

Case 2
History: 45 year old lady with RUQ pain and fever. 

Acute Cholecystitis
Enlarged non-compressible gallbladder. € Thickened wall. € U/S Murphy's sign
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Emphysematous Cholecystitis 

Case 3
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History: old man with LLQ pain and leukocystosis. 

Diverticulitis
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Diverticula are small sacculations of mucosa and submucosa through the muscularis of the colonic wall. They develop where the nerve and blood vessel pierce the muscularis between the teniae coli and mesentery. 

Diverticulitis
Diverticulitis occurs when the neck of a diverticulum becomes occluded, resulting in inflammation, erosion, and microperforation. € Subsequent pericolonic inflammation that typically is more severe than the inflammation of the colon itself.
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Complications of Diverticulitis
Abscess € Sinus tracts € Fistulas € Gas or thrombus in mesenteric or portal veins € Free air € Peritonitis € Liver abscesses
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Case 4
History: € Old male patient known to have IHD with severe sudden onset abdominal pain and distension. € Physical: abdominal guarding and rebound tenderness. € Lab: high WBC and Acidosis
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Intestinal ischemia and infarction Etiology
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Arterial disease
y Occlusion 2ndry to atherosclerosis y Occlusion 2ndry to emboli 50% y Trauma

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Venous disease
y Due to venous thrombosis y Portal hypertension y Estrogen use

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Other causes:
y Vasospasm, vasculitis, shock and severe

mechanical obstruction. 

Protocol
Dual phase imaging. € Water as oral contrast agent € 100-120 ml of omnipaque 350
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CT findings
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Luminal dilatation Bowel wall thickening Arterial occlusion, mesenteric or portal vein thrombosis. Lack of bowel wall enhancement Dilated mesenteric veins Edema in mesenteric fat Intramural gas Mesenteric or portal venous gas 

Portal Venous Gas
Ischemic bowel € Vascular catheterization € Diverticulitis € Acute gastric dilatation € Acute intestinal dilatation € Peptic ulceration € Post-colonoscopy € Post- ERCP
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Case 5
History: Mentally retarded patient with vomiting, abdominal pain and distension.
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Other Patient 

Other Patient 

SBO
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Small bowel obstruction is a common gastrointestinal diagnosis in the emergency department and hospital.
y y y y y y y y

H- Hernia A- Adhesion V- Volvulus E- Extrinsic mass (abscess) F- Foreign body I- Intussusception T- Tumor S- Stricture (Crohn's disease) 

RIGLER¶S TRIAD 

Gallstone Ileus
Mortality rate of 8-30% € Elderly patients € More common in women by 3-1 € Typical history of cholelithiasis or cholecystitis € Usually present with small bowel obstruction
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CT findings
Air in the biliary tree € Air in the gallbladder € Intestinal obstruction € Biliary enteric fistula € Stone in small bowel usually at least 2.5 cm
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Case 6
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History: healthy young man presented with short history of left flank pain. He is afebrile with a normal white count. 

Epiploic Appendagitis
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€ €

EA is a benign self-limited cause of acute abdominal pain that does not require surgery. A small pericolonic fatty mass with surrounding inflammation should prompt the diagnosis of EA. Occasionally, a dense ³dot´ is seen in the middle of the appendage that may represent the thrombosed vein. Left colon (about 65% of cases) If an epiploic appendage around the cecum is inflamed, this inflammation may mimic acute appendicitis. 

Case 7
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History: Patient with AML developed fever, abdominal pain and watery diarrhea while in hospital. 

Pseudomembranous Colitis
Acute inflammation of colon caused by toxins produced by clostridium difficile bacteria. € Usually involves the whole colon. € Colonic wall thickening with nodularity, Accordion sign (not specific). € Target sign (intense enhancing mucosa and edematous submucosa) € Mild pericolonic inflammatory changes.
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Case 8
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History: Immunocompromised patient with fever, RLQ pain and watery diarrhea 

Typhlitis
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€ €

€ € €

Inflammatory or necrotizing process involving the cecum, ascending colon and occasionally distal ilieum/appendix. Usually with patients post chemotherapy or transplant. Heterogeneously enhancing circumferential wall thickening of cecum +/- ascending colon. Decreased bowel attenuation due to edema. Pericecal inflammation Pneumatosis/pneumoperitoneum. Paralytic illeus. 

Case 9
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History: Old male patient with chronic constipation presented with abdominal distension. 

Sigmoid Volvulus
Sigmoid volvulus is a torsion or twisting of the sigmoid colon around its mesenteric axis resulting in a closed loop obstruction. € Risk: constipation, megacolon, and an excessively mobile colon. € As most patients are elderly with other co morbidities, they are preferentially treated conservatively with tube decompression per rectum.
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Case 10
History: € Middle aged man with severe epigastric pain radiating to the back.
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Acute Pancreatitis

Imaging of Acute Pancreatitis 
CT is the imaging modality of choice  No additional value of an early CT ³within 72 hours´  Early CT is only recommended when the diagnosis is uncertain 

Acute Pancreatitis

Balthazar et al, AJR 2008 

Acute Pancreatitis

Interstitial Pancreatitis

(Balthazar grade B, CTSI:2) 

Acute Pancreatitis Exudative Pancreatitis

Day 5

(Balthazar grade B, CTSI:2) (Balthazar grade E, CTSI:4)

Day 18 

Acute Pancreatitis Necrotizing Pancreatitis

(Balthazar grade E, CTSI:10) 

Acute Pancreatitis

Necrotizing Pancreatitis

Central gland necrosis 

Acute Pancreatitis

Follow up after 2/52 

Case 11
History: Female patient with rapid onset of RUQ pain, hypotension and deranged liver function tests.
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Budd-Chiari syndrome
The hallmarks of Budd-Chiari syndrome on contrast enhanced CT are an enlarged, heterogeneously enhancing liver with non-visualization or narrowing of the hepatic veins and IVC, as well as ascites. € Risk factors: € Polycythemia, Antiphspholipid antibody, protein C or S def, pregnancy, tumor invasion and membranous webs of IVC.
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Case 12
History: € RUQ pain, fever, tender hepatomegaly and high WBC count
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Case 13
History: € Known to have chronic epigastric pain presenting now with diffuse abdominal pain and tenderness.
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Perforated DU 

Case 14
History: € Acute Abdominal pain.
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Splenic Infarction
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Segmental
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Focal zones of the spleen involved More common One or more infarcts seen

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y y

Global
Entire spleen involved Often due to trauma 

Splenic Infarction
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Etiology
y Bacterial endocarditis, atrial fibrillation, SCA,

lymphoma, splenomegaly, etc
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CT appearance
y Wedged shaped area of decreased

attenuation which extends to the surface of the spleen. y Usually involve a portion of the spleen y CT appearance can vary over time 

Abdominal Trauma
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Trauma is the leading cause of death under the age of forty. Of all traumatic deaths, abdominal trauma is responsible for 10%.

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Abdominal Trauma
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Things to look in Abdominal trauma:
y Hemoperitoneum y Contrast blush consistent with active y y y y y y

extravasation Laceration: Linear shaped hypodense areas Hematomas: oval or round shaped areas Contusions: vague ill-defined hypodense areas that are less well perfused Pneumoperitoneum Devascularization of organs or parts of organs Subcapsular hematomas 

Abdominal Trauma
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Nowadays there is a trend towards nonoperative management of blunt abdominal trauma. More than 50% of splenic injury, 80% of liver injury and virtually all renal injuries are managed non-operatively.

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Trauma Protocol
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Blunt injury:
y portal venous phase and a subsequent delayed

excretory scan 3-5 minutes later if injury is detected on the initial scan. No oral contrast is administered.
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Penetrating injury:
y Most patients with penetrating trauma are

injured in the flank, so there is great risk for bowel perforation. y these patients get an additional scan after the administration of rectal contrast (50 ml contrast in 1000 ml saline). 

Splenic Injury
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The spleen is the most commonly injured solid organ (25%). The standard CT grade of splenic injury of the American Association for the Surgery of Trauma (AAST) is of limited value since it does not predict the success rate of a non-operative management. 

Liver Injury
In trauma the liver is the second most commonly involved solid organ in the abdomen after the spleen. However liver injury is the most common cause of death. € This is due to the fact that there are many major vessels in the liver, like the IVC, hepatic veins, hepatic artery and portal vein.
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Shown to be unreliable in predicting need for surgery 

Liver Injury
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Green arrow: oval shaped hypodense area consistent with hematoma Yellow arrow: linear shaped hypodense area consistent with laceration. Blue arrow: vague ill defined hypodense area consistent with contusion

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Liver Injury
o

Complete devascularization of right liver lobe. Contrast Blush

o

o

Hemoperitoneum

Patient needs OR 

Pancreas Injury
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Uncommon injury with a 0.4% overall incidence. 1.1% incidence in penetrating trauma and only 0.2% in blunt trauma. Rarely an isolated injury. Usually part of a 'package injury'.

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DrHomiedan@gmail.com
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