IMAGING IN ABDOMINAL PAIN

Sianny Suryawati, dr., Sp.Rad

Radiology Department Faculty of Medicine

Wijaya Kusuma University Surabaya
INTRODUCTION
Abdomen is a part of trunk that lies between the
thorax and pelvis
It is divided into 9 parts by 2 vertical lines : right and
left midclavicular lines; and also 2 horizontal lines :
subcostal and intertubercular lines
9 REGIONS OF ABDOMEN
ABDOMINAL PAIN
Acute abdominal pain is the chief complaint
in about 5% of ED visits
Most patients are discharged after ED
evaluation
Only about 10% require urgent surgery
APPROACH TO ABDOMINAL PAIN

THOROUGH HISTORY

CAREFUL EXAMINATION
HISTORY OF PAIN
Sudden onset
Perforation
Torsion/volvulus
Colicky pain
Hollow viscus obstruction/spasm
Constant pain
Inflammation
Radiation
Shoulder tip/back/loin to groin
EXAMPLES OF NON-TRAUMATIC CAUSES
 Role, indications and limitations of each imaging
modality : radiography, US, CT, MRI, scintigraphy
Appropriateness criteria
ACUTE ABDOMEN : A CLINICAL CHALLENGE
Severe abdominal pain develops over a period of
hours
Common chief complaints :
In USA,stomach and abdominal pain ranked first in
patient presentation to emergency departments
Difficult diagnosis :
Broad differentials
Nonspecific history and clinical examination
Nonspecific lab tests
 Require all resources to reach accurate diagnosis,
timely management and proper disposition
CONVENTIONAL RADIOGRAPHY
Often the first imaging evaluation
Acute abdominal series
Upright chest to evaluate for pneumonia,
subdiaphragmatic pneumoperitoneum
Upright and supine abdomen
Decubitus view of abdomen if upright radiograph not
possible
To detect small pneumoperitoneum
The patient must be in decubitus position for several
minutes (usually 15') before radiograph taken to allow
relocation of pneumoperitoneum to perihepatic space
 Helpful for the detection of :
Pneumoperitoneum
Bowel obstruction
Pneumonia mimicking abdominal pain
Suspected emphysematous pyelonephritis or
emphysematous cholecystitis on ultrasound
 Pitfalls/Limitations
Poor sensitivity to detect several causes of acute
abdomen including appendicitis, cholecystitis and
diverticulitis
Poor sensitivity to detect small pneumoperitoneum and
free fluid
Low interobserver agreement on the diagnosis of bowel
obstruction (particularly with low-grade small bowel
obstruction)
ULTRASOUND
Right upper quadrant (RUQ) ultrasound
Renal ultrasound
Abdominal ultrasound
Limited ultrasound
 RUQ ULTRASOUND
Evaluation of biliary tree (i.e. liver, intrahepatic
biliary duct, common bile duct and gallbladder),
pancreas, right kidney
Indications :
Right upper quadrant pain attributed to hepatobiliary
tract
Imaging of choice to evaluate acute cholecystitis
Intra/extrahepatic biliary duct dilatation
Right hydronephrosis, calculi
RUQ US LIMITATIONS (1)
Recent meal (within 4-6 hours) will contract
gallbladder, therefore :
Limiting evaluation for gallstones
May lead to 'false-postive' thickening of gallbladder
wall
Recent morphine will contract gallbladder and
mask the presence of sonographic Murphy's sign
 Limited evaluation in patients with :
Obesity (poor ultrasound beam penetration)
Fatty liver (obscuring liver pathology)
Significant bowel gas (obscuring pancreas)
Low sensitivity to detect CBD stones (CBD often
cannot be visualized in its entirety)
 RENAL ULTRASOUND
Evaluation of kidneys and bladder
Acute indications :
Hydronephrosis
Renal infection (pyelonephritis is not an imaging
diagnosis altough US can occasionally suggest the
diagnosis)
ABDOMINAL ULTRASOUND

Evaluation of hepatobiliary tract, both kidneys,

spleen, +/- aorta and IVC
Acute indications :
Patients contraindicated or unable to undergo CT or
MR imaging
Pregnant patients with trauma
Pediatric patients with abdominal pain
 LIMITED ULTRASOUND
Ultrasound performed at specific anatomic
location(s) according to clinical suspicion
Free fluid in trauma patients (FAST)
Suspected appendicitis
Suspected intussusception in pediatric patients
 COMPUTED TOMOGRAPHY (CT)
Evaluation of the whole abdomen and pelvis is
required
Options :
Without oral or IV contrast (urinary tract stone,
retroperitoneal hematoma)
With oral and without IV contrast (cannot receive IV
contrast)
With both oral and IV contrast (most indications)
With rectal contrast (appendicitis, colonic pathology i.e.
penetrating trauma)
 Indications
Contraindications :
Inappropriate use
History of severe contrast reaction (CECT)
Renal insufficiency (CECT)
Concerns
Use of iodinated contrast medium : nephrotoxicity,
adverse reactions
Radiation exposure
VALUE OF CT IN ACUTE ABDOMEN
Changes leading diagnosis
Changes were shown to be as high as 1/3 of all
cases ini prospective investigations
Increases physician's diagnosis certainty
CT doubled diagnosis certainty of ED physicians,
particularly in elderly
Changes patient management plan
CT influenced disposition in up to 60% of cases
CT INTRAVENOUS CONTRAST
Often required in acute abdomen imaging
Iodinated contrast medium enhances visibility of
vascular structures and organs
Characters
Water-based
Non-ionic (mostly used at present) vs ionic
Less osmolality decreases adverse reactions and
side effects
More hydrophilic less tendency to cross cell
membranes
CT IV CONTRAST REACTIONS
Can range from minimal (e.g. hives) to
anaphylactoid reactions; mostly idiosyncratic
(unpredictable, not dose-dependent)
Acute or delayed
Delayed reaction = 1 hour to 7 days after injection;
usually mild
Incidence
Mild reactions up to 3% (LOCM), 15% (HOCM)
Severe reactions 0.04% (LOCM), 0.22% (HOCM)
Fatal reactions exceedingly rare in both (1:170,000)
CT RADIATION EXPOSURE
CT accounts for 5% of radiologic examinations but
contributes 34% of collective radiation dose,
worldwide
Risk of radiation exposures
Deterministic effect : cell death; threshold level secified
when effect would occur; rarely seen with diagnostic x-
ray and CT
Stochastic effect : cancer, genetic effects; linear, non-
threshold model generally believed; seen with
diagnostic x-ray and CT
 Effective radiation dose of one abdominal-pelvic
CT scan equals to
10 mSv, comparable to 3 years of natural background
radiation
100 chest radiograph
Estimated risk of cancer death for those
undergoing CT is 12.5/10,000 population for each
pass of the CT scan through the abdomen.
Any efforts to reduce radiation dose from CT
should be done
MR IMAGING
Advantages over CT
High contrast resolution (good for imaging of pelvis,
hepatobiliary tract and pancreas)
No ionizing radiation
Can be performed in pregnancy
Total exam time usually <30 minutes. No contrast
needed in many cases
Limitations
Contraindications for MR : pacemaker,
claustrophobia, etc
Critically ill patients require MR-compatible life
supprt equipments
 Scientific evidence for MRI in acute abdomen still
is not extensive
Clinical applications
Suspected acute appendicitis (particularly during
pregnancy, and in children). Note that gadolinium-
based contrast agent cannot be used in pregnant
women.
Good results shown for MRI in sigmoid diverticulitis,
common bile duct stone, acute cholecystitis,
pancreatitis
SCINTIGRAPHY
Major drawback is limited availability in acute
setting; requires efforts to gather a team off-hours;
and limited resolution
Clinical applications
Acute cholecystitis : hepatobiliary scintigraphy
Higher accuracy and specificity than ultrasound
Reserved for patients whom diagnosis is unclear after
ultrasound
 Acute pulmonary embolism : ventilation-perfusion
(V/Q) scan
Considered V/Q scan in patients with a normal
chest radiograph suspected of having PE when
there is a contraindication to CT scan (renal
impariment, severe contrast reaction)
CONCLUSIONS
Imaging plays an increasingly important role in
diagnosis of etiology of abdominal pain
CT is widely used in abdominal indications; along
with ultrasound and MR imaging
Limitations of each imaging method and
appropriateness criteria should be considered
before selecting an imaging test for a particular
patient