IMAGING

GUIDE TO
ABDOMINAL
PAIN
Siswidiyati
ABDOMINAL
QUADRANTS AND
 CHALLENGI
NG
Urgent
therapeutic
Laboratory decision
finding  non
conclusive
Clinical  Management  vary : emergency
condition non
specific surgery, missdiagnosed  delayed
necessary tx/ unnecessary surgery
Severe
abdominal  Sonography and CT enable an
pain accurate and rapid triage of
patients with an acute abdomen.
 CLINICAL GUIDELINE
ABDOMINAL PAIN
Life
Self-limiting
Threatening
Aortic aneurysm Appendicitis Gastroenteritis
Rupture

Pancreatitis Cholecystitis Lymphadenitis

Bowel Ischemia Salpingitis Omental infarction

Perforated peptic ulcer Sigmoid diverticulitis Epiploic appendagitis

 USG CT SCAN MRI PLAIN DIGITAL
RADIOGRAPH FLUOROSCOP
Y Y

RADIOLOGY STRATEGY ???

- Before you perform an examination, obtain relevant information from the referring
clinician.
- Don't let the clinician simply 'order' a sonogram or CT, but discuss the patient's age and
posture, laboratory results and the number one clinical diagnosis and differential diagnosis
- Based on that information  Better USG or CT scan
- USG : close patient contact, enabling assesment of the spot of maximum tenderness and
the severity of illness without ionizing radiation.
- CT scan : diagnostic accuracy higher than USG
- We advocate the following two-step radiological approach of an acute abdomen.
1. Confirm or exclude the most common disease
2. Screen for general signs of pathology
 Third
First Second Rule Fourth
Rule Rule Rule
free of The Body hates
No “Free” obstruction and traffic jam,
Fluid intact known as stasis
Air only
inside the GI
Tract Free fluid  non
Stasis due to
specific, but is good ABDOMEN  full
obstruction or
marker of of pipes : bowel,
disruption of normal
inflammation or vessels, bile duct and
motility  increased
trauma  should renal collecting
risk of infection and
serve to heighten system and ureters.
associated inflamation
suspicion if present
 NORMAL
VARIANT
BOWEL
FIGURE
• A plain abdominal film has a limited value in
the evaluation of abdominal pain.
• A normal film does not exclude an ileus or
other pathology and may falsely reassure the
clinician.
• Plain abdominal film useful to detect :
PNEUMOPERITONEUM AND KIDNEY
STONE
RADIOLOGY STRATEGY
Confirm or Exclude the most
common disease
- RLQ pain  appendicitis
- LLQ pain  sigmoid diverticulitis
- RUQ pain  cholecystitis
- TRAUMA  free fluid intraabdomen
Screen for general signs of
pathology
 Screening the whole abdomen
 Look for inflamed fat, bowel wall
thickening, ileus, ascites and free air.
THE MOST COMMON
DISEASE
CHOLECYSTITIS (RUQ)
•Acute cholecystitis is one of the
most common reasons for hospital
admission with acute abdominal
pain.
•Approximately 90–95% of acute
cholecystitis is related to
gallstones, with 5–10% of cases
due to acalculous disease.
 https://www.ajronline.org/doi/full/10.2214/AJR.10.4340
- sonography is the preferred
imaging method for the evaluation
of cholecystitis, also allowing
assesment of the compressiblity
of the gallbladder.
- Do not rely on measurements.
Some galbladders happen to be
small and others are large.
SIGN OF
CHOLECYSTITI
S
- Hydrops gallbladder
- gallbladder wall thickening
- positive murphy sign
 The gallbladder may be
surrounded by inflamed fat,

ACUTE
but on sonography this
frequently is not seen, while

CHOLECYSTITIS
CT sometimes does show fat-
stranding.
- Gallbladder wall thickening+gallstone
using US  PPV 95% for diagnosis of
acute cholecystitis
Unfortunately, thickening of the
gallbladder wall in the absence of
cholecystitis may be observed in
systemic conditions, such as liver,
renal, and heart failure, possibly due to
elevated portal and systemic venous
pressures

https://www.ajronline.org/doi/full/10.2214/AJR.10.4340
 APPENDICITIS
• Ultrasound should be the first imaging modality for diagnosing acute appendicitis
• USG for acute appendicitis diagnosis will decrease ionizing radiation and cost.
• Sensitivity of US to diagnose acute appendicitis is lower than of CT/MRI.
• Non-visualization of the appendix should lead to clinical reassessment.
• Complementary MRI or CT may be performed if diagnosis remains unclear.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805616/
WHEN TO USE
IMAGING
 Classic symptoms of appendicitis are well described
 One third of patients with acute appendicitis have atypical
presentations
 Patients with alternative abdominal conditions may present with
clinical findings indistinguishable from acute appendicitis .
Thus, although appendicitis traditionally has been a clinical
diagnosis, many patients are found to have normal appendixes at
surgery.
 The misdiagnosis of this acute condition has led to the
inappropriate removal of a normal appendix in 8–30% of patients .
A rate of unnecessary removal as high as 20% has been considered
acceptable in the surgery literature
 However, negative laparotomy can be avoided in many patients if
modern diagnostic methods are used to confirm or exclude acute
appendicitis.

Read More: https://www.ajronline.org/doi/10.2214/ajr.185.2.01850406
 Direct Sign
• Non compressible app
• Diameter > 6 mm
• Single wall thickness ≥ 2 mm
• Target sign
• Appendicolith
• Color Doppler US :
• Hypervascular in acute
• Hypo/avascular in
necrosis/abscess
Indirect Sign
• Free fluid surrounding appendix
• Local abscess formation
• Increased echogenicity of local
mesenteric fat
• Enlarge local mesenteric lymph
node
• Thickening of peritoneum
• Signs of secondary small bowel
obstruction
16-year-old girl with acute appendicitis.
Axial CT after oral and IV contrast
material shows cecal wall thickening
around appendiceal orifice
Abscess is the most frequent complication of perforation.
The abscess remains localized if periappendiceal
fibrinous adhesions develop before rupture.

If the abscess is large (> 4 cm), percutaneous drainage

followed by delayed appendectomy is the preferred
treatment

 
https://www.ajronline.org/doi/10.2214/ajr.185.2.01850406
 Enhanced scan
shows dilated
appendix with
thickened,
hyperenhancing wall
(arrows, B). Notice
mural stratification of
appendix wall.
 ABDOMINAL TRAUMA
4
• Hepato-renal recess (Morrisons
pouch)
RUQ • Inferior pole of kidney into right
paracolic gutter
• Below diaphragm

LUQ
• Below the diaphragm (peri-splenic
space)
• Between spleen and left kidney
1 2
• Inferior pole left kidney (left

3
paracolicgutter)
• Rectovesical space
• Vesicouterine space
Suprapubic • Rectouterine pouch (pouch of
Douglas)
• Posterior wall of bladder
Subcosta
GENERAL SIGN OF
PATHOLOGY
IMAGING
BOWEL
OBSTRUCTION
addressing the following
questions :
• Is the small/large bowel
obstructed?
• How severe is the
obstruction
• Where is it located and
what is its cause?
• Is strangulation present?
THE KEY RADIOGRAPHIC
SIGN
- diagnostic accuracy and specificity of abdominal
radiography  low (50-60%)
- SBO and LBO
Radiographic sign of small bowel obstruction :
• Small bowel distention (25 mm), Large bowel distention
( > 50 mm)
• collapsed or normal caliber bowel distal to the
transitional point
• bowel wall thickening surrounding mesenteric fat
stranding indicating inflammation
•  the presence of more than two air-fluid levels
• air-fluid levels wider than 2.5 cm, and air-fluid levels
differing more than 2 cm in height from one another
within the same small bowel loop
-sonography is not commonly the first
choice for the initial work-up of patients
with SBO
- Findings USG :
 the fluid-filled small bowel loops is dilated to
more than 3 cm
 the length of the segment is more than 10 cm
 peristalsis of the dilated segment is increased,
as shown by the to-and-fro or whirling motion
of the bowel contents 
Real-time sonography may differentiate
between mechanical and functional
Intestinal Obstruction
The movement of the mechanically
obstructed bowel will initially increase
but will decrease later with the progress
of the obstruction and development of
bowel ischemia
• CT criteria for SBO. Axial CT scan
shows a disparity in caliber between
distended proximal small bowel loops
(diameter >3 cm) (dotted line) and
collapsed distal small bowel loops  
(arrows).
• The SEVERITY of obstruction can
be assessed
• The presence of free fluid between
dilated small bowel loops,
aperistalsis, and wall thickening (>3
mm) in a fluid-filled distended
bowel segment suggests bowel
infarction
BOWEL OBSTRUCTION
 The antrum is usually the most common
site of inflammation, and the submucosal
GASTRITIS layer is frequently colonized by H pylori.
Radiologically, gastric wall thickening
is one of the most important signs
Sonography can be used effectively to
evaluate the stomach and duodenum.
Loss of the normal multilaminar gut
signature at the posterior wall of the
gastric antrum is another useful
sonographic characteristic of
inflammation.
Antral Wall Thickness (> 6 mm),
Mucosal Layer Thickness (4 mm)
MESENTERIC
LYMPHADENITIS
• Mesenteric lymphadenitis is a common mimicker
of appendicitis.
• It is the second most common cause of right lower
quadrant pain after appendicitis

Key finding: Lymphadenopathy with a normal

appendix and normal mesenteric fat
CONCLUSION

Patients with an acute abdomen have high risk. Serious

consequences may result from misdiagnosis

We advocate a systematic approach:

1. First focus on the most common diseases and make a firm
diagnosis or exclude them.
2. Always screen the whole abdomen for general signs of
pathology.
Click icon to add picture

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