“Acute abdomen” is a term used to encompass a spectrum of surgical, medical and gynecological...
Transcript of “Acute abdomen” is a term used to encompass a spectrum of surgical, medical and gynecological...
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“Acute abdomen” is a term used to encompass a spectrum of surgical, medical and gynecological conditions (intra-abdominal process), ranging from the trivial to the life threatening, which require hospital admission, investigation and treatment
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Assesing the patient with an acute abdomen need many investigation including laboratory test and imaging studiesplain photo, US, CT and contrast study .
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Plain abdominal films: erect chest film, supine, and upright (optional:left lateral decubitus)
Abdominal US Abdominal CT
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Erect Chest Supine Abdomen Erect AbdomenLeft Lateral Decubitus Abdomen
Best for free air under right diaphragm
Best for abdominal detail: Organs, bones and joints, calcifications, fat and gas pattern
For air-fluid levels and little else
For free air and air-fluid levels
Plain abdominal film
Table 1 Plain abdominal film
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Looking for› Gas pattern› Calcifications› Soft tissue masses
Substitute – none
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Looking for› Free air› Air-fluid levels
Substitute – left lateral decubitus
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Hemorrhage GI perforation Bowel obstruction Inflammatory disorder Circulatory impairment
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Intraperitoneal hemorrhage› Rupture:
hepatoma aortic anuerysm ectopic pregnancy ovarian bleeding
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Gastrointestinal hemorrhage› Upper GI hemorrhage
Duodenal ulcer Gastric ulcer Hemorrhagic gastritis Esophageal or gastric varices ect.
› Lower GI hemorrhage Bleeding of colon cancer Ischemic colitis ect.
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US finding› Free peritoneal fluid accumulation on the
Morison’s pouch, the rectovesical pouch, the pouch of Douglas, and the bilateral subphrenic space
Abdominal CT› CTgold standars for specific intraabdominal
pathology
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Gastrointestinal perforation are serious disorder requiring rapid diagnosis and treatment
Since they may be severe enough to produce septic or hypovolemic shockrapid decision-making for urgent laparotomy is crucially important
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● Radiological appearances:
Plain abdominal film: - Oval/linear collection of gas: ♠ Subhepatic space ♠ Morison’s pouch ♠ Beneath the diaphragm (the cupola sign) ♠ In the centre of the abdomen over a fluid collection (the football sign) ♠ Fissure for ligamentum teres
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Rigler’s signFissure for ligamentum teres
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The first investigation when bowel obstruction is suspected is the supine plain abdominal X-ray, together with an erect chest film if perforation is a possibility
Occasionally, all the dilated bowel may be fluid fill and not visible on a plain X-ray and further imaging with contrast studies, CT or US may be needed to demonstrate dilated bowel
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Imaging aims: to confirm the presence of bowel obstruction, define the level obstruction, identify the cause and detect complications such as perforation
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Extrinsic Bowel wall IntraluminalAdhesions Neoplasia Intussusception
Hernia Strictures:inflammatory, radiation,chemical
Foreign body
Volvulus Intestinal ischaemia
Gallstone ileus
Inflammation/abscess
Malignant infiltration (e.g. peritoenal deposits)
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Etiology: - Adhesions due to previous surgery - Strangulated hernias - Volvulus - Gallstone ileus - Intussusception - Neoplastic, etc.
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Plain filmprimary investigation of choice Plain film of SBO:
Dilated small bowel loops:› Tend to the central› Numerous› 2.5-5.0 cm diameter› Have a small radius of curvature› Valvulae conniventes: thin, numerous, and
extend right across the bowel› Do not contain solid faeces
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Multiple fluid levels on the erect film String of beads sign on the erect film Absent or little air in the large bowel
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US:SBO
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CT sign of SBO› Small bowel loops measuring>2.5 cm in diameter› Identifiable focal transition zone from prestenotic
dilated bowel to post-stenotic collapsed bowel loops
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Fluid-filled loops Bowel calibre change
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Etiology:
- Neoplastic (benign & malignant)
- Volvulus (caecal & sigmoid), etc.
Radiological appearances:
Depends on the state of competence
of the ileocaecal valve:
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Plain-film signs of LBO:› Dilated large bowel loops which:
Tend to be peripheral Few in number Large: above 5.0 cm diameter Wide radius of curvature Haustra: thick and widely separated and may or
may not extend right across the bowel (compare these features with the valvulae conniventes found in the small bowel
Contain solid faeces
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› Caecum maybe dilated› Small bowel may be dilated
Contrast enema maybe helpful:› To differentiate pseudo-obstruction and may be
indistinguishable on plain film from mechanical of obstruction
› To localized the point of obstruction› To diagnose the cause of obstruction e.g.
tumour, inflamatory mass
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coffee bean sign
Plain film:Sigmoid volvulus
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Generalised paralytic ileus: ●Etiology: - Peritonitis - Post-operative - Hypokalaemia - General debility or infection - Drugs: morphine - Congestive cardiac failure, renal colic, etc.
●Radiological appearances: - Both small & large-bowel dilatation - Horizontal-ray films: multiple fluid levels
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Acute appendicitis Acute pancreatitis Acute cholecystitis Abdominal absces Peritonitis
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Abdominal x-ray (AXR)› Non-specific finding› Approximately 10%a calcified appendicolith
US› Generally, the normal cannot be defined with US,
clear visualization of the appendix is suggestif of inflammation
› Swollen, non compressible appendix greater than 7 mm in diameter with a target or bulls-eye configuration is produced by the hypoechoic dilated appendiceal lumen
› Assymetrical wall thickening due to phlegmonous infiltration, an appendicolith with acoustic shadowing
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US finding› Echogenic hallo form by omental tissues draped
over the appendix› Free fluid in the culdesac› Atony in the terminal ileum with compression US
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CT finding› 90% diagnostic accuracy to detect acute appendicitis› With the good contrastfilling of the terminal ileum
and the cecum (oral contrast given 1 hour before examination)
› Tubular structure 4 mm to 20 mm in diameter with a thickened wall that enhance after administration IV contrast medium
› Pericecal fluid collection and calcified appendicolith
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Plain film:apendicolith
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Severity of acute pancreatitis rangesmild edema with minimal symptoms to a severe necrotizing process that culminates in multiple organ failure
US and CT most precisely define the anatomic extent of the lesions and the detect local complications
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Plain filmsno significant plain film findings in up to two-thirds of patients wih acute pancreatitis
Plain-film signs may include:› Paralytic ileus in the left upper quadrant› Generalized ileus› Loss of left psoas outline› Separation of greater curve of stomach
from tranverse colon
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CXR signs that may be seen include:› Left pleura effusion› Atelectasis of left lower lobe› Elevated left hemidiaphragm
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US finding:› The acutely inflamed pancreasenlarged with
decreased echogenicity and blurred irregular margin
› Fluid collection are seen as hypoechoic areas› US can be used to guide aspiration and the
drainage procedures, and for follow up
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CTimaging investigation of choice for acute pancreatitis, and is particularly useful for the following:
› Confirmation of the diagnosis› Identification of necrotic gland tissue› Diagnosis of complication› Guidance of interventional procedures
CT signs of acute pancreatitis include:› Diffuse or focal pancreatic enlargement with
decreased density and indistinct gland margins› Thickening of surrounding fascial planes e.g. left
paranephric fascia
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› Acute fluid collections, most commonly related to pancreas though also in the lesser sac and in the left pararenal space
› Phlegmon appears as an irregular mass spreading along fascial planes and can be quite extensive
› Abscess› Pseudocyst
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Approximately 85%-90% of cases with acute cholecystitis (AC) develop as a complication of cholelithiasis
Conversely, approximately 10%-20% of patients with gallstone will require surgery for complication, usually cholecystitis, within 15 years after their stone disease is diagnosed
Acalculous cholecystitis account for 5%-15% of cases of acute cholecystitis (immunocompromize, critically ill,iatrogenic, congenital etc)
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Plain filmsinsensitive for acute cholecystitis
Plain films signnonspesific and include:› Gallstone (only seen in 10%)› Soft tissue mass in the right upper
quadrant due to distended gallbladeer› Paralytic ileus in the right upper quadrant
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USinvestigation of choice for suspected acute cholecystitis
US signs of acute cholecystitis include:› Gallstones:hyperechoic lesions with acoustic
shadowing which are mobile› Thickening of gallbladder wall to greater than
4 mm› Hypoechoic gallblader wall due to oedema› Surrounding fluid or localized fluid collection› Distended gallbladder› Localized tenderness to direct probe pressure
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CTscanning contribute little to diagnosis of cholecystitis
CTinvestigation of complicatiosbiliary or pericholecystic abscess
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Peritonitisan inflammatory or suppurative reaction of the peritoneum to direct irritation
Cause:› Inflammatory› Infectious› Ischemic
Exudation,Hematogenous,
Contiguous extension,Iatrogenic manipulation
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Plain abdominal radiograph: cannot provide specific› Air-fluid Levels› Stones› Ascites› Eggshell calcification › Air in Biliary tree.› Obliteration of psoas-shadow in retro-
peritoneal disease› Right lower quadrant sentinel loops in acute
appendicitis
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USnonspecific Abdominal CT
› CT signs Ascites (free or encapsulated) Infiltration of the omentum and/or mesentery Thickening of the parietal peritoneum
Angiography for ischaemia, hemorrhage
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• Acute inflammatory colitis• Toxic megacolon• Pseudomembranous colitis• Ischaemic colitis
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Plain film can assess : ♠ the extent of the colitis ♠ the state of mucosa: It can be assessed from : - the faecal residue: In left-sided disease, the proximal limit of faecal residue will indicate the extent of active mucosal lesion. - the width of the bowel lumen - the mucosal edge - the haustral pattern
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A fulminating form of colitis with transmural inflammation, extensive & deep ulceration & neuromuscular degeneration.
Involve the transverse colon Ro. Findings: Mucosal islands (=pseudopolyps) & dilatation (8
cm) Common complication: Perforation in the sigmoid & peritonitis
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Etiology: Vascular insufficiency & bleeding into the wall of the colon. Sudden onset of severe abd.pain in the early
hours of the morning, followed by bloody diarrhoea.
In middle-aged & elderly patients. The wall of splenic flexure & descending colon is
greatly thickened→ thumb printing (plain films). The right side of colon is frequently distended.
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thumb printing
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