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Department of Radiology
CT School, Novi Sad, 2012
1
Role of imaging in the evaluation of theacute abdomen
Prof. András Palkó MD, PhD
Department of RadiologyFaculty of General Medicine
University of SzegedHungary
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Department of Radiology
CT School, Novi Sad, 2012
2
Definition
• Sudden onset of severe symptoms requiring emergency
medical or surgical treatment,– typically characterized by intensive abdominal pain
– may be associated with:• muscular defense• paralytic ileus or hyper- (retro-) –peristalsis• nausea, vomiting, meteorism, hiccups•
fever, collapse, shock
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Department of Radiology
CT School, Novi Sad, 2012
3
Potential causes
• perforation• obstruction• ischemia•
bleeding• infection
peritoneal irritation
GI paralysis & defanse musculaire
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Department of Radiology
CT School, Novi Sad, 2012
4
Acute abdomen – top 8
1. Acute appendicitis2. Acute cholecystitis3. Small bowel obstruction (SBO)4. Acute gynecological disease
5. Acute pancreatitis6. Renal colic7. Perforated peptic ulcer8. Acute diverticulitis
account for 90 % of patients referredto hospital
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Department of Radiology
CT School, Novi Sad, 2012
5
Role of imaging
• After stabilizing the patient’s condition rapid diagnosisand therapeutic decision is essential to minimizeprogression and reduce mortality.
•
Clinical presentation, history, and lab test results are toooften non-specific.• Imaging examinations are of utmost importance to
establish diagnosis.
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Department of Radiology
CT School, Novi Sad, 2012
6
What’s wrong? – clinical findings
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Department of Radiology
CT School, Novi Sad, 2012
8
• Cholecystitis– Calculous– Acalculous– Emphysematous
• Hepatitis• Liver abscess• Spontaneous rupture
of a hepatic neoplasm• Right-sided LB diverticulitis• Retrocecal appendicitis
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Department of Radiology
CT School, Novi Sad, 2012
9
• Acute pancreatitis• Duodenal ulcer• Bowel obstruction• Abdominal aortic
aneurysm
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Department of Radiology
CT School, Novi Sad, 2012
10
• Bowel obstruction– SBO
• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous
– LBO• Carcinoma• Volvulus• Diverticulitis
• Perforation• Peptic ulcer• Diverticulitis• Iatrogenic
• Bowel ischemia– Mesenteric artery
• Thromboembolism• Atherosclerosis• Dissection
– Mesenteric vein• Hypercoagulable• Neoplastic• Strangulation,
volvulus• Infectious
• Gastroenterocolitis
• Pseudomembranous colitis
• IBD• Ulcerative colitis• Crohn’s disease
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Department of Radiology
CT School, Novi Sad, 2012
12
• (history, physical examination and lab tests)
• plain X-ray examination– abdomen
• erect or decubitus• supine
– chest• ultrasound
• computed tomography
Diagnostic algorithm
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Department of Radiology
CT School, Novi Sad, 2012
13
What’s wrong? – imaging findings
• Pathological gas accumulation• Localized/diffuse fluid accumulation• Diffuse/segmental gas/fluid levels• Extravasation, leakage• Pathological circulation• Wall thickening (bull’s eye) • Compartment syndrome• Foreign body
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Department of Radiology
CT School, Novi Sad, 2012
14
Pathological gas accumulation
• Pneumoperitoneum– perforation– iatrogenic– per vaginam
•
Pneumoretroperitoneum– perforation– iatrogenic
• Bowel wall– pneumatosis– infarction– necrosis
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Department of Radiology
CT School, Novi Sad, 2012
16
Pathological gas accumulation
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Department of Radiology
CT School, Novi Sad, 2012
17
Pathological gas accumulation
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Department of Radiology
CT School, Novi Sad, 2012
18
Pathological gas accumulation
• Pneumoperitoneum– perforation– iatrogenic– per vaginam
•
Pneumoretroperitoneum– perforation– iatrogenic
• Bowel wall– pneumatosis– infarction– necrosis
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Department of Radiology
CT School, Novi Sad, 2012
19
Pathological gas accumulation
• Pneumoperitoneum– perforation– iatrogenic– per vaginam
•
Pneumoretroperitoneum– perforation– iatrogenic
• Bowel wall– pneumatosis– infarction– necrosis
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Department of Radiology
CT School, Novi Sad, 2012
20
Pathological gas accumulation
• Pneumoperitoneum– perforation– iatrogenic– per vaginam
•
Pneumoretroperitoneum– perforation– iatrogenic
• Bowel wall– pneumatosis– infarction– necrosis
Gellett LR et al: Emerg Med J 2002;19:480-481
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Department of Radiology
CT School, Novi Sad, 2012
21
Pathological gas accumulation
• Biliary system– sphincter Oddi incompetence– postoperative– spontaneous fistula– emphysematous cholecystitis
• Portal vein– mesenteric infarction– air embolus– necrotizing enterocolitis
• Abscess
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Department of Radiology
CT School, Novi Sad, 2012
22
Pathological gas accumulation
• Biliary system– sphincter Oddi incompetence– postoperative– spontaneous fistula– emphysematous cholecystitis
• Portal vein– mesenteric infarction– air embolus– necrotizing enterocolitis
• Abscess
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Department of Radiology
CT School, Novi Sad, 2012
23
Pathological gas accumulation
• Biliary system– sphincter Oddi incompetence– postoperative– spontaneous fistula– emphysematous cholecystitis
• Portal vein– mesenteric infarction– air embolus– necrotizing enterocolitis
• Abscess
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Department of Radiology
CT School, Novi Sad, 2012
24
Pathological gas accumulation
h l d
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Department of Radiology
CT School, Novi Sad, 2012
25
Pathological gas accumulation
CT S h l N i S d 2012
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Department of Radiology
CT School, Novi Sad, 2012
26
Pathological gas accumulation –gasless abdomen
• Normal abdomen• Small bowel
obstruction/ischemia•
Ascites• Surgery (e.g. total
colectomy)• Gastroenteritis• Large abdominal mass
Thompson WM: AJR, 191:1093–1099, 2008
CT S h l N i S d 2012
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Department of Radiology
CT School, Novi Sad, 2012
27
Localized/diffuse fluid accumulation
• Ascites– cirrhosis– tumor– hypoalbuminaemia– portal hypertension– lymphatic obstruction
• Inflammation• Perforation• Abscess
Localized/diffuse fluid accumulation
CT School No i Sad 2012
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Department of Radiology
CT School, Novi Sad, 2012
28
Localized/diffuse fluid accumulation
• Ascites– cirrhosis– tumor– hypoalbuminaemia– portal hypertension– lymphatic obstruction
• Inflammation• Perforation• Abscess
CT School Novi Sad 2012
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Department of Radiology
CT School, Novi Sad, 2012
29
Localized/diffuse fluid accumulation
• Ascites– cirrhosis– tumor– hypoalbuminaemia– portal hypertension– lymphatic obstruction
• Inflammation• Perforation• Abscess
CT School Novi Sad 2012
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Department of Radiology
CT School, Novi Sad, 2012
30
Localized/diffuse fluid accumulation
• Ascites– cirrhosis– tumor– hypoalbuminaemia– portal hypertension– lymphatic obstruction
• Inflammation• Perforation• Abscess
CT School Novi Sad 2012
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Department of Radiology
CT School, Novi Sad, 2012
31
Diffuse/segmental gas/fluid levels
• Paralytic ileus
– Diffuse• peritonitis• gastroenteritis• abdominal pain• other (postoperative, drug
effect,electrolyte imbalance,pneumonia,retroperitoneal hemorrhage,etc.)
– Segmental (sentinel loop)• pancreatitis• cholecystitis• appendicitis,• diverticulitis• etc.
CT School Novi Sad 2012
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Department of Radiology
CT School, Novi Sad, 2012
32
Diffuse/segmental gas/fluid levels
• Paralytic ileus
– Diffuse• peritonitis• gastroenteritis• abdominal pain• other (postoperative, drug
effect,electrolyte imbalance,pneumonia,retroperitoneal hemorrhage,etc.)
– Segmental (sentinel loop)• pancreatitis• cholecystitis• appendicitis,• diverticulitis• etc.
CT School, Novi Sad, 2012
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Department of Radiology
CT School, Novi Sad, 2012
33
Diffuse/segmental gas/fluid levels
Paulsen SR, RadioGraphics, 26:641, 2006
• Obstruction
– Small bowel• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous
– Large bowel• Carcinoma• Volvulus• Diverticulitis
CT School, Novi Sad, 2012
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Department of Radiology
CT School, Novi Sad, 2012
34
Diffuse/segmental gas/fluid levels
• Obstruction
– Small bowel• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous
– Large bowel• Carcinoma• Volvulus• Diverticulitis
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CT School, Novi Sad, 2012
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Department of Radiology
, ,
36
Diffuse/segmental gas/fluid levels
E M Anderson, Imaging 2006;18:198
• Obstruction
– Small bowel• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous
– Large bowel• Carcinoma• Volvulus• Diverticulitis
CT School, Novi Sad, 2012
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Department of Radiology37
Diffuse/segmental gas/fluid levels
www.nypemergency.org
• Obstruction
– Small bowel• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous
– Large bowel• Carcinoma• Volvulus• Diverticulitis
CT School, Novi Sad, 2012
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Department of Radiology38
Diffuse/segmental gas/fluid levels
• Obstruction
– Small bowel• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous
– Large bowel• Carcinoma• Volvulus• Diverticulitis
CT School, Novi Sad, 2012
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Department of Radiology39
Extravasation, leakage
• Perforation (see also pathologic gas/fluid accumulation)
• Bleeding– Endoluminal
(ulcer, tumor, inflammation, iatrogenic, etc)– Extraluminal
(aneurysm, tumor, iatrogenic, etc)– Parenchymal organ
(tumor, iatrogenic, etc)
CT School, Novi Sad, 2012
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Department of Radiology40
Extravasation, leakage
• Perforation (see also pathologic gas/fluid accumulation)
• Bleeding– Endoluminal
(ulcer, tumor, inflammation, iatrogenic, etc)– Extraluminal
(aneurysm, tumor, iatrogenic, etc)– Parenchymal organ
(tumor, iatrogenic, etc)
Yoon W et al: Radiology 239:16-167, 2006
Detectable rate (arteriography): 0.5 – 1.5 mL/min
CT School, Novi Sad, 2012
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Department of Radiology41
Extravasation, leakage
• Perforation (see also pathologic gas/fluid accumulation)
• Bleeding– Endoluminal
(ulcer, tumor, inflammation, iatrogenic, etc)– Extraluminal
(aneurysm, tumor, iatrogenic, etc)– Parenchymal organ
(tumor, iatrogenic, etc)
CT School, Novi Sad, 2012
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Department of Radiology42
Extravasation, leakage
• Perforation (see also pathologic gas/fluid accumulation)
• Bleeding– Endoluminal
(ulcer, tumor, inflammation, iatrogenic, etc)– Extraluminal
(aneurysm, tumor, iatrogenic, etc)– Parenchymal organ
(tumor, iatrogenic, etc)
CT School, Novi Sad, 2012
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Department of Radiology43
Pathological circulation
• Arterial– thromboembolism (MI, rheumatic
heart disease, atrial fibrillation,etc.)
– arteriosclerosis– dissection– heart failure– others (iatrogenic, idiopathic,
strangulation/volvulus, septicemia,extrinsic mass, etc.)
• Venous– thrombosis– others (extrinsic mass, iatrogenic ,– strangulation/volvulus, etc.)
Kirkpatrick IDC et al: Radiology, 229:91-98, 2003
CT School, Novi Sad, 2012
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Department of Radiology44
Pathological circulation
• Arterial– thromboembolism (MI, rheumatic
heart disease, atrial fibrillation,etc.)
– arteriosclerosis– dissection– heart failure– others (iatrogenic, idiopathic,
strangulation/volvulus, septicemia,extrinsic mass, etc.)
• Venous– thrombosis– others (extrinsic mass, iatrogenic ,– strangulation/volvulus, etc.)
Shih MCP et al AJR 2007; 188:462-471
CT School, Novi Sad, 2012
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Department of Radiology45
Pathological circulation
• Arterial– thromboembolism (MI, rheumatic
heart disease, atrial fibrillation,etc.)
– arteriosclerosis– dissection– heart failure– others (iatrogenic, idiopathic,
strangulation/volvulus, septicemia,extrinsic mass, etc.)
• Venous– thrombosis– others (extrinsic mass, iatrogenic ,– strangulation/volvulus, etc.)
McMahon MA et al: Radiographics, 30:445-460, 2010
CT School, Novi Sad, 2012
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Department of Radiology46
Pathological circulation
• Arterial– thromboembolism (MI, rheumatic
heart disease, atrial fibrillation,etc.)
– arteriosclerosis– dissection– heart failure– others (iatrogenic, idiopathic,
strangulation/volvulus, septicemia,extrinsic mass, etc.)
• Venous– thrombosis– others (extrinsic mass, iatrogenic ,– strangulation/volvulus, etc.)
CT School, Novi Sad, 2012
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Department of Radiology47
Pathological circulation
• Arterial– thromboembolism (MI, rheumatic
heart disease, atrial fibrillation,etc.)
– arteriosclerosis– dissection– heart failure– others (iatrogenic, idiopathic,
strangulation/volvulus, septicemia,extrinsic mass, etc.)
• Venous– thrombosis– others (extrinsic mass, iatrogenic ,– strangulation/volvulus, etc.)
Okino Y et al: Radiographics, 21:1475-1490, 2001
CT School, Novi Sad, 2012
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Department of Radiology48
Wall thickening•
Infarction, ischemia• Intramural hematoma• Inflammation
– epiploic appendagitis– Groove pancreatitis
• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis
(clostridium difficile)– others (TBC, amebiasis, campylobacter,
shigella, etc.)• Neoplasm
Rha SE et al: RadioGraphics, 20:29-42, 2000
CT School, Novi Sad, 2012
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Department of Radiology49
Wall thickening
Dibbad R et al: The Internet Journal of Radiology, 12/1, 2010
•
Infarction, ischemia• Intramural hematoma• Inflammation
– epiploic appendagitis– Groove pancreatitis
• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis
(clostridium difficile)– others (TBC, amebiasis, campylobacter,
shigella, etc.)• Neoplasm
CT School, Novi Sad, 2012
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Department of Radiology50
Wall thickening
Noah Gudel, DO; Lisa M. Rock, MD, Medscape 2008
•
Infarction, ischemia• Intramural hematoma• Inflammation
– epiploic appendagitis– Groove pancreatitis
• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis
(clostridium difficile)– others (TBC, amebiasis, campylobacter,
shigella, etc.)• Neoplasm
CT School, Novi Sad, 2012
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Department of Radiology51
•
Infarction, ischemia• Intramural hematoma• Inflammation
– epiploic appendagitis– Groove pancreatitis
• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis
(clostridium difficile)– others (TBC, amebiasis, campylobacter,
shigella, etc.)• Neoplasm
Wall thickening
CT School, Novi Sad, 2012
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Department of Radiology52
Wall thickening•
Infarction, ischemia• Intramural hematoma• Inflammation
– epiploic appendagitis– Groove pancreatitis
• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis
(clostridium difficile)– others (TBC, amebiasis, campylobacter,
shigella, etc.)• Neoplasm
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Department of Radiology54
Wall thickening•
Infarction, ischemia• Intramural hematoma• Inflammation
– epiploic appendagitis– Groove pancreatitis
• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis
(clostridium difficile)– others (TBC, amebiasis, campylobacter,
shigella, etc.)• Neoplasm
CT School, Novi Sad, 2012
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Department of Radiology55
Wall thickening•
Infarction, ischemia• Intramural hematoma• Inflammation
– epiploic appendagitis– Groove pancreatitis
• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis
(clostridium difficile)– others (TBC, amebiasis, campylobacter,
shigella, etc.)• Neoplasm
CT School, Novi Sad, 2012
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Department of Radiology56
Foreign body
• Accidental/intentional/iatrogenic• Endoluminal/extraluminal• W./w.o. perforation
Maglinte DDT: Radiology, 236:763-767, 2005
CT School, Novi Sad, 2012
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Department of Radiology57
Abdominal compartment syndrome
• Increased intraabdominalpressure
• Various clinical conditions (massivehemorrhage and inflammation, severe gutedema, intestinal obstruction, ascites underpressure)
• Decrease in venous return,perfusion to the intra-abdominalorgans critically reduced
• Imaging (CT):– Round-belly sign - Abdominal
distention with increased (>0.80)sagittal-to-transverse diameter ratio
– Collapse of the vena cava– Bowel wall thickening with
enhancement– Bilateral inguinal herniation
CT School, Novi Sad, 2012
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Department of Radiology58
Acute abdomen - algorithm
• (history, physical examination and lab tests)
• plain X-ray examination– abdomen
•
erect or decubitus• supine
– chest• ultrasound
• computed tomography
CT School, Novi Sad, 2012
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Department of Radiology59
• (history, physical examination and lab tests)
• plain X-ray examination– abdomen
•
erect or decubitus• supine
– chest• ultrasound
• computed tomography
?
Acute abdomen - algorithm
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