changed the therapeutic management
Perspective
Sonography
and the Acute
Abdomen:
Practical
Considerations
Julien B. C. M. Puylaert1, Friso M.
van der Zant1, Arie M. Rijke2
O on indication of acute abdominal pain
ver the past 10 years, sonography
..has gained acceptance for examin ing
patients with acute abdominal
pain. Sonography is dynamic, noninvasive,
rapid, inexpensive, and readily accessible;
however, it has some serious drawbacks.
Use is
limited in obese patients; the ultrasound
beam
cannot penetrate bone or gas; and sonography,
more than other radiologic techniques, is operator-
dependent and requires skill, dedication,
and experience.
In this perspective, several practical aspects
of using sonography on patients with acute
abdominal pain are highlighted. These aspects
include the choice between sonography
and CT
as an initial examining technique, the timing
of
the sonographic examination, sonographically
guided puncture, the value of indirect
sonographic
findings, the significance of normal
findings on a sonogram, and, finally, commu nication
with the clinician.
Indications
Traditionally, surgeons have accepted a high
negative laparotomy rate to avoid the risks of
ill-advised surgical delay. Nonetheless, serious
surgical delay inside the hospital is common. A
prospective study of patients with a suspected
appendicitis showed a negative laparotomy
rate
of 27%; and concomitant serious therapeutic
delay in 14% of patients who needed surgery
[1]. Another prospective study dividing
patients
into three categories (high, equivocal, and low
clinical suspicion) showed that even in the
highsuspicion
group, 35% of the patients did not
have an appendicitis, whereas 5% of the
patients in the low-suspicion group had an
inflamed appendix [2]. In 30 patients with a
ruptured aortic aneurysm, treatment was
delayed more than 6 hr because of misdiagnosis
[3]. These figures show that the clinical
diagnosis
of an acute abdomen is unreliable and that
the threshold for radiologic imaging studies
should be low. The concept of sonography as
a helpful diagnostic tool used only in cases of
clinical doubt is and should be rejected.
The impact of sonography on clinical
management
of patients with an acute abdomen is
impressive. In a study of patients with suspected
appendicitis, sonographic findings
significantly
most tender region is deep in the pelvis, vaginal
in 26% of patients [4]. In three independent
studies using sonography, negative
laparotomy
rates were 13%, 13%, and 7%, respectively,
[4-61 with a concomitant reduction in
unnecessary
surgical delay. In our institution, virtually
all patients with acute or subacute abdominal
pain are referred for a sonogram, including
patients for whom surgery seems definitely
required as well as patients with a remote
possibility
ofrequiring surgery (Figs. 1 and 2).
Not surprisingly, sonography of the acute
abdomen has markedly affected routine
practice
in many institutions. Sonography performed
makes up 25% of all abdominal sonographic
examinations at our institution, and
nationwide,
acute abdominal pain has become the
most frequent reason for radiologists to go in
to the hospital when they are on call.
Sonography or CT as Initial
Technique?
Several acute abdominal conditions are more
easily detected on a CT scan than on a
sonogram.
They include a ruptured aortic aneurysm,
an aortic dissection, an esophageal rupture, a
mycotic aneurysm, an acute pancreatitis, an
incarcerated internal hernia, and perirenal
and
hepatic abscesses. In addition, CT scans
usually
provide better results in obese patients who
have retrocecal appendicitis, appendiceal
abscess, deeply located sigmoid diverticulitis,
closed-loop bowel obstruction, gastrointestinal
perforation to the retropetitoneum, and
emphysematous
cholecystitis. However, in experienced
hands, the sonograrn can still be used to
reliably diagnose most acute abdominal
conditions
in most patients [4]. Therefore, a reason-able
course of action is to begin with the least
expensive and least invasive technique and
proceed
to a CT scan only in cases of an
inconclusive
sonogram.
Examination Technique
Examination of the entire abdomen, from
the axilla to the groin. in
patients with acute
abdominal pain is more than a routine survey
of all abdominal organs. The examination
involves a sonographically guided. rational
approach to the clinical problem of that
particular
patient. During the examination, the
radiologist should continuously consider all
possible differential diagnoses depending on
the sonographic findings. This
symptomdirected
sonographic examination requires
communication with the patient because specific
findings may raise specific questions
and. conversely, information provided by the
patient may lead to a search for a specific
sonographic feature (Fig. 3).
Similarly. sonographic examination is closely
linked with physical examination. A dual
exami-nation is helpful when identifying what
organ or
structure corresponds to the most painful
area or
palpable mass. For example. if in women the
sonography may help not only in detecting
gynecologic
conditions but also in diagnosing sigmoid
diverticulitis 171or appendicitis [8] (Fig. 4).
Asking patients to point out the most tender
region can be especially important in conditions
that typically cause localized tenderness but do
not have conspicuous sonographic features.
Segmental
omental infarction 19]. Epiploic
appendagitis f 10), an incarcerated spigelian or
epiga.stric hernia, a small rectus hematoma [I I],
or sigmoid diverticulitis [ I 2, 13j are a few such
conditions (Figs. 5 and 6).
On the other hand. diagnostic signs can be
found at a considerable distance from the most
tender region. In appendicitis. the pain is
sometimes
diffuse in the lower abdomen, a patient
may present with a perforated duodenal
ulcer
that causes right lower quadrant pain because
the gastric contents track down the right
parecolic
gutter. small-bowel obstruction may cause
maximum pain at a marked distance from the
site of obstruction (Fig. 7), a stone in the distal
ureter may present with only flank pain, air
in
the biliary system with small bowel obstniction
may indicate a gallstone ileus, or liver
metastases may indicate an underlying
malignancy
in patients with an appendiceal mass.
These examples all emphasize the importance
of examining the entire abdomen.
If the anatomy is aberrant. especially in the
case of an inflamed appendix far removed
from the point where the gridiron incision is
normally made. The appendix should be
marked on the skin with an indelible pencil
(Fig. 8). Sonography in patients with an acute
abdomen should be performed with graded
compression similar to gentle palpation [ 14).
Compression shortens the distance from the
transducer to the abnormal structure and
allows
the use of a high-frequency probe. It is also
used to compress or displace gas-
containing
bowel. thereby reducing the disturbing effect
of
gas on the sonographic images. Compression
also involves determining the extent an organ
and its surrounding tissues can be compressed.
For instance, compression allows
identification
of gallbladder hydrops as well as assessment of
appendiceal rigidity in appendicitis (Fig. 9).
Finally, compression should always be applied
in a graded manner to minimize pain.
If. despite compression. gas continues to
hamper the sonographic examination, the
patient can be scanned with the transducer
positioned posterolaterally over the flank. In
this manner. ventrally located gas in partially
fluid-filled bowel loops or gas-containing
abscesses can be avoided (Fig. 10). With the
patient in a left lateral decubitus position, free
air should specifically be looked for between
the lateral abdominal wall and the liver.
Timing of the Sonographic
Examination
Many acute abdominal conditions show a
tendency toward spontaneous resolution;
however, symptoms may recur later.
Intermittent
episodes of abdominal pain are predominantly
seen in cases of obstruction.
When the obstruction is relieved, the
symptoms
resolve. and when the obstruction
recurs, the symptoms reappear.
This scenario is seen in biliary and urinary
stone disease. appendicitis. intussusception,
incarcerated hernia, and small-bowel obstruction
from adhesions. Sonographic findings during
an episode of pain may differ significantly
from findings immediately after such an
episode
and from the findings several days after
such an episode. For instance, if a patient is
examined during an episode of biliary colic, a
sonogram may show hydrops, thickening of
the
gallbladder wall, a sonographic Murphys
sign,
and an impacted stone. A few days later,
when
the symptoms have subsided, all that is found
is
a morphologically normal gallbladder
containing
a mobile stone. Sonographic findings
should always be correlated with the course of
the symptoms in time. Dilatation due to
an
obstruction ofthe gallbladder, kidney, bowel, or
appendix may disappear quickly after relief of
the obstruction. However, the inflammatory
changes associated with the process of
obstruction
often remain sonographically visible for
days or weeks even when the symptoms have
long since subsided. These residual changes
explain why an impressive cholecystitis or
appendicitis can be documented
sonographically
in a patient free ofsymptoms at the time of
the sonogram 16](Fig. I 1).
Preferably, the examination should be done
during an episode of pain for two reasons. Not
only is the chance of a diagnostic sonographic
finding greater but it also guarantees optimal
timing
of possible surgery. In case of intennirtent
episodes ofpain, the patient should be warned
to
seek immediate medical attention during the next
episode so that sonography, and possibly
surgery,
can be performed without delay (Fig. 12).
Sonographically Guided Puncture
In patients with an acute abdomen, a small
amount of free fluid may occur in both
surgical
and nonsurgical conditions and, as such,
is nonspecific. Identifying the nature of the
fluid, however, can be helpful.
Sonographically
guided puncture carries virtually no
risk and allows rapid differentiation between
blood, pus, and bile, and additional laboratory
investigation can distinguish further
between gastric fluid, pancreatic fluid, and
malignant ascites (Fig. 13).
Indirect Sonographic Findings
Many sonographic diagnoses such as
appendicitis,
renal colic, or cholecystitis are fairly
straightfoaward and can be made with
confidence.
However, sometimes the primary
condition
is not well, or not at all, recognizable by
sonography. In such cases, indirect sonographic
findings may be of help.
The most helpful indirect findings are related
to gastrointestinal pertration. such as may
occur in appendicitis, diverticulitis. Crohns
disease,
peptic ulcer disease, and bowel cancer. In
all of these conditions, protective migration
of
omentum, inesenteiy, and bowel loops to
the
site of imminent perThration occurs in an
attempt to seal offand prevent spillage of howel
contents into the peritoneal cavity. The
migrating,
inflamed fatty mesentery and omentum are
recognized as amorphous masses of
hyperechoic,
noncompressible tissue. This inflamed
fat is usually concentrated around the
diseased
organ and, although often prominent, can
easily
be overlooked on a sonogram. The most
conspicuous
feature of inflamed fat is its noncompressibility,
which is best observed by applying
intermittent graded compression with the
transducer.
Inflamed fat, especially in advanced
cases, is well recognized on a CT scan as
hyperattenuating
streaky (dirty) areas in the abdominal
fat(dirtyfat)(Fig. 14).
Secondary mural thickening of the neighboring
bowel loops, such as seen in appendicitis,
is another indirect sign. This finding can
be confusing and may be interpreted as such
primary bowel wall diseases as infectious
ileocolitis.
Crohns disease, or ischemia I 15).
Other useful indirect findings are associated
with abscesses, which occur when a
gastrointestinal perforation is not effectively
sealed off. Often the underlying
causeappendicitis,
diverticulitis, Crohns disease,
or a malignancy-can be determined. In
cases of large, gas-containing abscesses, this
determination may be difficult I 16, 17). An
abscessogram done some days after
percutaneous
drainage and a repeated sonogram
may, as yet, reveal the underlying
condition.
Another indirect sonographic sign is
related to free perforation. If the process of
sealing the bowel has been completely
ineffective
and the bowel contents are spilling
into the peritoneal cavity. first a local and
then a generalized peritonitis with paralytic
ileus will ensue. The presence of dilated
fluid-filled bowel loops with absent peristalsis
is an important clue and. in most cases,
indicates a gastrointestinal perforation
requiring
surgical treatment (Fig. 15).
Normal Sonographic Findings
It is not unusual to find no sonographic
abnormalities whatsoever in patients with an
acute abdomen. In patients with a low
clinical
suspicion of disease requiring surgery, a
negative
sonographic examination can usually be
taken as confirmation that no condition
requiring
surgery exists. lf however, clinical findings
and laboratory tests suggest a serious abnormality,
further workup is required. This problem
occurs frequently in young women in whom
appendicitis must be differentiated from
adnexi-tis. Normal sonographic findings do
not exclude
appendicitis or adnexitis. In this context, the
role of the erythrocyte sedimentation rate
must
be emphasized, because in adnexitis it is
usually
high at the time of admission. If the
etythrocyte
sedimentation rate is markedly elevated in a
young and not too obese woman with
normal
sonographic findings. adnexitis is strongly
favored. The reasoning is as follows: if the high
erythrocyte sedimentation rate had been caused
by appendicitis, conspicuous and extensive
inflammatory periappendiceal changes would
be present that would not have gone unnoticed
during sonography.
Another condition in which no sonographic
abnormalities are found in the presence ofa high
erythrocyte sedimentation rate is pyelonephritis;
however, this diagnosis is usually made on
clinical
presentation. It can, however,
masquerade as
a condition requiting surgery and lead to an
unnecessary laparotomy. Thickening ofthe
pyelocaliceal
wall and local tenderness over the kidney
may provide clues to the diagnosis [ I 8J.
Two other diseases that initially do not give
rise to abnormal sonographic findings are
pancreatitis
and mesenteric ischemia [19). Pancreatitis
is usually diagnosed by an elevated
amylase level in both urine and serum.
Mesenteric ischemia, however, can be a
diagnostic
nightmare.
When no sonographic abnormalities are
found in a patient with severe epigastric or
upper quadrant symptoms, a myocardial
infarction
or a pulmonary cause should be considered.
A subtle amount of pleural fluid or a
region of pulmonary consolidation may be
the first clue to the diagnosis of pulmonary
embolism or early pneumonia (Fig. 16).
If, in a patient with severe abdominal
symptoms, both sonographic and laboratory
findings are repeatedly normal. a psychogenic
cause or functional bowel disorder should be
suspected. If the sonographic examination
is
not conclusive, the most useful
complementary
study is a CT scan, especially if the
patient is obese or is not suitable for
sonography
in other respects.
Communication with the Clinician
For mote than a century, surgeons have been
taught to rely on their clinical impression in
their
decision between surgery and conservative
management
of patients with an acute abdomen.
Understandably, surgeons have viewed the ad vance
ofsonography in this field with caution and
perhaps even some distrust. The realization that
clinical astuteness is being challenged by
technology
has c&tsed both excitement and confusion
[20}; therefore, radiologists must have a good
relationship
with surgeons. A good relationship starts
with mutual confidence and good communication.
Radiologist and surgeon should speak acornmon
language. Tenns such as phlegmon,
perforation, walled-offperforation,
pseudoaneulysm,
and ileuscan mean differentthings to
a surgeon and a radiologist In difficult cases,
therefore, a morphologic description of the
intniabdominal
situation based on the sonographic
findings should be given, and a single-term
diagnosis
should be avoided. ln such cases, the radiolo gisi
should ask the surgeon to be present at the
sonographic examination.
In the final report, the sonographic find ings
should be integrated with the patients
history, physical signs, and laboratory data
as well as the results of a possible CT scan
and other radiologic examinations. Liberal
use and a clinical approach are the key points
in sonography of the acute abdomen.
Sonography
is a valuable tool to lower both the
number of unnecessary laparotomies and the
technique related to surgical delay.