ABDOMINAL IMAGING IN

EMERGENCY SETTING

THE ACUTE ABDOMEN

Sudden onset of acute abdominal pain developing over hours.

Worldwide stomach and abdominal pain are the chief complains in the ED
Clinical challenge, requiring all resources to determine the cause
REMEMBER- extra abdominal causes can be the cause of an acute
abdomen. PROPER clinical and CAREFUL THOROUGH radiological
evaluation is key.

Several organs in the

abdomen.

Diagnostic approach of the

acute abdomen relies on a
good clinical history and
assessment.

Different radiologic tools

can be used.
Each has its own strengths
and pitfalls.

Conventional radiography

May be the first imaging tool

Abdominal series:
- Erect
- Supine
- Lateral decubitus
Detects:
- Pneumoperitonium
- Pneumonia mimicking abdominal pain
- Bowel obstruction
- Calculi/FB
- Emphysematous cholecystitis/pyelonephritis
Images courtesy Dr. Matthew Smith

Pitfalls of plain radiography

Low sensitivity in detecting appendicitis, diverticulitis, cholecystitis
Low sensitivity in detecting minimal fluid and pneumoperitoneum
Inter observer variations in diagnosis of low grade intestinal obstruction

Ultrasound

RUQ
RENAL
LIMITED
ABDOMINAL

Pitfalls of ultrasonography
Recent meal contracts GB may result in false positives
Recent morphine administration may mask pain- Murphys sign sensitivity

Limited evaluation in obese patients, fatty liver and significant bowel gas
Low sensitivity in detecting CBD stones.
Low sensitivity in detecting minimal fluid.

Images courtesy kidney2 and radrounds

Computed tomogography

Evaluation of abdomen and pelvis

Options
- w/out oral or IV contrast: urinary tract calculi/ retroperitoneal hematoma
- With both oral and IV contrast: most indications
- With IV and w/out oral contrast: mesenteric ischemia/ high grade SBO
- With oral and w/out IV contrast: sensitivity to contrast
- With rectal contrast: appendicitis/colonic pathology e.g trauma

Imaging acute abdomen slideshare Dr Rathashai

Pitfalls in CT
Radiation dose

 IV contrast allergies

MRI
Extensive evidence on the use of MRI in emergency abdominal imaging is
lacking
Clinical applications
- Suspected acute appendicitis in pregnancy and children. Avoid Gadolinium
in pregnancy
- Good results shown in sigmoid diverticulitis, CBD calculus, acute
cholecystitis and pancreatitis

SCINTIGRAPHY

Limited resolution
Not readily available
Costly

HIDA scan showing normal GB filling at 45

min

OUTLINE

INFECTION/INFLAMMATION

APPENDICITIS
CHOLECYSTITIS
DIVERTICULITIS
PANCREATITIS

GYNECOLOGIC/UROLOGIC

EARLY PREGNANCY- ECTOPIC

OVARIAN TORSION
PELVIC ABSCESS
RENAL COLIC

TRAUMA

OTHERS

AORTIC ANEURYSM
INTESTINAL OBSTRUCTION
MESENTERIC ISCHEMIA
PERFORATED DUODENAL ULCER

INFECTION/INFLAMMATION

1. ACUTE APPENDICITIS

the appendix - long diverticulum 10cm in length arising postero-medial to

the caecum 3 cm from ileo-cecal valve.

base is constant in relation to the caecum, the rest is free accounting for
the clinical presentation depending on location.

rare in the extremes of age. perforation is also common in these extremes

due to mis-diagnosis or delayed diagnosis.

pathogenesis- luminal obstruction. Fecoliths only present in 11-52%

patients but associated with perforation and peri-appendiceal abscess.

Clinical Presentation

suggestive abdominal pain

usually afebrile/low grade fever

if fever >38.2 suspect perforation. Peritonitis free perforation into the

abdominal cavity

Plain Radiography
Not commonly used.
Secondary signs of appendicitis are seen.

ULTRASOUND
Graded compression technique to displace bowels and allow visualization
of the appendix.
Difficult in the obese patients.
Multi-slice CT is increasingly replacing it.
Advantages
- Real time imaging allowing visualization of paralytic ileus
- Guide intervention procedures.
- Allows direct communication with the patient.
- Flexible and mobile; can reach the patient.

pitfalls in US dx of appendicitis
ileum vs appendix

uncommon documented spontaneous resolution of appendicitis

not visualizing the entire appendix; Lim et al (92) emphasized the requirement
of visualizing the entire length of the appendix to avoid a false-negative diagnosis

retro-cecal or true pelvic appendix

perforated-decompressed appendix

images rad assistant

CT

Weltman et al showed that the use of 5-mm-section helical CT enabled

the improved visualization of abnormal appendices (94% vs 69%),
calcified appendicoliths (38% vs 19%), and periappendiceal inflammation
(98% vs 75%) compared with 10-mm-thicksection helical CT in the same
patient.

Diagnostic accuracy between men and women varies; 78%92% male and
58%85% females.

Weltman DI, Yu J, Krumenaker J, Huang SM, Moh PP.

Comparison of 5mm and 10mm CT sections in the same
patient in the diagnosis of acute appendicitis (abstr).
Radiology 1998; 209(P):368.

Imaging protocols differ in as far as anatomic area to be included. widely

accepted conservative imaging method is CT abdomen and pelvis with
oral and iv contrast.

adequate opacification of the terminal ileum and cecum is necessary to

avoid false positive results. av scanning time is 45-60min

expedited focused scanning in appendicitis demonstrated by Rao et al

involves:

helical CT scanning of the right lower quadrant after rapid administration

of colonic contrast allows scanning within 15minutes.

accuracy comparable to the conventional scanning

pitfall: negative results necessitate additional scanning in minority of

patients

fastest imaging protocol proposed by Lane et al:

scanning without contrast medium (iv or oral)

cost effective alternative to US

no bowel preparation needed

most effective for patients with large habitus

accurate in r/o alternative diagnosis

CT appearance

normal appendix-collapsed,1-2mm partially filled with fluid, contrast or air.

homogeneous surrounding fat

Appendicitis;
mild distension 5-6mm with normal surrounding fat

severe thickened walls, 7-15mm diameter with mural stratification (target sign) and
contrast uptake

other important findings include focal caecal wall thickening and the arrowhead sign.

images appendicitis in the millenium radiographics

appendiceal perforation is strongly suggested by an abscess or

phlegmon.

associated findings: extraluminal air, marked ileocecal thickening,

localized lymphadenopathy, peritonitis, and small-bowel obstruction
appendicolith within a periappendiceal abscess or phlegmon.

substantial inflammation may make differentiation from ileocolitis with

secondary inflammation of the appendix difficult.

images radiographics. appendicitis in the millenium

MRI

Dailyem.wordpress/surgery

complications of acute appendicitis

perforation
gangrene
phlegmon/ abscess
peritonitis septic seeding of mesenteric vessels
bowel obstruction

2. CHOLECYSTITIS

Acute inflammation of the GB

4th most common cause of admissions in hospitals in the US

slideshare

Imaging
US is better than CT > MRI > Scintigraphy

CT best in assessing complications

Scintigraphy differentiates between acute and chronic Cholecystitis

I. Plain radiographs- 15-20% gall stones visible

II. US
. preferred, sonographic Murphys sign sensitivity 92% (negative
in patients with emphysematous cholecystitis)
. mobile echogenic foci with posterior acoustic shadowing
. wall thickening (>3mm), wall edema
. distension >4cm, C sign: pericholecystic and perihepatic fluid
accumulation
. Hyperemic GB

Slideshare samir haffar

Courtesy slideshare

Patterns of GB wall thickening (non specific)

Uniformly echogenic
Central hypoechoic zone separated by two echogenic layers
Striated pattern

III. CT
stones in the GB
Mercedes Benz sign: NO fissuring within the stone in a star
shaped pattern
thickened GB
fat stranding
pericholecystic, perihepatic fluid
transient hepatic attenuation difference
intramural or intraluminal gas emphysematous cholecystitis
intraluminal membranes, intraluminal or GB wall gas,
discontinuous enhancement or wall defect gangrenous
cholecystitis

Images radiopedia and

MRI
Gb wall thickening
Pericholecystic fluid
on MR focal T2 fat sat intramural hyperintensities are seen in gangrenous
cholecystitis
IV contrast administration at Ct and MRI differentiates gangrenous
cholecystitis (no enhancement) from perforation

Radiopedia/radwinski

IV. CholeScintigraphy
biliary excretion of radioisotope within 10min of injection in the
absence of isotope accumulation at 1hr is typical of acute
cholecystitis. imaging should continue up to 3hr or morphine
administered at 1hr and further imaging done up to 30 min to r/o
HIDA scan images obtained over 60 minutes after injection of 99mTc Mebrofenin
delayed filling
(top left image obtained at time zero, bottom right image obtained after 60
minutes). Prompt and homogeneous tracer uptake is noticed throughout the liver
(L), followed by tracer uptake in the small bowel (SB). The gallbladder cannot be
identified after 60 minutes and even after Morphine injection (to increase the
intrabiliary pressure to help open the gallbladder). Please notice an area of
increased hepatic activity in the expected area of the gallbladder fossa (dotted
arrow), which is referred to as the rim sign and suggestive of acute cholecystitis
due to the increased blood flow to the inflamed neighboring liver parenchyma.
Asterisk is at the level of the papilla Vateri.
Patient needs to be at least 4 hours and a maximum of 24 hours NPO to exclude
false positive findings

Radiologytutorials.com

Complications
3 subtypes of perforation:
localized perforation

Cholecysto-enteric fistula

free intraperitoneal spillage biloma

perforation is commonest at the fundus

difficult to diagnose; MRI and ERCP may be invaluable

3. DIVERTICULITITS
Complication of diverticulosis.
Non-complicated diverticulitis characterized by local fat stranding +/- few
locules of gas

Multi slice CT has been found to be invaluable in assessing colonic disease.

5mm collimation; 3mm in case 3D imaging is required
0.5-1L contrast for opacification. Negative contrast may be more superior
IV contrast to determine extent of disease. Scanning started 50minutes
after injection.

disease staging; Modified Hinchey Classification System

CT Findings
segmental wall thickening

bowel wall enhancement

peri colic fat stranding

diverticula perforation

abscess formation

fistulae

Treatment
conservative stages I/II

percutaneous abscess drainage if large

surgery, if recurrence, failed medical Tx or fistula formation

Complications
abscess formation

fistulae

perforation

intestinal obstruction due to adhesions

PANCREATITIS

Acute phase
early inflammation +/- peripancreatic edema and ischemia resolution or
permanent necrosis and liquefaction.
severity is based on clinical parameters and presence of SIRS

mild pancreatitis- resolution of organ failure within 48hrs, 0%mortality

severe pancreatitis- organ failure lasting > 48 hrs or death

Marshall scoring system (clinical) for organ failure

Marshalls scoring system

Note.Organ failure is defined as score $ 2 for at least one of the three organ systems. Duration of organ failure is defined as
transient, (#48 hours from time of presentation), or persistent (.48 hours from time of presentation). Persistent multiorgan failure
is defined as two or more organs failing during same 3-day period.

Ratio of partial pressure of arterial oxygen to fraction of inspired oxygen.

Serum creatinine level. To convert to Systme International units (micromoles per liter), multiply by 88.4.
Systolic blood pressure.

adopted from radiographics

markers of severity (done within the first 72 hrs of admission):

lab invx: hematocrit, LDH, CRP, U/Cs, urine trypsinogen

radiology: chest pleural effusions, CT severity score

APACHE II and Ransons score

NB: Different scoring systems are used to prognosticate patients
presenting with acute pancreatitits at 24 and 48 hours.
Apache II (Acute Physiology and Chronic Health Evaluation) and
ransons criteria are example.
Juun Choo et al showed that the highest accuracy for prediction of
severe AP, corresponded to Ranson 3 and APACHE-II 8

late phase occurs for weeks or months:

characteristics - increasing necrosis, infection, and persistent multiorgan failure.

+/- bacteremia and sepsis when necrotic tissue becomes infected.

sterile necrosis mortality is low; superinfection triples the mortality rate to 20-30%

IMAGING
CT+ IV contrast is the imaging modality of choice.
Indicated after 72 hrs in patients likely to develop severe
pancreatitits or for follow up in those who have undergone
intervention procedures (percutaneous CT guided drainage)
patient >40 years with first episode of pancreatitis to r/o
neoplasia

 report should document:

-

presence of pancreatic necrosis

characterize pancreatic parenchymal and extrapancreatic fluid

collections

+/- ascites, gallstones, biliary dilatation, venous thrombosis,

aneurysms, and contiguous inflammatory involvement of the
gastrointestinal tract.

MRI
for patients in whom CT is contra-indicated
further characterization of peri-pancreatic collections
U/S
indicated when patients have raised creatine levels and cannot tolerate
iodinated contrast
visualization of stones
ERCP
no role in morphologic classification

TYPES OF PANCREATITIS

1. Interstitial edematous pancreatitis

Pancreas may be normal radiologically

mistiness of the surrounding fat

varying amounts of peri-pancreatic fluid

heterogeneous contrast uptake

presence of pancreatic necrosis is indeterminate

2. Necrotizing pancreatitis
3 types, characterized by areas of non enhancement; may be
sterile or infected:

pancreatic parenchymal necrosis alone- 5%, <30%/>30%

Peri-pancreatic necrosis alone- 20%, better prognosis but high

morbidity than above

pancreatic parenchymal necrosis with peri-pancreatic necrosismajority 75-80% patients

Revised Atlanta classification of fluid collections in acute pancreatitis (4). ANC = acute necrotic collection, APFC = acute peripancreatic fluid collection,
WON = walled-off necrosis.

adopted from radiographics 2012

Pancreatic and peri-pancreatic collections

Interstitial
1. APFC:
. occur <4weeks, no non liquefied collections

cause -pancreatic and peri-pancreatic inflammation / rupture of

small peripheral pancreatic side duct branches.

conform to the anatomic boundaries of the retroperitoneum

usually seen immediately next to the pancreas have no
discernable wall.

NB: Fluid collections in the pancreatic parenchyma should be

diagnosed as necrosis and not as APFCs + avoid intervention

RADIOPEDIA

2.

Pseudocyst

localized amylase-rich fluid collections located within pancreatic

tissue or adjacent to it .
Surrounded by a fibrous wall that does not possess an epithelial
lining (enhances post contrast)
develops within 4 weeks
establish connection with the pancreatic duct- possible on curved planar
reformats; MRCP is the best
may become infected

RADIOGRAPHICS

Necrotizing
1. ANC
. persisting collection within the first 4 week
. fluid and necrotic material
. may or may not have connection to the main duct
2. WON
. develops at or after 4 weeks
. maturation of the ANC developing a thick non epithelialized wall
. may or may not communicate with the pancreatic duct
EUROPEAN RADIOLOGY
RADIOPEDIA

Treatment and complications

conservative for as long as possible

failed conservative management:

Rarely in necrotizing pancreatitis after resection or in disconnected duct syndrome

courtesy revision of pancreatitis, atlanta workgroup

april 2008

complications
infection; most serious complication, defined on imaging by presence of gas bubbles
in the collection 40% cases only.
uncommon in the first week

potential radiologic reporting pitfall- occurs with spontaneous drainage in to the GI

tract
pseudoaneurysm
bleeding

FNA false negative rate 10%, if clinically infection is still suspected repeat FNA.

GYNECOLOGIC/UROLOGIC

1. ECTOPIC PREGNANCY
Goal of 1st tri US is to locate the GS (normal or abnormal)

TVS detects pregnancy at b HCG levels 2000mIU/ml, TAS threshold is

6500mIU/ml

typical hx- LAP and spotting or bleeding + amenorrhea of 5-9 weeks

work up should include b HCG (glycoprotein elevated in preganancy until

20wks, doubling time 48hrs; rise <50% in 48hrs= abnormal gestation) +
transvaginal US

TVS:
intradecidual sac sign 4.5 wk

double decidual sac sign 5wk

yolk sac 5.5wk/ GSD 10mm

FHR 5-6wk/GSD 18mm/ CRL 5mm>

subthreshold b HCG levels and non specific findings on US =

patient follow up with serial scans and bHCG

Tubal pregnancy
suggestive titres of bHCG and no gestational sac on US =
detailed search for ectopic pregnancy.
Ampulla 70%; Isthmus 12 %; Fimbria 11 %

courtesy radiographics vol

28 issue 6 2008

Intra-uterine findings
normal endometrium/ tri-laminar appearance
pseudogestational sac; 10% ectopic pregnancies, thick decidual
reaction surrounding a fluid collection,no double decidual sac
sign, centrally located
thin walled decidual cyst; seen at junction of myo and
endometrium in normal or ectopic pregnancies

extra-uterine finding of fluid in the POD has a 86-93% PPV, when

the bHCG is elevated. Finding of free fluid in the Morrisons pouch
is suggestive of rupture.

Interstitial pregancy
uncommon 2-4 %
eccentric GS located high up in the fundus with < 5mm of
myometrium surrounding it in all planes, specificity 88-93%,
sensitivity 40%
common risk factor intra-uterine instrumentation and IVF
implantation into the intra-myometrial portion of fallopia tube.
highly distensible = late detection up to 16 wk
interstitial line sign 98% specific, 80% sensitive

image courtesy BioMed central, Danielle et al 2015

cornual pregnancy
rare, refers to implantation of blastocyst in the cornua of septate
or bi-cornuate uterus
also has thin (<5mm) myometrial mantle.
ovarian pregnancy
3 % cases, associated with use of IUD
may manifest as heterotopic pregnancy

cervical pregnancy
finding of a GS below the internal os. rare <1 %
associations: prior curettage and IVF
hour glass or figure of 8 uterus
+ sliding sign- sliding of the GS within the cervix when gentle
pressure is applied.
Scar pregnancy
CS scar implantation, rare <1%
thinning of the anterior wall of the myometrium

images courtesy; US for ER physicians and

radiographics

Intra-abdominal pregnancy
rare. seen in IVF
mortality is high x 7.7other locations
Heterotopic pregnancy
seen more in IVF esp ovulation induction

2. OVARIAN TORSION
Torsion of the ovary and part of the fallopian tube on its vascular pedicle
Bi-modal age distribution: 15-30 yrs and post menopausal
20% occur in pregnancy

Causes:
- Hypermobility of ovary < 50%
- Adnexal mass; paraovarion cyst, dermoid 50-80%

CP: Severe intermittent or sustained abdominal pain

Ultrasound
Enlarged (most common US finding ) hyper or hypoechoic ovary
Midline ovary with peripherally displaced follicles
Free pelvic fluid
Normal doppler findings/ reduced arterial flow/ little or no intra ovarian
venous flow
Whirlpool sign

radiopedia

DDX
1.Hemorrhagic cysts: great imitator with variable US appearances
2. OHSS: rare, potentially fatal, iatrogenic complication of ovulation
stimulation for the treatment of infertility commonly occurring during the
luteal phase or early pregnancy

radiographics

CT
good at ruling out ovarian torsion
twisted ovarian pedicle is pathognomonic
torsion appears as a complex adnexal lesion representing:
enlarged ovary (>4.0 cm)
distended pedicle
possible underlying ovarian lesion
HU >50 on non-contrast CT suggests haemorrhagic necrosis
lack of enhancement may be seen
surrounding fat stranding, oedema,and free fluid

Pelvic MRI
Not the imaging modality of choice
If haemorrhagic infarction is present, signal changes include:
T1
thin rim of high signal (methaemoglobin) without contrast
enhancement
ddx: endometriosisand haemorrhagic corpus luteal cysts are less likely
to havehigh T1 rim and do not usually involve the entire ovary
T2:can have low signaldue tointerstitial haemorrhage

3. PELVIC ABSCESS
Collection of pus in the pelvis.
Causes:
- PID
- Recent surrgery
- Diverticulitis
Clinical Presentation:
- Back pain/ LAP
- Fever/ Leukocytosis

4. ACUTE RENAL COLIC (RENAL CALCULI)

Most patients tend to present between 30-60 years of age
Clinical presentation
- Pain
- Hematuria
most common stone is calcium oxalate
lifetime incidence of renal stones is high, 5 % women and 12% males

Risk factors
Reduced fluid intake
Hyperuricosuria
Congenital malformations of the urinary tract- horseshoe kidney
Recurrent renal tract infections
Hyperoxaluria
Hypercystinuria

 estimated that almost 50% of stone patients will present recurrence within
10years
MDCT is the gold standard due to its accuracy and ability to evaluate stone
load treatment planning
US should be used as the initial imaging tool as it is available and
affordable.
Evaluate for other renal parenchymal conditions that may mimic renal
colic.

Teichman JMH. Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med. 2004;350:684693. doi: 10.1056/NEJMcp030813

Abdominal radiography
Calcium containing stones are radiopaque
calcium oxalate +/- calcium phosphate 75%
struvite (triple phosphate) - usually opaque but variable 15%
pure calcium phosphate 5-7%
Lucent stones include
uric acid 5%
Cystine 1%
Indinavir stones
pure matrix stones

Fluoroscopy
IVUhas been replaced by non contrast CT.

radiopedia

Ultrasound
first investigation of choice but has reduced sensitivity
sensitivity 24%, specifity is 100% with stones < 3 mm not visualize (Fowler
et al and Sheafor et al).
Presence of UVJ edema is a useful sign of recent stone evacuatiion
Features of renal stones include
- echogenic foci
- acoustic shadowing
- Twinkle artifacton color Doppler
- Comet tail artifact

Additional findings on U/S

An absent, asymmetric and/or reduced ureteric jet
Increased resistive indexsign of acute obstruction, distinguishes
between obstructive and non-obstructive dilatation. A renal RI>0.70 +/10% difference between the kidneys is considered as diagnostic of
obstructive uropathy.

 Colour Doppler twinkling artefact: This artefact is a mixture of red and blue pixels on colour Doppler
secondary to the noise produced from rough interfaces composed of sparse reflectors such as urinary stones. It
is very useful to confirm findings of grey-scale, especially in doubtful cases due to small size of the stone or
located in difficult-to-visualise ureteral portions . study by Moore et al. , the sensitivity of US improved
from 47.6 to 86% when the twinkling sign was used. Ripolles et al., which analysed the specific value
of the twinkling artefact, the sensitivity of US using the twinkling artefact for detecting lithiasis was
90% and the specificity 100%. A total of 78% of the lithiases showed the twinkling artefact, including three
stones not identified by B-mode US, and in 68% of these stones, the artefact was detected before the stone itself
with B-mode.

Typically the artefact, which resembles the grey-scalecomet tail artifact, is seen in situation when a small highly
refractive (usually calcific) object is interrogated with colour Doppler.Twinkle artifactoccurs and immediately deep
to the object a tail linear aliased band of colour extends away from the probe.

Radiopedia and ncbi imaging in renal colic carlos nicolau et al

CT
On CT almost all stones are opaque, but vary considerably in density.
calcium oxalate +/- calcium phosphate: 400-600 HU
struvite (triple phosphate): usually opaque but variable
pure calcium phosphate: 400-600 HU
uric acid: 100-200 HU
cystine: opaque
Two radiolucent stones are worth mentioning11:
Indinavir stones: (anti-retroviral drug) radiolucent and usually undetectable
on CT5
pure matrix stones

OTHER CAUSES OF ACUTE ABDOMEN

ABDOMINAL AORTIC ANEURYSM

focal dilatations of the abdominal aorta; >3cm or >50% greater

in diameter than the proximal segment

13th leading cause of death in the US

more common in males > 65 yr (2-4%), rare before 50 yr. M:F 4:1

most are true aneurysms commonly located distal to the renal

arteries

risk factors for aneurysmal dilatation of the abdominal aorta

concurrent CAD
male
smoking
hypercholesterolemia
peripheral vasc disease
family history

CP:
pulsatile abdominal mass
abdominal or back pain

greatest risk factor for rupture is diameter

< 4 cm in diameter 6-year cumulative incidence of rupture 1 %

4- to 5-cm aneurysms estimated at 13% per year

611% per year for 5- to 7-cm aneurysms.

Aneurysms > 7 cm have a risk of rupture is 20% per year

ct findings of rupture

AJR:188, January 2007

a study by Siegel et al found no correlation with increased risk of

rupture with the length of the aneurysm

however in this retrospective study, he found that presence of

thrombus and thrombus calcification were associated with
reduced risk

luminal irregularity was similar in the control and risk groups

most ruptures are located in the posterolateral wall and

extravasate into the retroperitoneum

Siegel CL, Cohan RH, Korobkin M, Alpern MB, Courneya DL, Leder RA. Abdominal aortic
aneurysm morphology: CT features in patients with ruptured and nonruptured aneurysms. AJR
1994; 163:11231129

Causes
arterosclesrosis
vasculitis
connective tissue disease
mycotic aneurysm
trauma
chronic abdominal dissection
inflammatory abdominal aortic aneurysm

Associations
Common iliac artery aneurysms
AAA may extend into the CIA
CIA rarely exist alone

Popliteal artery aneurysm

10-14% patients with AAA have Pop artery aneurysm
upto 50% with Pop artery aneurysm have AAA

renal artery stenosis (22-30%)

inferior mesenteric artery occlusion (80%)

Role of imaging
detection

monitoring

pre-op planning

post op follow up

I. Plain radiographs
. paravertebral curvilinear calcification

II. Ultrasound
. 98% sensitive
. measurement of error is 4mm

RADIOPEDIA
BJCARDIO

CT
modality of choice, fast easily available
unenhanced scanning through the abdomen and pelvis at 5mm
collimation; followed by bolus tracking CTA at 1mm collimation;
then delayed (80s) scanning in the porto-venous phase
90ml iodinated contrast medium at 3-mls/s
patients not able to tolerate iodinated contrast, use of gadolinium
has been reported. 0.3-0.5mmol/kg with a 16 or > slice CT
scanner

MR ANGIOGRAPHY
3D contrast MRA is highly accurate in depicting location, extent and precise
diameter of an aneurysm
During interpretation, measurements should be obtained from source
images since MIP images represent a cast of lumen alone and may
underestimate the size and extent if disease.
Thrombus appears as intermediate signal within the lumen on T1,
calcification not well visualized
Pitfall- slow flow may mimic a thrombus

Complications
Rupture
Distal thromboembolism
Thrombotic occlusion of a branch vessel
infection
Pseudoaneurysm
Vertebral erosions
Compression of adjacent structures

INTESTINAL OBSTRUCTION

SBOaccounts for 80% allmechanical IO, 20% result from large bowel
obstruction.
mortality rate of 5.5%.
Causes
- Congenital: jejunal/ ileal atresia
meckels diverticulum
midgut volvulus
- Acquired:
Extrinsic- adhesions
intussusception
hernia

IntrinsicLuminal- meconium

ileus
endometriosis

tumor
swallowed

bezoar
intestinal
ischemia

Algorithm for imaging work-up of patients suspected to have SBO. MDCT = multidetector CT.
RadioGraphics,
http://pubs.rsna.org/doi/abs/10.1148/rg.292085514

Plain abdominal radiography - diagnostic in 50%60% of cases .

High sensitivity only for high-grade obstructions.

Sonography- limited by bowel gas. Not able to visualize adhesions.

Fluid filled obstructed bowel segments may help localize the
level of obstruction and demonstrate the level of obstruction.

SBO: WHAT TO LOOK FOR:

Radiographics March- April 2009
vol 29 issue 4

103

Contrast studies- enteroclysis and computed tomographic (CT)

enteroclysis are used mainly in patients with clinically suspected
low-grade SBO. Sensitivity is 100%
CT - best modality for determining patients likely to benefit from
conservative management and close follow-up Vs immediate
surgical intervention. sensitivity of 90%96%, specificity of 96%,
and accuracy of 95% in high grade obstructions

radiographics

SBO

20% of all surgical admissions for acute abdominal pain

Causes: adhesions, Crohns disease, malignancy, hernia, lead point

intussusception.

Key questions: Is the small bowel obstructed? How severe is the

obstruction, where is it located, and what is its cause? Is strangulation
present?

Abdomen X ray SBO features:

dilated loops > 30mm or exceeding 50% diameter of largest
visible colon
2/> air-fluid levels, air-fluid levels wider than 2.5 cm, and air-fluid
levels differing > 2 cm in height from one another within the
same small bowel loop (high grade)

Large bowel
Cecal volvulus:
- Torsion of cecum along its mesentry.
- 11% of all intestinal voluvuls
- Young patients 30-60%
Sigmoid volvulus:
- 60%; common in the elderly

Sigmoid volvulus is differentiated from aceacal volvulusby its ahaustral wall

and the lower end pointing topelvis

 Coffee bean sign

Frimann Dahl sign- three dense lines converge towards site of obstruction
absent rectal gas

radiopedia

MESENTERIC ISCHEMIA

vascular compromise of the small bowel secondary to any cause

Causes:
- Thromboembolism
- Non occlusive
- Neoplasia
- Drugs (chemo)
- Radiation
- Trauma
- vasculitis

 Imaging findings are similar regardless of the primary cause.

CT is the imaging modality of choice
- Most common finding is bowel wall thickening (non specific)
Target sign
- Other findings include; lack of bowel wall enhancement
Arterial occlusion/ venous thrombus
Intramural gas
Porto-venous gas
Increased enhancement
Infarction of other organs

 Free intra-peritonial gas is an ominous sign

Specific sign for bowel ischemia is absent or poor enhancement
SMA embolus is more common than SMV thrombosis. Usually
caused by underlying cardiovascular problems
CT sensitivity is wide 37-80%

 Angiography was considered the gold standard but now surpassed

by CT/ MRI
Instrumental in non-occlusive disease showing spasm, arterial
occlusion, or diminished flow

Plain radiographs and Contrast studies

- Bowel distension
- Bowel wall thickening
- Pneumatosis intestinalis
- Pneumatosis portalis

US SBO features:
- Dilated loops >30mm
- Increased peristalsis
- Length > 10
- Presence and characterization of hernia

Cross sectional Imaging:

- Transition between normal and dilated bowel
- Cause of obstruction like bezoars, tumor, intussusception, crohns..

PERFORATED DUODENAL ULCER

CT is the current imaging of choice

s/s may mimic appendicitis requiring further evaluation with US
or CT
US defines the ulcer, demonstrates the free fluid, and can guide puncture of this
fluid in cases of uncertainty.

Plain Radiographs
visualization of air under the diaphragm
US
ring down artifacts from free air in classic locations

TRAUMA

FAST
most studies : sensitivity of FAST for the detection of free intraperitoneal
fluid 64-98%

Overall specificity of FAST high, at 86-100%

detectability of free fluid , strongly dependent on the volume of fluid

present. Branney et al found a minimum detectable fluid volume of about
200 mL.

role in the diagnosis of injuries to solid organs is limited. published

studies, solid organ injuries without concomitant hemoperitoneum were
frequently missed at FAST examinations.

CURRENT ROLE OF EMERGENCY US

IN TRAUMA : radiographics 2008;
28: 225-244

116

E.g sensitivity of FAST in the detection of liver injuries range from 0.15 to
0.88, with high specificity of 0.99 1.00 (wide variabilityin the diagnostic
value of FAST as a tool)

McGahan et al described widely differing US appearances of liver

lacerations, ranging from hypoechoic to hyperechoic . In general,
lacerations become hypoechoic or even cystic over time.

lack of a uniform pattern of liver echogenicity makes the detection of

hepatic injuries difficult at US. Alterations of the liver parenchyma caused
by entities such as steatosis, regenerative nodules, or focal changes in fat
distribution also may complicate the detection of injuries

CURRENT ROLE OF EMERGENCY US

IN TRAUMA: Radigraphics 2008;
28: 225-244

117

Areas to be scanned
The Right Upper Quadrant
The Left Upper Quadrant View
The Pelvic View
The Pericardial View
The Anterior Thoracic View
The Pleural Space Views
The Apical View

SPLEEN INJURY SCALE

Grade 1- subcapsular hematoma, laceration < 1cm deep
Grade 2- subcapsular hematoma 10-50% of surface area, lacerations 13cm not involving trabeculae vessels
Grade 3- subcapsular hematoma >50% surface area or expanding,
lacerations > 3cm, ruptured subcapsular or parenchymal hematoma
Grade 4- laceration involving segmental or hilar vessels with major
devascularisation >25 % of the spleen
Grade 5- shattered spleen, hilar injury with devascularized spleen.

INJURY SCORING SCALE: AAST

119

RENAL INJURY SCALE

Grade 1- contusion or non enhanceing subcapsular perirenal hematoma, no
laceration
Grade 2- superficial laceration< 1cm, not involving the collecting system
Grade 3- laceration> 1cm without extension into the renal pelvis or
collecting system
Grade 4- laceration extends to renal pelvis, segmental infarctions without
associated lacerations, expanding hematoma compressing the kidney
Grade 5- shattered kidney, avulsion at the hilum, ureteropelvic avulsions

REFERENCES

Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gyn
Obstet 1990; 171:185-188.
Weltman DI, Yu J, Krumenaker J, Huang SM, Moh PP. Comparison of 5mm and 10mm CT sections in the same
patient in the diagnosis of acute appendicitis (abstr). Radiology 1998; 209(P):368
Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C. Acute appendicitis: CT and US correlation
in 100 patients. Radiology 1994; 190:31-35.
Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review; Danielle et al BioMed
Central

LozeauAM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician2005; 72: 1707
1714.
LipscombGH, Stovall TG, Ling FW. Nonsurgical treatment of ectopic pregnancy. N Engl J Med2000; 343: 1325
1329.
AttarE. Endocrinology of ectopic pregnancy. Obstet Gynecol Clin North Am2004; 31: 779794.
EyvazzadehAD, Levine D. Imaging of pelvic pain in the first trimester of pregnancy. Radiol Clin North Am2006;
44: 863877.
DartR, Ramanujam P, Dart L. Progesterone as a predictor of ectopic pregnancy when the ultrasound is
indeterminate. Am J Emerg Med2002; 20: 575579
LevineD. Ectopic pregnancy. Radiology2007; 245: 385397.
RussellSA, Filly RA, Damato N. Sonographic diagnosis of ectopic pregnancy with endovaginal probes: what
really has changed? J Ultrasound Med1993; 12: 145151
DialaniV, Levine D. Ectopic pregnancy: a review. Ultrasound Q2004; 20: 105117.
AtriM, Leduc C, Gillett P, et al. Role of endovaginal sonography in the diagnosis and management of ectopic
pregnancy.RadioGraphics1996; 16: 755774

Jacobs DO . Clinical practice: diverticulitis. N Engl J Med 2007;357:20572066.

Laurell H , Hansson LE , Gunnarsson U . Acute diverticulitis: clinical presentation and differential diagnostics.
Colorectal Dis 20
Rao PM, Rhea JT, Novelline RA, Mostafavi AA, Lawrason JN, McCabe CJ. Helical CT combined with contrast
material administered only through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol 1997;
169:1275-1280.
Zarins CK, Hill BB, Wolf YG. Aneurysmal vascular disease. In: Townsend CM Jr, Beauchamp DR, Evers MB,
Mattox KL, Sabiston DC, eds. Sabiston textbook of surgery, 16th ed. Philadelphia, PA: Saunders, 2001:1357
1372
www.slideshare.net/rathachai/imaging-acute-abdomen-part-1
Radiologytutorials
Comparison of scoring systems in predicting the severity of acute pancreatitis; World J
Gastroenterol. 2015 Feb 28; 21(8): 23872394 juun cho et al

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