Documente Academic
Documente Profesional
Documente Cultură
TheroleofthePlainFilmAbdominal
Series
MIZucker,MD
AdrZLecture
TheAbdominalSeries
Forallacuteabdominalcomplaintswhere
plainfilmimagingisindicated,geta
COMPLETEabdominalseries
Exceptions:Suspectedrenalcalculusor
foreignbody,whereasingleviewisOK
CTandultrasoundareoftenperformed
afterplainfilms
AbdominalSeries
Indications:
Highestyield:Presentationssuggestiveof
freeairorobstruction
Notverygoodformasses,ascites,
organomegaly,biliarytractdisease,GI
bleedingandvagueabdominalcomplaints
Yieldishigherintheelderly
TheAbdominalSeries
Erectchest,APsupineanderectabdomen
Or,ifpatientunabletosit/stand:
supinechest,supineandleftlateral
decubitusabdomen
Forcalculusorforeignbody:APsupine
abdomen
TheErectChest
Bestforfreeair
Toevaluateforintrathoracicabnormalities
presentingwithabdominalcomplaints,
especiallypneumonia(morecommonin
kids)
SupineAbdomen
Bestforabdominaldetail:Organs,bones
andjoints,calcifications,fatandgaspattern
ErectAbdomen
Forairfluidlevelsandlittleelse
LeftLateralDecubitusAbdomen
Substituteforerectchest(freeair)anderect
abdomen(airfluidlevels)inapatient
unabletositorstand
Indicationsforasingleerect
abdomenfilmONLY
NONE
None
None
None
TheCheckList
Bonesandjoints
Calcifications
Organs
Fat
Gas:Inbowelandoutsideofbowel
Amemoryaid
Firstorgans,bones,andstones,
Thenmasses,fat,andgas.
Dontforgetthecornerzones,
Andyoullalwayscoveryoursubject
TheNormalAbdominalSeries
Chest
Supineabdomen
Erectabdomen
Leftlateraldecubitusabdomen
Chest
SupineAbdomen
ErectAbdomen
LeftLateralDecubitusAbdomen
Dontforgettolookfor
pneumonia
GAS
Inthegut,andelsewhere
PNEUMOPERITONEUM
FREEAIR:PerforatedGut
FreeAir
Bestviews:Erectchestandleftlateral
decubitusabdomen
Erectabdomenislesssensitive
Supineabdomenisinsensitive
HowSensitive?
Plainfilmsare85%sensitiveforfreeair
Theoreticalthresholdis2cc
CTismuchmoresensitiveandistheGold
Standard
FreeAir:ErectChest
Airunderthediaphragm
Usuallyontheright
Occasionallyonlyseenontheleft
FreeAir:ErectChest
FreeAir:ErectChest
FreeAir:ErectChest
FreeAir:LeftLateralDecubitus
Rightsideup,leftsidedown
Patientwhocantsitorstand
Airunderrightabdominalwall
FreeAir:LeftLateralDecubitus
FreeAir:SupineAbdomen
Doublebowelwallsign
Falciformligamentsign
DoubleWallsign
FalciformLigamentsign
Pneumoretroperitoneum
Fromperforationofposterior
extraperitonealportionsofduodenumor
colon
Extensionfromorthroughthemediastinum
Pneumoretroperitoneum
AirinBiliarySystem
Bileducts
Gallbladder
AirinBiliarySystem
Usuallysecondarytosurgeryonbileducts
Canbeduetobiliarybowelfistulafrom
infectionorneoplasm
Rarely,canbeduetoinfection
AirinBileDucts
AirinGallBladder
PortalVenousAir
Asignofdeadordyingbowel
PortalVenousAir
TheGUT
GasandFluid
TooMuchandTooLittle
TheGasPattern
Canbespecificforobstruction
Often,nonspecific:Generalileus,focal
ileus,ischemia,orobstruction
Apaucityofgasmaybeduetovomitingor
fluidfilledbowel
OBSTRUCTION
Smallbowel
Colon
OBSTRUCTION
Smallbowelobstructionmuchmore
commonthancolon:70:30
SmallBowelObstruction:
Causes
Adhesions80%
Hernia15%
Tumors,intussusception,midgutvolvulus,
etc.
SmallBowelObstruction:
Findings
Stepladderdilatedbowelloopsonsupine
view
Stepladderairfluidlevelson
erect/decubitusviews
Stretchsignonsupineview
Stringofpearlssignonerect/decubitus
views
HowBigisBig?
Inanadult,anyvisiblesmallbowelis
abnormal,butsmallamountsoftennot
significant.Kidsnormallyhavesmall
amounts.
Jejunumover3cmandileumover2cm
diameterisveryabnormal,butnotspecific
forobstruction
Air,FluidorBoth?
Smallbowelcanbedistendedbyeitherair
orfluidorboth
Fluidfilledbowelmaybemoresignificant
thanairfilledbowel,butoftenthe
significanceisthesame
AirFilledSmallBowel
FluidFilledSmallBowel
AirFluidLevels
Alwaysabnormalinsmallbowel,butnot
specific;oftennormalincolon
Theheightofthefluidlevels,sameor
different,isNOThelpfulindistinguishing
ileusfromobstruction
SmallBowelAirFluidLevels
WhatisDilated?
Ifsmallbowelandcolondilatedequally,
probablynotsmallbowelobstruction:
nonspecificILEUS
Ifsmallbowelsignificantlymoredilated
thancolon,suggestsSBO
SomegasincolondoesNOTexcludeSBO
Ileus
ClassicSmallBowelObstruction,
Supine
ClassicSmallBowelObstruction,
Erect
StretchSign:Supine
StringofPearlsSign:Erect
SBO:Hernia
COLONObstruction
Causes
Carcinomaofthecolon80%
Volvulus5%
Diverticulitis5%
Fecalimpaction5%
Everythingelse5%
ColonObstruction:Carcinoma
ColonObstruction:Volvulus
5%oftotal
80%sigmoid
20%cecum
Volulus:Sigmoid
Volvulus:Cecum
ColonObstruction:
Measurements
Thececumisthemostdistensiblepartof
thecolon
Acecumof9cmdiameteriscausefor
concern
Acecumof11cmisimpendingperforation
DistendedCecum
OtherEmergencyConditionsof
theGut
Toxicmegacolon:Crohn,UC;5cm
transversecolonisimpendingperforation
Enterocolitis:C.diff.andothermicrobes
Ischemia
ToxicMegacolon
AwordonThumbprinting
Itmeansthickenedbowelwall
ItcanoccuracutelyinC.diff.orischemia
orhemorrhage
Chronically,itcanbeseenininflammatory
boweldiseaseandneoplasmandafew
otherlesscommondiseases
C.diff.Enterocolitis
IschemicBowelDisease
Arterialemboli:A.fib.,MI
Arterialthrombi:ASCVD
Venousthrombi:Hypercoag.,neoplasm
Nonocculsivemesentericischemia:Low
flowstates
Ischemia:Findings
Normalgaspattern
Nonspecificileus
Thumbprinting
Gasinbowelwall
Gasinportalveinsystem
Freeair
Ischemia:Thumbprinting
Ischemia:CT
ACUTEAPPENDICITIS
AcuteAppendicitis:Findings
Normal
Focalileus
Appendicolith
Mass
Freeairisveryrare
FocalIleus
Appendicolith
AcuteAppendicitis:CT
AcuteAppendicitis:CT
GallBladderDisease
Cholelithiasis
Cholelithiasis:Ultrasound
PANCREATITIS
Acute
PANCREATITIS:Findings
Normal
Generalnonspecificileus
Focalileus:Sentinelloop,coloncutoff
sign
PancreaticcalculiarefoundinCHRONIC
pancreatitis,notacute
FocalIleus
ChronicPancreatitis
AbdominalAorticAneurysm
AAA
Plainfilmsarenotsensitive,butcanbe
diagnostic
Calcifiedwallsofaortacanallow
measurementoflumen
AAAifover3cmAPdiameter
UltrasoundandCTaremuchmoresensitive
AAA
AAA:CT
Afewmore
Theoddandtheinteresting
Echinococcuscyst
Ascariasis
Ascariasis
ForeignBody:Battery
ForeignBody:Battery
TongueOrnamentMisadventure
BodyPackerorMule
CustomerofBodyPacker
???
GOODBYE
Copyright2004
MIZucker,MD