FOCUS ON ABNORMAL AIR:

DIAGNOSTIC ULTRASONOGRAPHY
FOR THE ACUTE ABDOMEN
Agustiane Mawarni Aly
PEMBIMBING
Dr. Novita E.R Sp. Rad
COMPOSITION
1 . CANALIS ALIMENTARIUS ( ALIMENTARY CANAL) :
1.1. CAVUM ORIS
1.2. PHARYNX
1.3. OESOPHAGUS
1.4. TRACTUS GASTRO INTESTINALIS.
1.4.1. GASTER
1.4.2. INTESTINUM TENUE MESOSTENIALE
1.4.2.1. DUODENUM
1.4.2.2. JEJUNUM
1.4.2.3. ILEUM
1.4.3. INTESTINUM CRASSUM
1.4.3.1. APPENDIX VERMIFORMIS.
1.4.3.2. CAECUM
1.4.3.3. COLON ASCENDENS
1.4.3.4. COLON TRANSVERSUM
1.4.3.5. COLON DESCENDENS
1.4.3.6. COLON SIGMOID
1.4.3.7. RECTUM
1.4.3.8. CANALIS ANALIS.
1.4.3.9. ANUS
2. ORGANA DIGESTIVA ACCESSORIAE
2.1 GLD.SALIVATORIAE
2.1.1. GLD.PAROTIS 2.1.2. GLD.SUBMAXILLARIS 2.1.3. GLD.SUBLINGUALIS
2 .2. HEPAR 2.3. VESICA FELLEA . 2.4.. PANCREAS
:
 NYERI ABDOMEN

SARAF RESEPTOR SPESIFIKASI LOKASI RANGSANGAN

NYERI
VISCERAL S.OTONOM PERITONEUM TAK JELAS (SUKAR SUKAR KEJANG TARIK
VISCERALIS DIJELASKAN) DISTENSI

SOMATIK S. SENTRAL PERITONEUM JELAS JELAS SENTUH

PARIETALIS TAJAM (MENUNJUK) TEKANAN
MENUSUK PANAS
RADANG

REVERSED PAIN
NYERI YANG DIALIRKAN KARENA KONFERGENSI SARAF PADA TRAKTUS SPINOTALAMIK
(EMBRIOLOGIS)
Appendix
Ileum Perforation
Liver Abscess
Gaster Perforation
Others
Visceral and NOT Referred Pain
referred to areas
corresponding to the
embryonic origin of the
affected structure.
Foregut structures
(stomach, duodenum, liver,
and pancreas) cause upper
abdominal pain.
Midgut structures
(small bowel, proximal
colon, and appendix) cause
periumbilical pain.
Hindgut structures
(distal colon and GU tract)
cause lower abdominal pain
Localizing pain -- RUQ
Hepatitis
Cholecystitis
Cholangitis
Pneumonia
Subdiaphragmatic
abscess
Localizing pain -- LUQ
Splenic infarct
Splenic abscess
Gastritis/PUD
Localizing pain -- RLQ
Appendicitis
Inguinal hernia
Nephrolithiasis
IBD
Salpingitis
Ectopic pregnancy
Ovarian pathology
Localizing pain -- LLQ
Diverticulitis
Inguinal hernia
Nephrolithiasis
IBD
Salpingitis
Ectopic pregnancy
Ovarian pathology
Localizing pain -- epigastric
PUD
Gastritis
Pancreatitis
GERD
Cardiac (MI,
pericarditis, etc)
Localizing pain -- periumbilical
Pancreatitis
Obstruction
Early appendicitis
Small bowel pathology
Gastroenteritis
Localizing pain -- pelvic
UTI
Prostatitis
Bladder outlet
obstruction
PID
Uterine pathology
Localizing pain -- diffuse
Gastroenteritis
Ischemia
Obstruction
DKA
IBS
 Emergency ultrasonography is a frequently used imaging
tool in the bedside diagnosis of the acute abdomen.
Classic indications include imaging for acute abdominal
aneurysm, acute cholecystitis, hydronephrosis, and free
Intraabdominal fluid in patients with trauma or suspecte
d vascular or ectopic pregnancy rupture.
Point of care
sonographic imaging often emphasizes the diagnostic
utility of fluid and edema, both as a significant finding a
nd as a desirable adjunct for improved imaging .
This article will discuss four groups of
abnormal air patterns found in the abdomen and the
retroperitoneum and the respective scanning techniques,
with a focus on the use of ultrasound for diagnosing
pneumoperitoneum and a suggested scanning approach
in the emergency setting.
 Ultrasonography is widely recognized as an indispensable
tool in the bedside diagnosis of the acute abdomen

Introduction Even for practitioners with limited ultrasound training,

initial assessment of the peritoneal patient often includes
a bedside FAST examination to document the presence of
free fluid, both for traumatic and for medical presentations

To appreciate the presence of pathological air within the

abdomen, one must first recognize the appearance of
Background physiologic air within abdominal and thoracic structures,
including the gastrointestinal tract and the lung paren
chyma as it descends during inspiration.
 Findings of pathologic intra-abdominal air can be divided
into several categories:
(a) free air, seen in the peritoneal and retroperitoneal
space
(b) air seen in the lumen of preformed intraperitoneal or
retroperitoneal structures or cavities, such as the
bladder and the gallbladder, biliary tree, common
pancreatic duct, portal vein, hepatic veins, and other
blood vessels.
Air may also form (c) within the abdominal wall tissues
or organ parenchyma, as in kidney, liver, and abdominal
wall abscesses.
(d) intramural air, as seen in pneumatosis of the bladder
wall or in pneumatosis intestinalis, can be a crucial
finding in a patient with abdominal complaints
Abnormal findings and sonographic technique
Extraluminal free air: pneumoperitoneum and
pneumoretroperitoneum
 Pneumoperitoneum: is an expected finding after
certain
procedures including abdominal laparoscopy or la
parotomy,percutaneous needle biopsy, peritoneal
dialysis, culdocentesis or paracentesis.
Free air after surgery may be absorbed within a few
days, but can as long as 18 days, with incidence and
quantity declining over time.
Acute pneumoperitoneum in nonpost operative
scenarios can be caused by pathologic findings such
as ruptured viscous, peritonitis with gas-forming
organisms, intra abdominal abcess rupture, bowel
obstruction with permeation of gas through the
bowel wall, cardioplmonary resuscitation,
mechanical ventilation, cocaine use, and extension
of pneumothorax or pneumomedistinum
 Sonographic technique for pneumoperitoneum:

Most authors agree that the best initial place to

look for pneumoperitoneum is in the right hypochondri
um, superficial to the liver, with the patient in the
supine position with the thorax slightly elevated or in a
semi lateral decubitus position.
When the patient is positioned in semileft or semiright
lateral decubitus, free air frequently collects in the ventral
hepatoperitoneal space (right) or at the lower pole of the
spleen (left).
Another study suggest that optimal positioning is achieved
with the supine patient at 10-200 inclination. Alternatively,
an intercostal view was obtained with the patient in the
lest lateral decubitus posisition, with the abdomen and
thorak elevated to 30 - 400
 Pneumoperitoneum
This is a rare complication ofendoscopic retrog
rade cholangiopancreatography (0.5%)
and other iatrogen-invasive procedures,
but can also be because of trauma,
inflammation, infection, or neoplastic processes.
Typical sonographic findings include air
collections around the right kidney, causing it to
appear overcast or veiled, air ventral to the
aorta and the inferior vena cava, giving the
appearance of vanishing great vessels, and air
collections around rertoperitoneal parts of
duodenum, pancreatic head, and posterior to the
gallbladder.
Intraparenchymal free air: abnormal air withi
n organ parenchyma and tissues
Intramural air
 Conclusion
Although sonographic detection of abnormal fr
ee air has been described and recognize for
decades, it is often overlooked in traditional
ultrasound teaching, especially in the emergency
medicine and critical care communities. This is
unfotunate, given evidence that in experienced or
perhaps even CT at diagnosing
pneumoperitoneum.
A scanning protocol used in our emergency de
partment to screen for pneumoperitoneum
suggest placement of the patient in either a
semilateral left decubitus or a supine position
with a slightly elevated thorax.
 Abdominal ultrasound instruction should
include the teaching of techniques described
above to detect pneumoperitoneum, so that
the next generation of practitioners may
routinely acquire the skill necessary to make
the diagnosis with confidence.
Large prospective and the interrater reability
of sonography for pneumoperitoneum
performed by diverse groups of trained
emergency or critical care physicians.