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IMAGING OF ACUTE ABDOMEN

IMAGING OF ACUTE ABDOMEN. Dr. Rista D. Soetikno, dr.,Sp.Rad (K),M.Kes. INTRODUCTION.

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IMAGING OF ACUTE ABDOMEN

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  1. IMAGING OF ACUTE ABDOMEN Dr. Rista D. Soetikno, dr.,Sp.Rad (K),M.Kes

  2. INTRODUCTION • “Acute abdomen” is a term used to encompass a spectrum of surgical, medical and gynecological conditions (intra-abdominal process), ranging from the trivial to the life threatening, which require hospital admission, investigation and treatment

  3. Assesing the patient with an acute abdomen need many investigation including laboratory test and imaging studiesplain photo, US, CT and contrast study .

  4. Imaging studies • Plain abdominal films: erect chest film, supine, and upright (optional:left lateral decubitus) • Abdominal US • Abdominal CT

  5. Plain abdominal film Table 1 Plain abdominal film

  6. Supine abdomen • Looking for • Gas pattern • Calcifications • Soft tissue masses • Substitute – none

  7. Erect abdomen • Looking for • Free air • Air-fluid levels • Substitute – left lateral decubitus

  8. Etiologies • Hemorrhage • GI perforation • Bowel obstruction • Inflammatory disorder • Circulatory impairment

  9. HEMORRHAGE • Intraperitoneal hemorrhage • Rupture: • hepatoma • aortic anuerysm • ectopic pregnancy • ovarian bleeding

  10. Gastrointestinal hemorrhage • Upper GI hemorrhage • Duodenal ulcer • Gastric ulcer • Hemorrhagic gastritis • Esophageal or gastric varices ect. • Lower GI hemorrhage • Bleeding of colon cancer • Ischemic colitis ect.

  11. Imaging • US finding • Free peritoneal fluid accumulation on the Morison’s pouch, the rectovesical pouch, the pouch of Douglas, and the bilateral subphrenic space • Abdominal CT • CTgold standars for specific intraabdominal pathology

  12. US

  13. CT

  14. Gastrointestinal perforation • Gastrointestinal perforation are serious disorder requiring rapid diagnosis and treatment • Since they may be severe enough to produce septic or hypovolemic shockrapid decision-making for urgent laparotomy is crucially important

  15. ● Radiological appearances:Plain abdominal film: - Oval/linear collection of gas: ♠ Subhepatic space ♠ Morison’s pouch ♠ Beneath the diaphragm (the cupola sign) ♠ In the centre of the abdomen over a fluid collection (the football sign) ♠ Fissure for ligamentum teres

  16. - Small triangular collections of gas between loops of bowel.- Visualisation of the outer as well as the inner wall of a loop of bowel (Rigler’s sign).USnot as sensitive as plain radiography for demonstatingpneumoperitoneumCT:Free gas over the liver, anteriorly in the mid abdomen, & in the peritoneal recesses.

  17. Plain photo

  18. Pneumoperitoneum Fissure for ligamentum teres Rigler’s sign

  19. Football sign

  20. BOWEL OBSTRUCTION • The first investigation when bowel obstruction is suspected is the supine plain abdominal X-ray, together with an erect chest film if perforation is a possibility • Occasionally, all the dilated bowel may be fluid fill and not visible on a plain X-ray and further imaging with contrast studies, CT or US may be needed to demonstrate dilated bowel

  21. Imaging aims: to confirm the presence of bowel obstruction, define the level obstruction, identify the cause and detect complications such as perforation

  22. Table 2. Cause of bowel obstruction

  23. Small-Bowel Obstruction: • Etiology:- Adhesions due to previous surgery - Strangulated hernias - Volvulus - Gallstone ileus - Intussusception - Neoplastic, etc.

  24. Small bowel obstruction (SBO) • Plain filmprimary investigation of choice • Plain film of SBO: Dilated small bowel loops: • Tend to the central • Numerous • 2.5-5.0 cm diameter • Have a small radius of curvature • Valvulae conniventes: thin, numerous, and extend right across the bowel • Do not contain solid faeces

  25. Multiple fluid levels on the erect film • String of beads sign on the erect film • Absent or little air in the large bowel

  26. SBO: valvulaeconniventes

  27. SBO:stepladder pattern

  28. Small-Bowel Obstruction:String of beads sign

  29. ♥ Ultrasound: - Dilated fluid-filled loops of small-bowel obstruction. - Assessment of the peristaltic activity.

  30. US:SBO

  31. CT sign of SBO • Small bowel loops measuring>2.5 cm in diameter • Identifiable focal transition zone from prestenotic dilated bowel to post-stenotic collapsed bowel loops

  32. CT:SBO Fluid-filled loops Bowel calibre change

  33. LARGE-BOWEL OBSTRUCTION • Etiology: - Neoplastic (benign & malignant) - Volvulus (caecal & sigmoid), etc. • Radiological appearances: Depends on the state of competence of the ileocaecal valve:

  34. Large bowel obstruction (LBO) • Plain-film signs of LBO: • Dilated large bowel loops which: • Tend to be peripheral • Few in number • Large: above 5.0 cm diameter • Wide radius of curvature • Haustra:thick and widely separated and may or may not extend right across the bowel (compare these features with the valvulaeconniventes found in the small bowel • Contain solid faeces

  35. Caecum maybe dilated • Small bowel may be dilated • Contrast enema maybe helpful: • To differentiate pseudo-obstruction and may be indistinguishable on plain film from mechanical of obstruction • To localized the point of obstruction • To diagnose the cause of obstruction e.g. tumour, inflamatory mass

  36. Contrast-enema

  37. Plain film:Sigmoid volvulus coffee bean sign

  38. Plain film: Caecal Volvulus

  39. PARALYTIC ILEUS • Generalised paralytic ileus: • ●Etiology: • - Peritonitis • - Post-operative • - Hypokalaemia • - General debility or infection • - Drugs: morphine • - Congestive cardiac failure, renal colic, etc. • ●Radiological appearances: - Both small & large-bowel dilatation - Horizontal-ray films: multiple fluid levels

  40. PARALYTIC ILEUS

  41. INFLAMMATORY DISSORDERS • Acute appendicitis • Acute pancreatitis • Acute cholecystitis • Abdominal absces • Peritonitis

  42. Acute appendicitis • Abdominal x-ray (AXR) • Non-specific finding • Approximately 10%a calcified appendicolith • US • Generally, the normal cannot be defined with US, clear visualization of the appendix is suggestif of inflammation • Swollen, non compressible appendix greater than 7 mm in diameter with a target or bulls-eye configuration isproduced by the hypoechoic dilated appendiceal lumen • Assymetrical wall thickening due to phlegmonous infiltration, an appendicolith with acoustic shadowing

  43. US finding • Echogenic hallo form by omental tissues draped over the appendix • Free fluid in the culdesac • Atony in the terminal ileum with compression US

  44. CT finding • 90% diagnostic accuracy to detect acute appendicitis • With the good contrastfilling of the terminal ileum and the cecum (oral contrast given 1 hour before examination) • Tubular structure 4 mm to 20 mm in diameter with a thickened wall that enhance after administration IV contrast medium • Pericecal fluid collection and calcified appendicolith

  45. Plain film:apendicolith

  46. CT

  47. Acute pancreatitis • Severity of acute pancreatitis rangesmild edema with minimal symptoms to a severe necrotizing process that culminates in multiple organ failure • US and CT most precisely define the anatomic extent of the lesions and the detect local complications

  48. Imaging • Plain filmsno significant plain film findings in up to two-thirds of patients wih acute pancreatitis • Plain-film signs may include: • Paralytic ileus in the left upper quadrant • Generalized ileus • Loss of left psoas outline • Separation of greater curve of stomach from tranverse colon

  49. CXR signs that may be seen include: • Left pleura effusion • Atelectasis of left lower lobe • Elevated left hemidiaphragm

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