Role of imaging in the evaluation of the acute abdomen
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1 Prof. András Palkó MD, PhD Role of imaging in the evaluation of the acute abdomen Faculty of General Medicine University of Szeged Hungary 1
2 Definition Sudden onset of severe symptoms requiring emergency medical or surgical treatment, typically characterized by intensive abdominal pain may be associated with: muscular defense paralytic ileus or hyper- (retro-) peristalsis nausea, vomiting, meteorism, hiccups fever, collapse, shock 2
3 Potential causes perforation obstruction ischemia bleeding infection peritoneal irritation GI paralysis & defanse musculaire 3
4 Acute abdomen top 8 1. Acute appendicitis 2. Acute cholecystitis 3. Small bowel obstruction (SBO) 4. Acute gynecological disease 5. Acute pancreatitis 6. Renal colic 7. Perforated peptic ulcer 8. Acute diverticulitis account for 90 % of patients referred to hospital 4
5 Role of imaging After stabilizing the patient s condition rapid diagnosis and therapeutic decision is essential to minimize progression and reduce mortality. Clinical presentation, history, and lab test results are too often non-specific. Imaging examinations are of utmost importance to establish diagnosis. 5
6 What s wrong? clinical findings 6
7 Acute pancreatitis Duodenal ulcer Bowel obstruction Abdominal aortic aneurysm Cholecystitis Calculous Acalculous Emphysematous Hepatitis Liver abscess Spontaneous rupture of a hepatic neoplasm Right-sided LB diverticulitis Retrocecal appendicitis Bowel obstruction SBO Adhesion Crohn s Neoplasm Hernia Radiation Miscellaneous LBO Carcinoma Volvulus Diverticulitis Perforation Peptic ulcer Diverticulitis Iatrogenic Bowel ischemia Mesenteric artery Thromboembolism Atherosclerosis Dissection Mesenteric vein Hypercoagulable Neoplastic Strangulation, volvulus Infectious Gastroenterocoliti s Pseudomembranou s colitis IBD Ulcerative colitis Crohn s disease Urological Urinary tract obstruction Gynecological PID Ovarian vein thrombosis Hemorrhagic ovarian cyst Rupture of ovarian dermoid Ovarian torsion Rupture of ectopic pregnancy Endometriosis Necrotic uterine leiomyoma Intestinal Acute appendicitis IBD Mesenteric adenitis Perforated carcinoma Epiploic appendagitis Omental infarction Cecal diverticulitis Infectious ileocolitis Sigmoid diverticulitis Obstructive sigmoid carcinoma 7
8 Diagnostic algorithm (history, physical examination and lab tests) plain X-ray examination abdomen erect or decubitus supine chest ultrasound computed tomography 8
9 What s wrong? imaging findings Pathological gas accumulation Localized/diffuse fluid accumulation Diffuse/segmental gas/fluid levels Extravasation, leakage Pathological circulation Wall thickening (bull s eye) Foreign body 9
10 Pathological gas accumulation Pneumoperitoneum perforation iatrogenic per vaginam Pneumoretroperitoneum perforation iatrogenic Bowel wall pneumatosis infarction necrosis 10
11 Pathological gas accumulation Pneumoperitoneum perforation iatrogenic per vaginam Pneumoretroperitoneum perforation iatrogenic Bowel wall pneumatosis infarction necrosis Note: Ogilvie-sy! 11
12 Pathological gas accumulation 12
13 Pathological gas accumulation 13
14 Pathological gas accumulation Pneumoperitoneum perforation iatrogenic per vaginam Pneumoretroperitoneum perforation iatrogenic Bowel wall pneumatosis infarction necrosis 14
15 Pathological gas accumulation Pneumoperitoneum perforation iatrogenic per vaginam Pneumoretroperitoneum perforation iatrogenic Bowel wall pneumatosis infarction necrosis 15
16 Pathological gas accumulation Pneumoperitoneum perforation iatrogenic per vaginam Pneumoretroperitoneum perforation iatrogenic Bowel wall pneumatosis infarction necrosis Gellett LR et al: Emerg Med J 2002;19:
17 Pathological gas accumulation Biliary system sphincter Oddi incompetence postoperative spontaneous fistula emphysematous cholecystitis Portal vein mesenteric infarction air embolus necrotizing enterocolitis Abscess 17
18 Pathological gas accumulation Biliary system sphincter Oddi incompetence postoperative spontaneous fistula emphysematous cholecystitis Portal vein mesenteric infarction air embolus necrotizing enterocolitis Abscess 18
19 Pathological gas accumulation Biliary system sphincter Oddi incompetence postoperative spontaneous fistula emphysematous cholecystitis Portal vein mesenteric infarction air embolus necrotizing enterocolitis Abscess 19
20 Pathological gas accumulation 20
21 Pathological gas accumulation 21
22 Pathological gas accumulation gasless abdomen Normal abdomen Small bowel obstruction/ischemia Ascites Surgery (e.g. total colectomy) Gastroenteritis Large abdominal mass Thompson WM: AJR, 191: ,
23 Localized/diffuse fluid accumulation Ascites cirrhosis tumor hypoalbuminaemia portal hypertension lymphatic obstruction Inflammation Perforation Abscess 23
24 Localized/diffuse fluid accumulation Ascites cirrhosis tumor hypoalbuminaemia portal hypertension lymphatic obstruction Inflammation Perforation Abscess 24
25 Localized/diffuse fluid accumulation Ascites cirrhosis tumor hypoalbuminaemia portal hypertension lymphatic obstruction Inflammation Perforation Abscess 25
26 Localized/diffuse fluid accumulation Ascites cirrhosis tumor hypoalbuminaemia portal hypertension lymphatic obstruction Inflammation Perforation Abscess 26
27 Diffuse/segmental gas/fluid levels Paralytic ileus Diffuse peritonitis gastroenteritis abdominal pain other (postoperative, drug effect, electrolyte imbalance, pneumonia, retroperitoneal hemorrhage, etc.) Segmental (sentinel loop) pancreatitis cholecystitis appendicitis, diverticulitis etc. 27
28 Diffuse/segmental gas/fluid levels Paralytic ileus Diffuse peritonitis gastroenteritis abdominal pain other (postoperative, drug effect, electrolyte imbalance, pneumonia, retroperitoneal hemorrhage, etc.) Segmental (sentinel loop) pancreatitis cholecystitis appendicitis, diverticulitis etc. 28
29 Diffuse/segmental gas/fluid levels Obstruction Small bowel Adhesion Crohn s Neoplasm Hernia Radiation Miscellaneous Paulsen SR, RadioGraphics, 26:641, 2006 Large bowel Carcinoma Volvulus Diverticulitis 29
30 Diffuse/segmental gas/fluid levels Obstruction Small bowel Adhesion Crohn s Neoplasm Hernia Radiation Miscellaneous Large bowel Carcinoma Volvulus Diverticulitis 30
31 Diffuse/segmental gas/fluid levels Obstruction Small bowel Adhesion Crohn s Neoplasm Hernia Radiation Miscellaneous Large bowel Carcinoma Volvulus Diverticulitis Takeyama,et al: RadioGraphics 2005; 25:
32 Diffuse/segmental gas/fluid levels Obstruction Small bowel Adhesion Crohn s Neoplasm Hernia Radiation Miscellaneous Large bowel Carcinoma Volvulus Diverticulitis E M Anderson, Imaging 2006;18:198 32
33 Diffuse/segmental gas/fluid levels Obstruction Small bowel Adhesion Crohn s Neoplasm Hernia Radiation Miscellaneous Large bowel Carcinoma Volvulus Diverticulitis 33
34 Diffuse/segmental gas/fluid levels Obstruction Small bowel Adhesion Crohn s Neoplasm Hernia Radiation Miscellaneous Large bowel Carcinoma Volvulus Diverticulitis 34
35 Extravasation, leakage Perforation (see also pathologic gas/fluid accumulation) Bleeding Endoluminal (ulcer, tumor, inflammation, iatrogenic, etc) Extraluminal (aneurysm, tumor, iatrogenic, etc) Parenchymal organ (tumor, iatrogenic, etc) 35
36 Extravasation, leakage Perforation (see also pathologic gas/fluid accumulation) Bleeding Endoluminal (ulcer, tumor, inflammation, iatrogenic, etc) Extraluminal (aneurysm, tumor, iatrogenic, etc) Parenchymal organ (tumor, iatrogenic, etc) Detectable rate (arteriography): ml/min Yoon W et al: Radiology 239:16-167,
37 Extravasation, leakage Perforation (see also pathologic gas/fluid accumulation) Bleeding Endoluminal (ulcer, tumor, inflammation, iatrogenic, etc) Extraluminal (aneurysm, tumor, iatrogenic, etc) Parenchymal organ (tumor, iatrogenic, etc) 37
38 Extravasation, leakage Perforation (see also pathologic gas/fluid accumulation) Bleeding Endoluminal (ulcer, tumor, inflammation, iatrogenic, etc) Extraluminal (aneurysm, tumor, iatrogenic, etc) Parenchymal organ (tumor, iatrogenic, etc) 38
39 Pathological circulation Arterial thromboembolism (MI, rheumatic heart disease, atrial fibrillation, etc.) arteriosclerosis dissection heart failure others (iatrogenic, idiopathic, strangulation/volvulus, septicemia, extrinsic mass, etc.) Kirkpatrick IDC et al: Radiology, 229:91-98, 2003 Venous thrombosis others (extrinsic mass, iatrogenic, strangulation/volvulus, etc.) 39
40 Pathological circulation Arterial thromboembolism (MI, rheumatic heart disease, atrial fibrillation, etc.) arteriosclerosis dissection heart failure others (iatrogenic, idiopathic, strangulation/volvulus, septicemia, extrinsic mass, etc.) Venous thrombosis others (extrinsic mass, iatrogenic, strangulation/volvulus, etc.) Shih MCP et al AJR 2007; 188:
41 Pathological circulation Arterial thromboembolism (MI, rheumatic heart disease, atrial fibrillation, etc.) arteriosclerosis dissection heart failure others (iatrogenic, idiopathic, strangulation/volvulus, septicemia, extrinsic mass, etc.) Venous thrombosis others (extrinsic mass, iatrogenic, strangulation/volvulus, etc.) McMahon MA et al: Radiographics, 30: ,
42 Pathological circulation Arterial thromboembolism (MI, rheumatic heart disease, atrial fibrillation, etc.) arteriosclerosis dissection heart failure others (iatrogenic, idiopathic, strangulation/volvulus, septicemia, extrinsic mass, etc.) Venous thrombosis others (extrinsic mass, iatrogenic, strangulation/volvulus, etc.) 42
43 Pathological circulation Arterial thromboembolism (MI, rheumatic heart disease, atrial fibrillation, etc.) arteriosclerosis dissection heart failure others (iatrogenic, idiopathic, strangulation/volvulus, septicemia, extrinsic mass, etc.) Venous thrombosis others (extrinsic mass, iatrogenic, strangulation/volvulus, etc.) Okino Y et al: Radiographics, 21: ,
44 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm Rha SE et al: RadioGraphics, 20:29-42,
45 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm Dibbad R et al: The Internet Journal of Radiology, 12/1,
46 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm Noah Gudel, DO; Lisa M. Rock, MD, Medscape
47 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm 47
48 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm 48
49 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm Poletti PA et al, AJR 2004; 182:
50 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm 50
51 Wall thickening Infarction, ischemia Intramural hematoma Inflammation epiploic appendagitis Groove pancreatitis Infection appendicitis sigmoiditis typhlitis (neutropenic colitis) pseudomembranous colitis (clostridium difficile) others (TBC, amebiasis, campylobacter, shigella, etc.) Neoplasm 51
52 Foreign body Accidental/intentional/iatrogenic Endoluminal/extraluminal W./w.o. perforation Maglinte DDT: Radiology, 236: ,
53 Acute abdomen - algorithm (history, physical examination and lab tests) plain X-ray examination abdomen erect or decubitus supine chest ultrasound computed tomography 53
54 Acute abdomen - algorithm (history, physical examination and lab tests) plain X-ray examination abdomen erect or decubitus supine chest? ultrasound computed tomography 54
55 55
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