Acute Abdomen 急腹症 钱黎俊. Radiology, Renji Hospital. Shanghai Jiaotong University School of Medicine

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1 Acute Abdomen 急腹症 Radiology, Renji Hospital Shanghai Jiaotong University School of Medicine 钱黎俊

2 Learning objectives To understand the normal anatomy of the erect abdominal plain film To understand and able to identify the image findings of acute abdomen on plain film Be familiar with the role of CT in diagnosis of acute abdomen

3 Outline Acute abdomen Plain film and normal anatomy Gastrointestinal perforation 胃肠道穿孔 Intestinal obstruction 肠梗阻 Small bowel obstruction Large bowel obstruction Volvulus of sigmoid colon 乙状结肠扭转 Acute intussusception 肠套叠 Role of CT in diagnosis of acute abdomen

4 Acute abdomen Acute abdomen: a sudden, severe abdominal pain of unclear etiology that is less than 24 hours in duration Common causes including GI tract 消化道 Hepato-cholangio-pancreatic 肝胆胰 Urinary system 泌尿系 Gynecology 妇科 Aorta 主动脉

5 Plain film & normal anatomy The erect abdominal plain film Cover the bilateral diphragm To look for Soft tissue Gas pattern Fat shadow Bony structure R. diaphragm L. diaphragm Gastric bubble breast liver spleen L. Kidney R. Kidney sacroiliac joint Gas in small bowel

6 GI tract perforation 胃肠道穿孔

7 Gastrointestinal perforation diaphragm Free air diaphragm Free air Findings on erect plain film Gastric bubble Free gas beneath the diaphragm Sickle-, crescent-shaped translucency ( 镰刀状 新月状透亮影 ) not confused with gastric bubble Large quantity of free gas beneath bilateral hemi-diaphragm may merge together

8 Comparison of gastric bubble vs. free air Gastric bubble diaphragm thick layer in-between diaphragm gas beneath right diaphragm always indicates free air Free air diaphragm thin layer in-between Gas beneath right hemi-diaphragm always indicates free air Sickle-, crescent-shaped gas indicative of free air free air is very closed to the diaphragm

9 Large quantity of free gas beneath bilateral hemi-diaphragm may merge together

10 Gastrointestinal perforation: value of CT

11 Intestinal obstruction, Ileus (focus on small bowel obstruction) 肠梗阻 ( 主要讨论小肠梗阻 )

12 Small bowel obstruction Most common cause Adhesion (~75%) Findings on erected plain film distended bowel loops > 3 cm multiple air fluid levels on erect film Collapsed colon Air-fluid level = swallowed air + bowel fluid The 3,6,9 rule

13 Gas pattern Jejunum shows dense mucosal folds Ileum has fewer folds Both serosa of the jejunum and the ileum are smooth The colon has serosa indented by haustra, and mucosal folds do not cross the lumen colon valvulae conniventes 小肠环状襞 colon haustra 结肠袋

14 Jejunum Ileum Colon Jejunum shows dense mucosal folds whereas the ileum has fewer folds The colon has serosa indented by haustra, and mucosal folds do not cross the lumen

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16 mechanical (simple, strangulated ) Paralytic 血运性 : thrombosis of PV system

17 肠梗阻影像学表现 麻痹性肠梗阻 腹部平片上表现为整个胃肠道普遍性扩张, 胃 小肠及结肠呈轻到中度扩大 胀气 肠道内气体多, 液体少

18 肠梗阻影像学表现 麻痹性肠梗阻 肠腔内液平面较低, 甚至肠道内几乎全为气体 胀气结肠和小肠靠紧, 类似蜂房状

19 paralytic ileus

20 paralytic ileus

21 Ileum Jejunum Identify the gas pattern: Jejunum shows dense mucosal folds whereas the ileum has fewer folds. Both serosa of the jejunum and the ileum are smooth

22 Distended bowel loop > 3cm Air-fluid levels String of pearls sign Jejunum obstruction: the distended bowel loops are generally located in the upper abdomen with the gas pattern of jejunum

23 Distended bowel loop > 3cm Air-fluid levels Ileum obstruction: the distended bowel loops are generally located in the lower abdomen with the gas pattern of ileum

24 Distended bowel loop > 3cm Air-fluid levels Jejunum obstruction: the distended bowel loops are generally located in the upper abdomen

25 Distended bowel loop > 3cm Air-fluid levels

26 Distended bowel loop > 3cm Air-fluid levels

27 Distended bowel loop > 3cm Air-fluid levels surgical clips

28 Distended bowel loop > 3cm Air-fluid levels String of pearls sign String of pearls sign: a row of small air bubbles in the abdomen on erect plain film. Indicative of a small amount of air trapped between the folds of the valvulae conniventes along the wall of predominantly fluid filled, dilated small bowel loops

29 Distended bowel loop > 3cm Air-fluid levels Jejunum shows dense mucosal folds whereas the ileum has fewer folds

30 jejunum ileum String of pearls sign

31 Small bowel obstruction: value of CT

32 Volvulus of sigmoid colon 乙状结肠扭转

33 Volvulus of sigmoid colon Volvulus: Obstruction of bowel loop by a twist around its mesenteric attachment Image findings Highly distended sigmoid colon (usually > 10cm) inverted-u shape white line (interposed colon walls) runs toward the pelvis coffee-bean sign Large air-fluid level on erect plain film

34 inverted-u shape white line to pelvis highly distended bowel loop

35 inverted-u shape highly distended bowel loop white line to pelvis Large air-fluid level Sigmoid volvulus: highly distended sigmoid bowel loop with inverted-u shape, white line of interposed colon walls toward the pelvis, the coffee-bean sign

36 Sigmoid volvulus: value of CT

37 Quiz M55yo after surgery with acute abdomen What s the diagnosis? A. Small bowel (jejunum) obstruction B. Small bowel (ileum) obstruction C. Small bowel obstruction complicated by perforation D. Sigmoid volvulus

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39 Quiz M78yo with acute abdomen What s the most probable diagnosis? A. Small bowel obstruction B. Large bowel obstruction C. Sigmoid volvulus D. Paralytic ileus

40 Forget me not! Small bowel obstruction:

41 Thank you Dr. 钱黎俊 / dearqlj@hotmail.com