1. IMAGING IN
ACUTE ABDOMEN
DR. WAN NAJWA ZAINI WAN MOHAMED
RADIOLOGIST, HOSPITAL QUEEN ELIZABETH II
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
4. DEFINITION
“Any sudden non-traumatic disorder whose chief
manifestation is in the abdominal area and for which urgent
operation may be necessary”
A clinical syndrome “sudden onset of severe abdominal pain
requiring emergency medical or surgical treatment”
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
5. In a review of 30,000 patients with acute abdomen
1. Acute Cholecystitis
2. Acute Renal Colic
3. Acute Appendicitis
4. Acute Pancreatitis
5. Hepatic Abscess
6. Intestinal Obstruction/
Intussusception
7. Psoas Abscess
8. Abdominal Trauma
9. Ob/Gyn Emergency
appendicitis
small-bowel obstruction
no cause
(non
specific
abdominal
pain)
acute cholecystitis
AJR 2000; 174:901-913
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
6. ROLE OF IMAGING
• To narrow down the differential diagnosis
Prompt and accurate diagnosis essential to minimize
morbidity and mortality
• To help surgeon decide whether patient requires surgery or
not, and if so, how soon?
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
8. IMAGING TOOLS
• PLAIN RADIOGRAPH
• ULTRASOUND
• CT SCAN
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
9. PLAIN RADIOGRAPH
• Long established as essential imaging method
• Often less specific; low diagnostic yield (10– 20%)
• Overutilization of AXR in AE setting (42.7 – 55.8%) due to
inappropriate requests lower diagnostic accuracy
• Despite technical advances, plain radiography should be the
first imaging study for suspected cases of bowel perforation
or obstruction
• Remote setting without CT Scan facility: remains main
modality for initial investigation in acute abdomen
10. PLAIN RADIOGRAPH
• Views: Supine AXR, Erect
CXR
• Added views: Erect AXR, Left
Lateral Decubitus AXR,
Horizontal AXR
• Erect CXR – Best for small
pneumoperitoneum (air under
diaphragm), valuable pre-op
baseline
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
11. PLAIN RADIOGRAPH
TABLE 1: Royal College of Radiologists (RCR),London
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
12. ULTRASOUND
• Commonly used as primary screening tool
• Improvements in US resolution and probe technology – first
modality in assessing paediatric or female patients with O&G
problems.
• Advantage: widely available, low cost, absence of radiation
exposure
• Drawback – operator dependent, presence of ileus obscuring
area of interest which commonly accompanies acute abdomen
• Technique: B-mode (grey scale), curvilinear probe
• Need to: fast for gallbladder pathology, full bladder for O&G cases
& bladder/ pelvic assessment.
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
14. CT SCAN
• Better detection and higher accuracy rates (almost 95%)
• Most beneficial in patients who present with confusing or
conflicting clinical signs and symptoms
• Useful in diagnosing, detecting and characterizing the full
extent of disease
• Technique:
Scans obtained from diaphragm to beneath the symphysis
pubis
Collimation of 5-7 mm and a pitch of 1.0-1.5
Data reconstructed at intervals of 3-7 mm, depending on the
clinical indication
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
15. CT SCAN
• Use of contrast media depends on indication/working
diagnosis, time and local setting
• IV contrast
Opacifies the abdominal vasculature and provides useful
information regarding enhancement of the parenchymal organs
and intestine
Exceptions include evaluation of suspected ureteral colic
Carries risk of nephrotoxicity and potential contrast material
reaction.
Volume: 125 – 150 ml, rate: 2 – 3 ml/sec
Scans obtained during portal venous phase at 60 – 70 sec
delay
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
16. CT SCAN
Arterial phase imaging useful in suspected hemorrhage, bowel
ischemia, and arterial thrombosis cases
Delayed scans can reveal renal and bladder mass/disease that
might be overlooked during earlier phases
• Oral contrast
Used primarily to differentiate bowel loops from abdominal and
pelvic masses and abscesses
May obscure the diagnosis of bowel hemorrhage or ischemia
Exceptions – high-grade small bowel obstruction, ureteral colic
In suspected gastric disease or gastrointestinal bleeding, water
can be used
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
17. CT SCAN
Volume: 800-1000 ml of oral diluted water-soluble contrast
material at least 1 hr before scanning
Practical difficulties – time consuming, randomness of contrast
opacification, inability of sick patients to consume and retain
sufficient quantities
• Rectal contrast
Not routinely used
Advocated by some to optimize the detection of appendicitis,
diverticulitis, and epiploic appendagitis
Volume: 400-600 ml of a 3% solution of water-soluble contrast
material administered rectally by gravity through a soft rubber
rectal catheter.
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
19. Analyzing AXR
A. Bowel Loops (Intraluminal Air)
B. Extra Luminal Air
C. Soft Tissue
D. Calcification
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
20. A. Bowel Loops (Intraluminal Air)
• Stomach
Relatively large amount of gas
Gastric rugae (supine)
Long air fluid level in
fundus (erect)
• Small bowel
Central position, valvulae
conniventes
Calibre 2.5cm, usu. small amt
of gas
> 2 fluid levels & dilated –
abnormal
• Large bowel
Peripheral position, haustra
Calibre:
Transverse colon : 5.5 cm
Caecum >9 cm - danger of
perforation
Fluid levels – common, 3-5
fluid levels (< 2.5 cm in
length) may be seen esp. in
right lower quadrant
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
21. Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 34067
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
22. A. Bowel Loops (Intraluminal Air)
Abnormal Site/Distribution
Lumen Size /Content
Wall Appearance
I. Gasless Abdomen
II. Bowel Dilatation
a. Gastric Dilatation
b. Mechanical Obstruction
c. Pseudo-obstruction
d. Paralytic Ileus
III. Mucosal Wall
Abnormality
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
23. I. Gasless Abdomen
• Total paucity of gas – rare
• Fluid filled bowels, common in
children
• Highly suggestive of high
obstruction
• Other causes: excessive
vomiting, diarrhea, early
stages of appendicitis,
Addisonian crisis (adrenal
crisis), cerebral depression
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
24. II. Bowel Dilatation
a. Gastric Dilatation
• Mechanical/ gastric outlet obstruction
Duodenal ulcer, antral carcinoma, extrinsic compression
Huge fluid-filled stomach with little or no bowel gas beyond
• Paralytic ileus
“acute gastric dilatation”
Fluid & electrotrolyte disturbance
> in old people, high mortality
• Gastric volvulus
Grossly dilated, air-filled stomach
Spherical, left upward
Elevated diaphragm
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
25. II. Bowel Dilatation
b. Mechanical Obstruction
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
26. II. Bowel Dilatation
Small Bowel Obstruction
• Causes – adhesion,
strangulated hernias,
intussusception, volvulus, tumor,
gallstone ileus
• 3 signs highly suggestive:
two or more air–fluid levels
air–fluid levels wider than 2.5
cm
air–fluid levels differing more
than 5 mm from one another in
the same loop of small bowel
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
28. II. Bowel Dilatation
Large Bowel Obstruction
• Left > right
• Depends on site of obstruction/ patency of ileocaecal valve
• Common causes:
• Tumor, Abscess, Diverticular ds, Volvulus
• Extrinsic compression by pelvic tumor
• Both small & large bowels dilated ~ mimic paralytic ileus
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
30. II. Bowel Dilatation
Pseudo-obstruction
• Symptomatically, clinically and radiologically mimic intestinal
obstruction
• May be acute & self limiting
• Pneumonia, sepsis, drugs, DM, collagen & neurologic
disorders, amyloid ds or idiopathic
• Gastric, small or large bowel distension with fluid levels
• Contrast study
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
31. II. Bowel Dilatation
Paralytic Ileus
• Occurs when intestinal
peristalsis ceases, fluid and
gas accumulation in bowel
• Occurs most freq. in
inflammatory conditions,
peritonitis & post operative
• Local inflammation – ileus of
1 or 2 loops of small bowel
“sentinel loops”
• Gas Distribution: Generalized
presence of gas throughout
all quadrants
• Bowel Dilatation: The degree
of bowel dilatation is
proportional
• Arrangement of Loops:
Disorderly arrangement “a
bag of popcorn”
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
33. Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
MECHANICAL OBSTRUCTION PARALYTIC ILEUS
Gas distribution
Too much air in the small bowel (and not
much gas in the large bowel) or too much air
in the large bowel (and not much gas in the
small bowel).
Poor gas distribution or gasless
Good gas distribution over most of the
abdomen
Too much air in both large and small bowel
* Warning: This could also appear in large
bowel obstruction with an incompetent
ileocecal valve, or in an early or intermittent
small bowel obstruction
Bowel dilatation
Smooth bowel walls (resembles sausages or
a hose)
Preferential dilatation of the bowel proximal
to the obstruction
Dilatation of the bowel in proportion to each
other, so that the colon remains larger than
the small intestine
Look for sentinel loops
Air-fluid levels
Many dilated air-fluid levels in both limbs of a
given loop, at different heights (candy
canes)
Fewer and/or smaller (less dilated) air-fluid
levels scattered throughout the abdomen
Arrangement of loops
(supine only)
Orderly arrangement of dilated loop
“Stepladder" fashion from left upper
quadrant to right lower quadrant
A bag of sausages
Disorderly loops scattered throughout the
abdomen
A bag of popcorn
Table 3: Comparison between Mechanical Obstruction and Paralytic Ileus
34. III. Mucosal Wall Abnormality
• Irregularity, thickening
inflammation, ischaemia (oedema, haemorrhage)
• Thumbprinting sign
Submucosal haemorrhage
• String of beads sign
Gas in between valvulae conniventes
• Intramural air
hypoxaemia, infection, emphysema, cystic pneumatosis
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
36. ANALYZING AXR
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
A. Bowel Loops (Intraluminal Air)
B. Extra Luminal Air
C. Soft Tissue
D. Calcification
37. B. Extraluminal Air
I. Intramural air
II. Pneumoperitoneum (Intraperitoneal air)
III. Pseudo-pneumoperitoneum
IV. Air in lumen – portal vein, biliary tree
V. Air in an organ
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
38. I. Intramural Air
• Cystic pneumatosis
May be due to gas leak
1-3cm cysts in subserosal and
submucosal layer
Interstitial emphysema
Sign of impending rupture in
toxic megacolon
• Gas forming infection
• Hypoxaemia due to infarction
or thrombosis
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
39. II. Pneumoperitoneum
• Perforated hollow viscus
Ulcer, neoplasm, bowel
obstruction, ischaemic bowel,
diverticulitis, surgical Cx
• Through the peritoneum
Penetrating injury
• Via Female Reproductive
System
Exercise, postpartum,
douching, intercourse
• From chest, retroperitoneum
• Signs:
Central Tendon
Double Wall Sign (Rigler Sign)
Football Sign
Falciform Ligament
Parahepatic Air
Umbilical Ligament, Urachus
Lucent Liver Sign
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
42. IV. Air in Lumen
Air in Portal Vein
• Aeroportia
• Associated with presence of
air within bowel wall
• E.g. Necrotizing enterocolitis,
bowel infarction
• Signify grave prognosis when
occur in bowel necrosis
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
DELICATE & PERIPHERAL
43. IV. Air in Lumen
Air in Biliary Tree
• Aerobilia
• Occur in patulous sphincter,
post ERCP/ sphincterectomy,
any fistulous communication
between biliary tree and
bowel
• Gas forming infection of the
gallbaldder
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
CHUNKY AND CENTRAL
44. V. Air in Organ
• Infection caused by gas
forming organism
• Collects within the organ wall
or cavity
• Linear lucency within wall or
confined lucency in the region
of involved organ
• Air fluid level may be seen
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
45. ANALYZING AXR
A. Bowel Loops (Intraluminal Air)
B. Extra Luminal Air
C. Soft Tissue
D. Calcification
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
46. C. Soft Tissue
• Fat lines: Posterior extraperitoneal fat pad
Completely surround kidneys, psoas, post. borders of liver and
spleen
Extends anteriorly and laterally to surround parietal peritoneum
(properitoneal fat)
Responsible for visualisation of intraabdominal organs
• Can be displaced by organ enlargement or effaced by
inflammation or fluid
• May be blurred or not identified at all
Spleen not be identified in 42%
Right psoas blurred in 19%
Properitoneal outlines lost in 18%
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
47. Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
PSOAS ABSCESS INTUSSUSCEPTION
Soft tissue mass with air crescent sign
48. ANALYZING AXR
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
A. Bowel Loops (Intraluminal Air)
B. Extra Luminal Air
C. Soft Tissue
D. Calcification
49. D. CALCIFICATION
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
Calcification Acute condition
Gallstones Cholecystitis
Pancreatitis
Biliary colic (stone may be close to spine)
Empyema of gallbladder
Gallstone ileus (stone in abnormal location)
Calcified gallbladder wall Cholecystitis
Limy bile Cholecystitis
Appendix calculus Appendicitis
Calculus in:
Meckels,jejunal & colonic diverticulum
Acute inflammation or perforation
Pancreatic calculi Pancreatitis
Ureteric calculus Renal colic
Calcified aneurysmsaortic, splenic, hepatic Rupture
Teeth or bone in ovarian dermoid Torsion
52. Acute Cholecystitis
• Non compressible, tender
gallbladder distension
• Wall thickening > 3mm
• Pus/sludge content +/-
calculus
• Pericholecystic collection
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
53. Obstructive Uropathy
• Dilated pelvicalyceal system/
ureter
• Cortical thinning
• Renal or ureteric calculi
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
54. Acute Appendicitis
• Wall-to-wall diameter >6mm
• Surrounding inflamed fat
• Faecolith
• Hypervascularity
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
55. Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
Acute Pancreatitis
• Hypoechogenicity
surrounding the
peripancreatic area
• Complex striated pattern with
hemorrhage
56. Liver Abscess
• Hypoechoeic collection with
posterior enhancement
• Moving pus/sediment within
• Perilesional hypervascularity
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
57. Acute Diverticulitis
• Diverticulosis with segmental
colonic wall thickening
• Inflammatory changes in the
fat surrounding a diverticulum
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
58. Bowel Dilatation/ Thickening
• Bowel Dilatation
Distended loops of bowel
Ileus – fluid filled
• Ileitis/Colitis
Mural wall thickening, oedema
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
59. Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
Ascites/ Free fluid
62. Acute Diverticulitis
• Inflammatory change in the
pericolic fat
• Mural wall thickening
• Phlegmon or frank abscess
formation
• Diverticula
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
63. Bowel Obstruction
• Dilated fluid filled bowels with
transition zone
• Causative agent : mass,
hernia, intussusception,
abscess, inflammatory
thickening vs adhesion
• Closed loop obstruction
Strangulated bowel
Twisted C or U-shaped loop
with converged mesenteric
vessels
Engorged mesenteric
vasculature, edema, bowel
wall thickening
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
64. Bowel Ischaemia
• Causes :
vascular occlusion or
thrombosis from arterial/
venous disease
hypoperfusion
• Mural thickening with target or
halo appearance
• Pneumatosis intestinalis
• Air in the bowel wall,
mesentery or portal venous
system – grave prognosis
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
65. GI Perforation
• Pneumoperitoneum, most
non dependent area –
anterior to liver surface
• Extravasation of oral contrast
• Loculated fluid and gas, focal
mesenteric or omental
infiltration, focal enhancement
of the parietal peritoneum can
help pinpoint site of
perforation
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018
69. CONCLUSION
• In patients with an acute abdomen ‘the stakes are high’ –
important to recognize life-threatening conditions from self-
limiting causes
• Although AXR limited role, still valuable in remote/ district
hospitals and certain conditions
• Sonography and CT more accurate and rapid
• A systematic approach to radiological imaging:
Confirm or exclude the most common diseases
Screen the whole abdomen for general signs of pathology
Emergency And Trauma Imaging: Recognizing The Basics, 9 – 11 Nov 2018