CT School, Novi Sad, 2012

Prof. Andrs Palk MD, PhD

Role of imaging in the evaluation of the

acute abdomen
Department of Radiology
Faculty of General Medicine
University of Szeged
Hungary

Department of Radiology

CT School, Novi Sad, 2012

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

Department of Radiology

CT School, Novi Sad, 2012

Potential causes
perforation
obstruction
ischemia
bleeding
infection
peritoneal irritation

GI paralysis & defanse musculaire

Department of Radiology

CT School, Novi Sad, 2012

Acute abdomen top 8

1.
2.
3.
4.
5.
6.
7.
8.

Acute appendicitis
Acute cholecystitis
Small bowel obstruction (SBO)
Acute gynecological disease
Acute pancreatitis
Renal colic
Perforated peptic ulcer
Acute diverticulitis

account for 90 % of patients referred

to hospital

Department of Radiology

CT School, Novi Sad, 2012

Role of imaging
After stabilizing the patients 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
establish diagnosis.

Department of Radiology

are

of

utmost

importance

to

CT School, Novi Sad, 2012

Whats wrong? clinical findings

Department of Radiology

CT School, Novi Sad, 2012

Urological

Gynecological

Department of Radiology

Urinary tract obstruction

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
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CT School, Novi Sad, 2012

Cholecystitis

Calculous
Acalculous
Emphysematous

Hepatitis
Liver abscess
Spontaneous rupture
of a hepatic neoplasm
Right-sided LB diverticulitis
Retrocecal appendicitis

Department of Radiology

CT School, Novi Sad, 2012

Department of Radiology

Acute pancreatitis
Duodenal ulcer
Bowel obstruction
Abdominal aortic
aneurysm

CT School, Novi Sad, 2012

Bowel obstruction

SBO

LBO

Bowel ischemia

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous
Carcinoma
Volvulus
Diverticulitis

Peptic ulcer
Diverticulitis
Iatrogenic

Mesenteric artery

Thromboembolism

Atherosclerosis

Dissection
Mesenteric vein

Hypercoagulable

Neoplastic

Strangulation,
volvulus

Infectious

Perforation

Department of Radiology

Gastroenterocoliti
s
Pseudomembranou
s colitis

IBD

Ulcerative colitis
Crohns disease

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CT School, Novi Sad, 2012

Acute pancreatitis
Duodenal ulcer
Bowel obstruction
Abdominal aortic
aneurysm

Bowel obstruction

Cholecystitis

Calculous
Acalculous
Emphysematous

Hepatitis
Liver abscess
Spontaneous rupture
of a hepatic neoplasm
Right-sided LB diverticulitis
Retrocecal appendicitis

Urological

Gynecological

Department of Radiology

Urinary tract obstruction

PID
Ovarian vein thrombosis
Hemorrhagic ovarian cyst
Rupture of ovarian dermoid
Ovarian torsion
Rupture of ectopic pregnancy
Endometriosis
Necrotic uterine leiomyoma

SBO

LBO

Bowel ischemia

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous
Carcinoma
Volvulus
Diverticulitis

Peptic ulcer
Diverticulitis
Iatrogenic

Mesenteric artery

Thromboembolism

Atherosclerosis

Dissection
Mesenteric vein

Hypercoagulable

Neoplastic

Strangulation,
volvulus

Infectious

Perforation

Gastroenterocoliti
s
Pseudomembranou
s colitis

IBD

Ulcerative colitis
Crohns disease

Intestinal

Acute appendicitis
IBD
Mesenteric adenitis
Perforated carcinoma
Epiploic appendagitis
Omental infarction
Cecal diverticulitis
Infectious ileocolitis
Sigmoid diverticulitis
Obstructive sigmoid
carcinoma
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CT School, Novi Sad, 2012

Diagnostic algorithm
(history, physical examination and lab tests)
plain X-ray examination
abdomen
erect or decubitus
supine

chest

ultrasound
computed tomography

Department of Radiology

12

CT School, Novi Sad, 2012

Whats wrong? imaging findings

Pathological gas accumulation
Localized/diffuse fluid accumulation
Diffuse/segmental gas/fluid levels
Extravasation, leakage
Pathological circulation
Wall thickening (bulls eye)
Compartment syndrome
Foreign body

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Pneumoperitoneum
perforation
iatrogenic
per vaginam

Pneumoretroperitoneum
perforation
iatrogenic

Bowel wall
pneumatosis
infarction
necrosis

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Pneumoperitoneum
perforation
iatrogenic
per vaginam

Pneumoretroperitoneum
perforation
iatrogenic

Bowel wall
pneumatosis
infarction
necrosis

Note: Ogilvie-sy!

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Pneumoperitoneum
perforation
iatrogenic
per vaginam

Pneumoretroperitoneum
perforation
iatrogenic

Bowel wall
pneumatosis
infarction
necrosis

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Pneumoperitoneum
perforation
iatrogenic
per vaginam

Pneumoretroperitoneum
perforation
iatrogenic

Bowel wall
pneumatosis
infarction
necrosis

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Pneumoperitoneum
perforation
iatrogenic
per vaginam

Pneumoretroperitoneum
perforation
iatrogenic

Bowel wall
pneumatosis
infarction
necrosis

Department of Radiology

Gellett LR et al: Emerg Med J 2002;19:480-481

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CT School, Novi Sad, 2012

Pathological gas accumulation

Biliary system

sphincter Oddi incompetence

postoperative
spontaneous fistula
emphysematous cholecystitis

Portal vein
mesenteric infarction
air embolus
necrotizing enterocolitis

Abscess

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Biliary system

sphincter Oddi incompetence

postoperative
spontaneous fistula
emphysematous cholecystitis

Portal vein
mesenteric infarction
air embolus
necrotizing enterocolitis

Abscess

Department of Radiology

22

CT School, Novi Sad, 2012

Pathological gas accumulation

Biliary system

sphincter Oddi incompetence

postoperative
spontaneous fistula
emphysematous cholecystitis

Portal vein
mesenteric infarction
air embolus
necrotizing enterocolitis

Abscess

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

Department of Radiology

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CT School, Novi Sad, 2012

Pathological gas accumulation

gasless abdomen
Normal abdomen
Small bowel
obstruction/ischemia
Ascites
Surgery (e.g. total
colectomy)
Gastroenteritis
Large abdominal mass

Department of Radiology

Thompson WM: AJR, 191:10931099, 2008

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CT School, Novi Sad, 2012

Localized/diffuse fluid accumulation

Ascites

cirrhosis
tumor
hypoalbuminaemia
portal hypertension
lymphatic obstruction

Inflammation
Perforation
Abscess

Department of Radiology

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CT School, Novi Sad, 2012

Localized/diffuse fluid accumulation

Ascites

cirrhosis
tumor
hypoalbuminaemia
portal hypertension
lymphatic obstruction

Inflammation
Perforation
Abscess

Department of Radiology

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CT School, Novi Sad, 2012

Localized/diffuse fluid accumulation

Ascites

cirrhosis
tumor
hypoalbuminaemia
portal hypertension
lymphatic obstruction

Inflammation
Perforation
Abscess

Department of Radiology

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CT School, Novi Sad, 2012

Localized/diffuse fluid accumulation

Ascites

cirrhosis
tumor
hypoalbuminaemia
portal hypertension
lymphatic obstruction

Inflammation
Perforation
Abscess

Department of Radiology

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CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Paralytic ileus

Diffuse

Segmental (sentinel loop)

Department of Radiology

peritonitis
gastroenteritis
abdominal pain
other (postoperative, drug
effect,
electrolyte imbalance,
pneumonia,
retroperitoneal hemorrhage,
etc.)

pancreatitis
cholecystitis
appendicitis,
diverticulitis
etc.

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CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Paralytic ileus

Diffuse

Segmental (sentinel loop)

Department of Radiology

peritonitis
gastroenteritis
abdominal pain
other (postoperative, drug
effect,
electrolyte imbalance,
pneumonia,
retroperitoneal hemorrhage,
etc.)

pancreatitis
cholecystitis
appendicitis,
diverticulitis
etc.

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CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Obstruction

Small bowel

Paulsen SR, RadioGraphics, 26:641, 2006

Department of Radiology

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous

Large bowel

Carcinoma
Volvulus
Diverticulitis

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CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Obstruction

Small bowel

Large bowel

Department of Radiology

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous

Carcinoma
Volvulus
Diverticulitis

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CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Obstruction

Small bowel

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous

Large bowel

Carcinoma
Volvulus
Diverticulitis

Takeyama,et al: RadioGraphics 2005; 25:9971015

Department of Radiology

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CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Obstruction

Small bowel

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous

Large bowel

Carcinoma
Volvulus
Diverticulitis

E M Anderson, Imaging 2006;18:198

Department of Radiology

36

CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Obstruction

Small bowel

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous

Large bowel

Carcinoma
Volvulus
Diverticulitis

www.nypemergency.org

Department of Radiology

37

CT School, Novi Sad, 2012

Diffuse/segmental gas/fluid levels

Obstruction

Small bowel

Large bowel

Department of Radiology

Adhesion
Crohns
Neoplasm
Hernia
Radiation
Miscellaneous

Carcinoma
Volvulus
Diverticulitis

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CT School, Novi Sad, 2012

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)

Department of Radiology

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CT School, Novi Sad, 2012

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): 0.5 1.5 mL/min

Yoon W et al: Radiology 239:16-167, 2006

Department of Radiology

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CT School, Novi Sad, 2012

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)

Department of Radiology

41

CT School, Novi Sad, 2012

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)

Department of Radiology

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CT School, Novi Sad, 2012

Pathological circulation

Arterial

thromboembolism (MI, rheumatic

heart disease, atrial fibrillation,
etc.)

arteriosclerosis
dissection
heart failure
others (iatrogenic, idiopathic,

Kirkpatrick IDC et al: Radiology, 229:91-98, 2003

strangulation/volvulus, septicemia,
extrinsic mass, etc.)

Venous

thrombosis
others (extrinsic mass, iatrogenic,

strangulation/volvulus, etc.)

Department of Radiology

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CT School, Novi Sad, 2012

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; 188:462-471

Department of Radiology

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CT School, Novi Sad, 2012

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, 30:445-460, 2010

Department of Radiology

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CT School, Novi Sad, 2012

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.)

Department of Radiology

46

CT School, Novi Sad, 2012

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.)

Department of Radiology

Okino Y et al: Radiographics, 21:1475-1490, 2001

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CT School, Novi Sad, 2012

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, 2000

Department of Radiology

48

CT School, Novi Sad, 2012

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

Department of Radiology

Dibbad R et al: The Internet Journal of Radiology, 12/1, 2010

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CT School, Novi Sad, 2012

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 2008

Department of Radiology

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CT School, Novi Sad, 2012

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

Department of Radiology

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CT School, Novi Sad, 2012

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

Department of Radiology

52

CT School, Novi Sad, 2012

Wall thickening

Infarction, ischemia

Intramural hematoma

Inflammation

epiploic appendagitis

Groove pancreatitis

Infection

appendicitis

sigmoiditis

typhlitis (neutropenic colitis)

pseudomembranous colitis
(clostridium difficile)

Poletti PA et al, AJR 2004; 182:1159-1165

others (TBC, amebiasis, campylobacter,

shigella, etc.)

Neoplasm

Department of Radiology

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CT School, Novi Sad, 2012

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

Department of Radiology

54

CT School, Novi Sad, 2012

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

Department of Radiology

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CT School, Novi Sad, 2012

Foreign body

Accidental/intentional/iatrogenic

Endoluminal/extraluminal

W./w.o. perforation

Maglinte DDT: Radiology, 236:763-767, 2005

Department of Radiology

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CT School, Novi Sad, 2012

Abdominal compartment syndrome

Increased intraabdominal
pressure

Various clinical conditions

(massive
hemorrhage and inflammation, severe gut
edema, intestinal obstruction, ascites under
pressure)

Decrease in venous return,

perfusion to the intra-abdominal
organs critically reduced

Imaging (CT):

Round-belly sign - Abdominal

distention with increased (>0.80)
sagittal-to-transverse diameter ratio

Collapse of the vena cava

Bowel wall thickening with

enhancement

Bilateral inguinal herniation

Department of Radiology

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CT School, Novi Sad, 2012

Acute abdomen - algorithm

(history, physical examination and lab tests)
plain X-ray examination
abdomen
erect or decubitus
supine

chest

ultrasound
computed tomography

Department of Radiology

58

CT School, Novi Sad, 2012

Acute abdomen - algorithm

(history, physical examination and lab tests)
plain X-ray examination
abdomen
erect or decubitus
supine

chest

ultrasound
computed tomography

Department of Radiology

?
59

CT School, Novi Sad, 2012

Acute abdomen - algorithm

(history, physical examination and lab tests)
plain X-ray examination
abdomen
erect or decubitus
supine

chest

ultrasound
computed tomography

Department of Radiology

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CT School, Novi Sad, 2012

Department of Radiology

61