acute non-trauma disclosure abdomen - scbtmr 303 - yeh.pdf · 1 acute non-trauma abdomen benjamin m...
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Acute non-trauma abdomen
Benjamin M Yeh, MD
UC Department of RadiologySFUC Department of RadiologySF
Disclosure
• General Electric: Research Agreement, consultant, speaker
• NIH R01; R21
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Appendix found…is it appendicitis?
• Appendiceal enlargement – Accuracy depends on
threshold» 6 mm: Poor specificity,
many false positivesmany false positives» 12 mm: Poor sensitivity
• Wall Thickening• Periappendiceal fat
stranding• Fascial thickening• Arrowhead sign• Hyperenhancement
Ives, et al. Acta Radiol 2008:15;996-1004
Complications of AppendicitisComplications of Appendicitis
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Troublesome common scenariosscenarios
Appendix not seen
• If secondary signs present – Probable appendicitis (37-53%)
• If secondary signs absentAppendicitis unlikely (< 2%)– Appendicitis unlikely (< 2%)
• Consider – Coronal / Sagittal reformations– Left lateral decubitus positioning
Ganguli et al, Radiology 2006; 241:175-80Daly, et al. AJR. 2005:184:1813-20
Nikolaidis, et al. AJR. 2004: 183:889-92
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Normal appendix but secondary signs of inflammation
• 26% appendicitis
• Consider alternate diagnosis– Crohns
– Right-sided diverticulits
– Colitis
– Omental torsion
Daly, et al. AJR 2005:184:1813-20
Radiological appendicitis but no surgical concern
• Patients with CT findings of appendicitis (n=498)– 13 (3%) did not receive treatment
5 (38%) f th 13 b tl– 5 (38%) of these 13 subsequently underwent appendectomy for acute appendicitis within 1.5 yrs
» 4 were perforated
Stengel, et al, Submitted
Alternative diagnosesAlternative diagnoses
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Right-sided diverticulitis
• Younger mean age than left-sided diverticulutis
R l f t• Rarely perforates
Jhaveri et al. JCAT 2002
CT techniqueCT technique
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Unenhanced CT
• Sensitivity: 95-96%
• Specificity 92-99%
• Alternate Diagnosis in 35% of true negatives
• Does not assess for hyperenhancement nor gangrene
Lane, et al. Radiology 1999; 213:341-6
Cakirer, et al. Emergency Radiology 2002:9:155-61
Review of CT findings
of bowel ischemia
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Do CT findings reflect the causeof bowel ischemia?of bowel ischemia?
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Bowel Obstruction
Find the transition point
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SBO: Getting to the point!• Diminishing bowel
contrast– Contrast dilutes out near
the transition point
• Small bowel feces sign Dilated bowel with 30 seconds– Dilated bowel with particulate matter
– Suggests high grade obstruction
• Prior surgical incisions
• Bowel tracking 1 – 2 minutes
Take home points
• Use landmarks to find critical structures– Ileocecal valve appendix– Gonadal vein ovary
• Assess severity of bowel disease– Perforation / gangrene
• Consider alternative diagnoses
• SBO: Use shortcuts to find transition point