acute pain in the right upper quadrant: diagnostic...

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Acute pain in the right upper quadrant: Diagnostic imaging

Poster No.: C-1986

Congress: ECR 2017

Type: Educational Exhibit

Authors: P. G. Oliveira1, M. Cruz1, C. Ferreira1, L. Curvo Semedo1, F.

Caseiro Alves2; 1Coimbra/PT, 2Coimbra, Coimbra/PT

Keywords: Acute, Localisation, Diagnostic procedure, Ultrasound, CT, BiliaryTract / Gallbladder, Emergency, Abdomen

DOI: 10.1594/ecr2017/C-1986

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Learning objectives

To review the disease entities causing acute pain in the right upper quadrant. To discussthe role of ultrasonography in the assessment of patients presenting with this symptom.Additionally, we will briefly discuss the value of tomography as a problem-solving tool.

Background

An acute abdomen means a disorder of sudden onset with duration of less 24 hoursthat is manifested as abdominal pain and associated with gastrointestinal symptoms.Abdominal pain in the right upper quadrant is a very common symptom and constitutesa recognized pattern in which hepatobiliary disease in general (e.g. acute cholecystitis)is the primary diagnostic consideration.

Although the patient history, physical examination, and laboratory test results cannarrow the differential diagnosis, these findings are sometimes confusing and imaging isgenerally indicated in order to reach a specific diagnosis, which frequently is importantto select the adequate therapy approach.

Findings and procedure details

The ultrasonography (US) is the primary and initial imaging modality of choice for patientspresenting with right upper quadrant pain, although there are situations where additionalimaging may be required, namely computed tomography (CT).

The most common causes of acute pain in the abdominal quadrants are listed below:

• Acute cholecystitis and its complications (gangrene cholecystitis,emphysematous cholecystitis and gallbladder perforation)

• Choledocholithiasis• Ascending cholangitis• Liver abscess• Acute pancreatitis• Painful liver neoplasms• Hepatic artery aneurysm• Budd-chiari syndrome

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• Perforated duodenal ulcer• Gallstone ileus• Intraperitoneal focal fat infarction• Ascending Retrocecal Appendicitis

1. ACUTE CHOLECYSTITIS AND ITS COMPLICATIONS

Acute cholecystitis is a primary diagnostic consideration in patients presenting with acuteright upper quadrant pain. Classically, these patients experience an acute pain thatincreases in intensity over several minutes and then persists for several hours. It canbe accompanied by nausea, vomiting, anorexia and fever. The physical examination ispresented with murphy´s sign.

Most cases of acute cholecystitis are acute calculous cholecystitis. About 95% ofthese cases are related due to calculous obstruction of the gallbladder neck or cysticduct. However, the cholecystitis can be acalculous, in critically ill or injured patients,by conditions that can promote ischaemia injury to the gallbladder, such as: majorsurgery, serious trauma, mechanical ventilation, extensive burns, or prolonged parenteralnutrition.

IMAGING FINDINGS:

The ultrasound has an important and fundamental role in the diagnosis of acutecholecystitis. The presence of gallstones in combination with maximal tenderness overthe gallbladder has a high degree of prediction. Other signs less sensitivity and specificitycan be seen, such as gallbladder wall edema and thickening, pericholecystic fluid anddistended gallbladder.

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Fig. 1: Acute cholecystitis - Distended gallbladder filled with echogenic sludge andgallstones. The gallbladder wall is markedly thickened with presence of pericholecysticfluid (arrows).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

Fig. 2: Acute cholecystitis - The gallbladder is filled with echogenic sludge andgallstones. The wall is markedly thickened and there is pericholecystic fluid (arrows).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

1.1 Gangrenous Cholecystitis

Gangrenous cholecystitis is a rare and severe complication of acute cholecystitis. Theincreased intraluminal pressure may produce gallbladder wall ischemia following bynecrosis. The murphy sign is only present in 33% of patients, maybe because of damage

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to the gallbladder wall innervation by gangrenous changes. These patients have a highrisk of perforation, and must be treated as soon as possible.

IMAGING FINDINGS:

In ultrasound assessment, it is traduced by alternating hyperechoic and hypoechoicbands in an irregularly thickened gallbladder wall, traducing intraluminal membranes. AtCT is seen gas in the wall or lumen, intraluminal membranes, irregular or absent walland abscess.

Fig. 3: Gangrenous Cholecystitis - Irregularly thickened gallbladder wall, withhypoechoic intraparietal areas compatible with a process of necrosis (arrowheads).There are a calculus and sludge inside the gallbladder.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

1.2 Emphysematous Cholecystitis

Emphysematous cholecystitis is characterized by the presence of intramural and/orintraluminal gas. The disease begins with acute cholecystitis followed by ischemia organgrene of the gallbladder wall and an infection caused by gas-producing bacteria(commonly Clostridium perfringens, Escherichia coli and Bacterioides fragilis).Thiscondition has a significantly increased rates of mortality (15-25%) and it is considereda surgical emergency.

IMAGING FINDINGS:

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The imaging findings have an important diagnostic value in this cases. The conventionalradiography may show air in the wall or lumen of the gallbladder with presence of air-fluid levels. The ultrasonography may demonstrate highly echogenic reflectors with low-level posterior shadowing and reverberation artifact. In some cases, can be performingCT to a best evaluation, since it is the most sensitive and specific imaging modality in thediagnosis of emphysematous cholecystitis.

Fig. 4: Emphysematous cholecystitis - The conventional radiography shows gas inthe right hypochondrium (arrows), compatible with air in the gallbladder wall. Thelevel air-fluid seen adjacent to the gallbladder is related with "sentinel loop". Theultrasonography demonstrates a distended gallbladder with thickened wall and acalculus in the infundibulum. There are highly echogenic reflectors with low-levelposterior shadowing and reverberation artefact (arrowhead).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

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Fig. 5: Emphysematous cholecystitis - Computed Tomography shows signs ofcholecystitis (gallbladder distention, wall thickening, pericholecystic fat stranding) withpresence of gas in the wall and lumen (arrowhead).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

1.3 Gallbladder Perforation

Gallbladder perforation is a serious complication of acute cholecystitis and carry arelatively high mortality rate. It complicates acute cholecystitis in up to 10% of cases.

Niemeier classified gallbladder perforations in three categories: acute free perforationwith generalized peritonitis (type I) ; subacute pericholecystic abscess (type II) ; chroniccholecystoenteric fistulation (type III). Subacute perforations are the most common,accounting for 60% of all cases. The cholecystoduodenal fistula is the most commonchronic perforation and can be following by pneumobilia.

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IMAGING FINDINGS:

Ultrasound and CT scans are reliable tools for diagnosing gallbladder perforations byidentifying the defect in the wall, despite CT is more accurately to demonstrate the fistulas.

Fig. 6: Gallbladder perforation type II - We can see two clinic cases (A and B) of acutecholecystitis complicated with wall perforation, with illustration of the focal wall defect(arrows) and pericholecystic abscess (arrowheads).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

2. Choledocholithiasis

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Choledocholithiasis is the presence of a gallstone in the common bile duct. When a stonebecomes lodged in the duct and obstructs it, the patient may experience acute right upperquadrant and/or jaundice.

IMAGING FINDINGS:

The diagnosis is performed initially by ultrasound that has relatively higher sensibility inthe detection of choledocholithiasis. Ultrasound should be performed both proximal anddistal common bile duct individually, in longitudinal and transverse planes.

If choledocholithiasis is suspected but cannot be confirmed with US, MRcholangiopancreatography is an excellent choice for further investigations, with highsensibility and specificity (approaching 100%). It is the gold standard for the diagnosis ofcholedocholithiasis. Another alternative is computed tomography.

Fig. 7: Choledocholithiasis - We can see two clinic cases of gallstones in the commonbile duct causing obstruction and bile duct dilatation.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

3. Ascending Cholangitis

Ascending cholangitis is an infection of the bile duct, usually caused by bacteriaascending from its junction with the intestine. It tends to occur in an obstructed biliary

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system, most commonly due to bile duct stones. Patients with cholangitis are febrile,often have abdominal pain, and are jaundiced (Charcot triad).

IMAGING FINDINGS:

Noninvasive diagnostic techniques include sonography, which is the recommended initialimaging modality. On ultrasound we should see thickening of the walls of the bile ductsand biliary dilatation with stones and/or echogenic content within the common bile duct.CT can be important to confirm the cause of biliary obstruction, but others findings ofcholangitis are non-specific and should be interpreted in the correct clinical context.

Fig. 8: Ascending Cholangitis - Ultrasonography illustrates thickening of the bile ductswalls and biliary dilatation.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

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Fig. 9: Ascending Cholangitis - CT scan shows dilatation of the intrahepatic bile ductswith parietal thickening (arrows) and heterogeneous content. There is aerobilia.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

4. Liver Abscess

Hepatic abscess is a circumscribed, often encapsulated and purulent inflammation withnecrosis of the local parenchyma caused by a multitude of pathogens (most of themare anaerobic). Patients with liver abscess usually present with fever and right upperquadrant pain. Others less common symptoms are jaundice, anorexia or weight loss.

IMAGING FINDINGS:

The sonographic appearances are varied. Usually is a low echoic to mixed-echoic lesionand the margin may be blurred or irregular due to inflammation of surrounding areas.There may be internal septations or stranding. Gas bubbles may also be seen. ColorDoppler will demonstrate absence of central perfusion. Sometimes hepatic abscess

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can have a most solid sonographic appearance and, mainly in this cases, CT maycomplement ultrasonography by demonstrating areas of liquefaction.

Fig. 10: Liver abscess - We can see two cases of pyogenic liver abscesses withhypoechoic solid appearance.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

Fig. 11: Liver abscesses. A) Contrast-enhanced CT shows a pyogenic abscess.Grouping of low attenuation lesions in the liver - cluster sign; B) Contrast-enhanced CTshows a klebsiella abscess in the right liver lobe. Discontinuous septa (white arrow)- septal breakage sign; C) Contrast-enhanced CT shows a amoebic abscess. Thickenhancing wall and outer hypodense rim - Double target sign (black arrow).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

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5. Acute Pancreatitis

Acute pancreatitis is an acute inflammation of the pancreas.The most common cause isgallstones that can lodge in the common bile duct and block the pancreatic duct.

The diagnosis is usually made by the presence of acute onset of persistent, severe upperabdomen pain (most often located in the epigastric) and lipase/amylase elevation threetimes upper the limit of normal. Diagnostic imaging may be obtained when the clinicdiagnosis is in doubt, when pancreatitis is severe, or when a given study might providespecific information required.

IMAGING FINDINGS:

Acute pancreatitis manifests with interstitial edema and an enlarged hypoechoic glandon ultrasound. It is also useful to the detection of cholelithiasis and choledocholithiasisand identification of peripancreatic acute fluid collections. Contrast-enhanced CT can beimportant to evaluate the pancreatic morphology and viability. Nonenhancement of all orpart of the gland is termed "necrosis". CT is 100% specific for necrosis if greater than30% of the gland is nonenhancing.

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Fig. 12: Acute pancreatitis - Interstitial edema and an enlarged hypoechoic gland.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

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Fig. 13: Acute pancreatitis - Axial contrast-enhanced CT scan shows an enlargedpancreas and small focus of non-enhancing (arrow), indicative of parenchymalnecrosis. There is a small amount of peripancreatic fluid collection (arrowheads) andfat infiltration.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

6. Painful Liver Neoplasms

A liver mass can develop acute pain in result of some complications as rupture orhemorrhage. In this context, one of the most important liver mass is the hepatic adenoma.Hepatic adenoma is a rare benign liver tumor associated with women that using oralcontraceptive pills, anabolic steroids and type 1 glycogen storage disease (or Von Gierkedisease).

IMAGING FINDINGS

On ultrasound, the hepatic adenoma may appear as a well-demarcated heterogeneousmass with a variable echogenicity and a hypoechoic halo of focal fat sparing.On CT may appear as a well marginated lesion and isoattenuating to liver. Oncontrast administration, they demonstrate transient relatively homogenous enhancementreturning to near isodensity on portal venous and delayed phase image. The presenceof a heterogeneous liver mass with internal hemorrhage and/or hemoperitoneum issuggestive of spontaneous rupture or hemorrhage.

Fig. 14: Rupture and hemorrhage of a hepatic adenoma - (a) Non-Contrast-EnhancedCT - heterogenous liver mass with spontaneously hyperdense areas; (b) Contrast-Enhanced CT - the tumor shows minimal heterogeneous enhancement, inferior to theliver parenchyma; (c) Non-Contrast-Enhanced CT - In the pelvis there is a moderateamount of spontaneously hyperdense fluid - hemorrhagic.

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References: Radiology Department, Coimbra University Hospital - Coimbra/PT

Others neoplasms can development acute pain in the right upper quadrant as aresult from rupture or hemorrhage: hepatocellular carcinoma, its estimated rupture andspontaneous hemorrhage occurs in up to 10% of cases; cavernous hemangiomas, itsrupture and hemorrhage is very rare; vascular liver metastases, for example from renalcell carcinoma and neuroendocrine tumors.

7. Hepatic Artery Aneurysm

Hepatic artery aneurysms are rare lesions (20% of all visceral aneurysms) and difficultto diagnose clinically. Nevertheless, it can be present as right upper quadrant pain,obstructive jaundice, or rarely as bleeding into the gastrointestinal tract.

IMAGING FINDINGS:

US is an excellent noninvasive method in detection of hepatic artery aneurism. SpectralDoppler can aid in differentiating vascular from other types of masses and color Dopplershows arterial or turbulent flow in the lesion suggestive of it being a mass of vascularorigin. The CT angiography is useful for detecting aneurysms and assessing anatomicaldetails, and is being used instead of angiography.

Fig. 15: Hepatic artery aneurysm - CT scan after intravenous contrast clearlydemonstrates the lumen of the hepatic artery aneurysm (arrow).

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References: Radiology Department, Coimbra University Hospital - Coimbra/PT

8. Budd-Chiairi Syndrome

Budd-Chiari syndrome is a very rare condition. The condition is caused by hepaticvenous outflow obstruction at any level from the small hepatic veins to the junction of theinferior vena cava and the right atrium. There are many causes of obstruction, includingthrombosis of the hepatic vein and compression of the hepatic vein by an outside structure(e.g. tumor). Usually it presents with the classical triad of abdominal pain, ascites andhepatomegaly, although this is non-specific presentation.

IMAGING FINDINGS:

The imaging findings of Budd-Chiari syndrome are variable and depend on the stageof the disease. In the acute stage, usually ultrasound can show hepatomegaly,splenomegaly, heterogeneous echotexture and ascites. Duplex Doppler ultrasonography(US) shows absent or flat flow in the hepatic veins, reversed flow in the hepatic veins,inferior vena cava or both, and intrahepatic collateral pathways. At the level of the portalvein, reveals slow hepatofugal flow (< 11 cm/s).

Computed tomography reveals a decreased peripheral hepatic enhancement causedby portal and sinusoidal stasis and stronger enhancement of the central portion of theliver parenchyma. The caudate lobe is enlarged and demonstrates increased contrastenhancement compared with the remainder of the liver.

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Fig. 16: Budd-Chiairi Syndrome - Contrast- enhanced CT depicts a moderatelyenlarged liver with characteristic patchy enhancement and sparing of the caudate lobe(white asterisk), and also a small amount of peritoneal fluid (more evident in b).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

9. Perforated Duodenal Ulcer

Perforation complicates duodenal ulcer about half as often as bleeding and mostperforated ulcers are on the anterior surface of the duodenum.

The first and most characteristic symptom is an intense and severe epigastric pain thatrapidly becomes generalized. The abdominal findings are characteristically described asof board-like rigidity.

IMAGING FINDINGS:

As an initial evaluation, the radiography can show the presence of gas within peritonealcavity. CT is the following modality of choice in this situation. The signs of duodenalperforation include extraluminal air, pneumoperitoneum, duodenal wall thickening,periduodenal fat stranding, discontinuity of the duodenal wall, air bubbles in closeproximity to the site of perforation, extravasation of oral contrast material and abscess.

Fig. 17: Perforated Duodenal Ulcer - a) CT shows the location of the duodenal ulcerperforation (white arrow), with gas accumulation and positive oral contrast in the right

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anterior pararenal space (black asterisk); b) Endoscopy reveals wide and deep necroticulceration in the posterior wall of the duodenal bulb.References: Radiology and Gastroenterology Departments, Coimbra UniversityHospital - Coimbra/PT. Courtesy of J. Brito, Portimão/PT

Fig. 18: Duodenal perforation after endoscopic retrograde cholangiopancreatography(ERCP) - a and b) Radiographs of the chest and abdomen show extensivecollections of gas, with pneumoretroperitoneum and pneumomediastinum, as wellas subcutaneous and cervical emphysema; c and d) CT with positive hydrosolubleoral contrast shows retroperitoneal extravasation to the right anterior pararenal space(arrow) with abundant retroperitoneal gas. The gallbladder is distended with presenceof gallstones. There are gas in the intrahepatic bile ducts and dilatation of the mainpancreatic duct with marked atrophy of the pancreatic parenchyma.References: Radiology Department, Coimbra University Hospital - Coimbra/PT.Courtesy of J. Brito, Portimão/PT

10. Gallstone Ileus

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Gallstone Ileus is an uncommon cause of mechanical small bowel obstruction. It occurswhen gallstones impact in the lumen of the bowel. The stone enters the gastrointestinaltract usually through a cholecystenteric fistula located between the gallbladder and theduodenum.

Gallstone ileus can acutely present as colicky abdominal pain and abdominal distensionin the course of small bowel obstruction.

IMAGINNG FINDINGS:

Classically the findings on abdominal radiographs are a small bowel obstruction, gaswithin the biliary tree and a ectopic gallstone on abdominal plain radiograph - Rigler´striad. CT is very helpful in diagnosing of lithiasis, although it depends of the quantityof calcification. In these situations, ultrasound can be useful, because gallstone alwaysappears as a hyperechoic mass with distal acoustic shadowing.

Fig. 19: Gallstone Ileus - a) Radiograph of the abdomen reveals an air-fluid level in thegallbladder (arrow) and a calculus (arrowhead); b and c) CT scan shows air-fluid level

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in gallbladder (asterisk) and diffuse thickening of the duodenal wall (arrow); d) There isa calculus in the small bowel (arrow).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

11. Intraperitoneal Focal Fat Infarction

The term intraperitoneal focal fat infarction (IFFI) includes a variety of acute abdominalclinical conditions with focal fatty tissue necrosis. In clinical practice, most cases of IFFIinclude torsion and/or infarction of the greater omentum or of the epiploic appendages.

Epiploic appendagitis is an uncommon cause of abdominal pain. The greatestconcentration of epiploic appendages is in the cecum and sigmoid colon. Involvement ofthe proximal colon is less common, although not unusual.

IMAGING FINDINGS:

The characteristics of acute epiploic appendagitis on US images are an ovalnoncompressible hyperechoic mass at the site of maximum tenderness, adjacent tothe colon, with no central blood flow depicted on color Doppler US images.The mostcommon CT feature is an oval fat-density lesion less than 5 cm in diameter withsurrounding inflammatory changes abutting the anterior colonic wall. Thickening of theparietal peritoneum, secondary to the spread of inflammation, also may be observed. Thepresence of a central area of high attenuation within the fat (due to venous thrombosis)is useful for the diagnosis.

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Fig. 20: Epiploic appendagitis - CT scan illustrates a rounded mass adjacent to theascending colon (arrows) displaying a central density of fat and a denser peripheralrim.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

Omental infarction is a rare cause of acute abdomen resulting from vascular compromiseof the greater omentum. The right inferior portion of the omentum is more vulnerable toinfarction due to a more tenuous blood supply. However, it can occur along of all portionsof the omentum.

IMAGING FINDINGS:

Ultrasonography shows a focal area of increased echogenicity in the omental fat. On CT,classically it appears as a fatty and large (>5 cm) encapsulated mass, with hyperdenseperipheral halo and soft-tissue stranding adjacent to the ascending colon.

Fig. 21: Omental Infarction - Ultrasonography show a focal area of increasedechogenicity in the omental fat (arrows)References: Radiology Department, Coimbra University Hospital - Coimbra/PT

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Fig. 22: Omental infarction - CT scan illustrates a fatty and large (>5 cm) mass (arrow)associated with soft-tissue stranding in the greater omentum, anterior to the ascendingcolon.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

12. Ascending Retrocecal Appendicitis

Acute appendicitis is the most common cause of acute abdominal pain in adults.However, some patients may have atypical presentation related to the position of theappendix that may lead to a delay in diagnosis and increased complications.

Most of the patients with ascending subhepatic retrocecal appendicitis may experienceright upper abdominal pain. It may give rise to an abscess in the subhepatic space andspread to the tail of the liver, or it may spread along the right paracolic gutter, and extendto the right subphrenic spaces.

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IMAGING FINDINGS:

Ultrasound is used frequently in the assessment of suspected acute appendicitis in youngchildren and sometimes in adults, but it requires expertise, and dedicated techniquesusing graded compression to expose the appendix and displace surrounding bowel loops.However, in adults, un-enhanced CT has been shown to be more sensitive in diagnosingacute appendicitis than ultrasound is. CT is very sensitive for evaluating the normaland thickened wall appendix, inflamed peri-appendiceal fat, collections, and presenceof free gas in ruptured appendix. Signs of appendicitis are a thickened appendiceal wallabove 2 mm with ringlike contrast enhancement, a cross-sectional diameter above 6 mm,periappendiceal fat attenuation, a calcified appendicolith, and abscess formation.

Fig. 23: Ascending retrocecal appendicitis - Contrast-enhanced CT - A. Coronalreconstruction shows the long thickened and inflamed ascending retrocecal appendix(arrow) reaching the subhepatic region with inflammatory stranding; B (a-d). Ascendingcross sections of the abdomen show thickened ascending retrocecal appendix (arrow)with mild inflammatory changes and presence of a calcified appendicolith in theappendix (arrowhead).References: Radiology Department, Coimbra University Hospital - Coimbra/PT

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Fig. 24: Ascending retrocecal appendicitis - Contrast-enhanced CT - A. Coronalreconstruction shows the long ascending retrocecal appendix (arrow) reaching thesubhepatic region and a fluid collection in the right lateral paracolic gutter extendingsuperiorly to the subhepatic region (asterisk) with inflammatory stranding; B (a-d).Ascending cross sections of the abdomen show long ascending retrocecal appendix(arrows), with stranding of the surrounding fat and fluid collection in the subhepaticregion (arrowhead), surrounding the tip of the right liver lobe.References: Radiology Department, Coimbra University Hospital - Coimbra/PT

Images for this section:

Fig. 1: Acute cholecystitis - Distended gallbladder filled with echogenic sludge andgallstones. The gallbladder wall is markedly thickened with presence of pericholecysticfluid (arrows).

© Radiology Department, Coimbra University Hospital - Coimbra/PT

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Fig. 2: Acute cholecystitis - The gallbladder is filled with echogenic sludge and gallstones.The wall is markedly thickened and there is pericholecystic fluid (arrows).


Fig. 3: Gangrenous Cholecystitis - Irregularly thickened gallbladder wall, with hypoechoicintraparietal areas compatible with a process of necrosis (arrowheads). There are acalculus and sludge inside the gallbladder.


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Fig. 4: Emphysematous cholecystitis - The conventional radiography shows gas inthe right hypochondrium (arrows), compatible with air in the gallbladder wall. Thelevel air-fluid seen adjacent to the gallbladder is related with "sentinel loop". Theultrasonography demonstrates a distended gallbladder with thickened wall and a calculusin the infundibulum. There are highly echogenic reflectors with low-level posteriorshadowing and reverberation artefact (arrowhead).


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Fig. 5: Emphysematous cholecystitis - Computed Tomography shows signs ofcholecystitis (gallbladder distention, wall thickening, pericholecystic fat stranding) withpresence of gas in the wall and lumen (arrowhead).


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Fig. 6: Gallbladder perforation type II - We can see two clinic cases (A and B) of acutecholecystitis complicated with wall perforation, with illustration of the focal wall defect(arrows) and pericholecystic abscess (arrowheads).


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Fig. 7: Choledocholithiasis - We can see two clinic cases of gallstones in the commonbile duct causing obstruction and bile duct dilatation.


Fig. 8: Ascending Cholangitis - Ultrasonography illustrates thickening of the bile ductswalls and biliary dilatation.


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Fig. 9: Ascending Cholangitis - CT scan shows dilatation of the intrahepatic bile ductswith parietal thickening (arrows) and heterogeneous content. There is aerobilia.


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Fig. 10: Liver abscess - We can see two cases of pyogenic liver abscesses withhypoechoic solid appearance.


Fig. 11: Liver abscesses. A) Contrast-enhanced CT shows a pyogenic abscess.Grouping of low attenuation lesions in the liver - cluster sign; B) Contrast-enhanced CTshows a klebsiella abscess in the right liver lobe. Discontinuous septa (white arrow)- septal breakage sign; C) Contrast-enhanced CT shows a amoebic abscess. Thickenhancing wall and outer hypodense rim - Double target sign (black arrow).


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Fig. 12: Acute pancreatitis - Interstitial edema and an enlarged hypoechoic gland.


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Fig. 13: Acute pancreatitis - Axial contrast-enhanced CT scan shows an enlargedpancreas and small focus of non-enhancing (arrow), indicative of parenchymal necrosis.There is a small amount of peripancreatic fluid collection (arrowheads) and fat infiltration.


Fig. 14: Rupture and hemorrhage of a hepatic adenoma - (a) Non-Contrast-EnhancedCT - heterogenous liver mass with spontaneously hyperdense areas; (b) Contrast-Enhanced CT - the tumor shows minimal heterogeneous enhancement, inferior to theliver parenchyma; (c) Non-Contrast-Enhanced CT - In the pelvis there is a moderateamount of spontaneously hyperdense fluid - hemorrhagic.


Fig. 15: Hepatic artery aneurysm - CT scan after intravenous contrast clearlydemonstrates the lumen of the hepatic artery aneurysm (arrow).


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Fig. 16: Budd-Chiairi Syndrome - Contrast- enhanced CT depicts a moderately enlargedliver with characteristic patchy enhancement and sparing of the caudate lobe (whiteasterisk), and also a small amount of peritoneal fluid (more evident in b).


Fig. 17: Perforated Duodenal Ulcer - a) CT shows the location of the duodenal ulcerperforation (white arrow), with gas accumulation and positive oral contrast in the rightanterior pararenal space (black asterisk); b) Endoscopy reveals wide and deep necroticulceration in the posterior wall of the duodenal bulb.

© Radiology and Gastroenterology Departments, Coimbra University Hospital - Coimbra/PT. Courtesy of J. Brito, Portimão/PT

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Fig. 18: Duodenal perforation after endoscopic retrograde cholangiopancreatography(ERCP) - a and b) Radiographs of the chest and abdomen show extensive collectionsof gas, with pneumoretroperitoneum and pneumomediastinum, as well as subcutaneousand cervical emphysema; c and d) CT with positive hydrosoluble oral contrast showsretroperitoneal extravasation to the right anterior pararenal space (arrow) with abundantretroperitoneal gas. The gallbladder is distended with presence of gallstones. There aregas in the intrahepatic bile ducts and dilatation of the main pancreatic duct with markedatrophy of the pancreatic parenchyma.

© Radiology Department, Coimbra University Hospital - Coimbra/PT. Courtesy of J. Brito,Portimão/PT

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Fig. 19: Gallstone Ileus - a) Radiograph of the abdomen reveals an air-fluid level in thegallbladder (arrow) and a calculus (arrowhead); b and c) CT scan shows air-fluid levelin gallbladder (asterisk) and diffuse thickening of the duodenal wall (arrow); d) There isa calculus in the small bowel (arrow).


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Fig. 20: Epiploic appendagitis - CT scan illustrates a rounded mass adjacent to theascending colon (arrows) displaying a central density of fat and a denser peripheral rim.


Fig. 21: Omental Infarction - Ultrasonography show a focal area of increasedechogenicity in the omental fat (arrows)


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Fig. 22: Omental infarction - CT scan illustrates a fatty and large (>5 cm) mass (arrow)associated with soft-tissue stranding in the greater omentum, anterior to the ascendingcolon.


Fig. 23: Ascending retrocecal appendicitis - Contrast-enhanced CT - A. Coronalreconstruction shows the long thickened and inflamed ascending retrocecal appendix(arrow) reaching the subhepatic region with inflammatory stranding; B (a-d). Ascendingcross sections of the abdomen show thickened ascending retrocecal appendix (arrow)with mild inflammatory changes and presence of a calcified appendicolith in the appendix(arrowhead).


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Fig. 24: Ascending retrocecal appendicitis - Contrast-enhanced CT - A. Coronalreconstruction shows the long ascending retrocecal appendix (arrow) reaching thesubhepatic region and a fluid collection in the right lateral paracolic gutter extendingsuperiorly to the subhepatic region (asterisk) with inflammatory stranding; B (a-d).Ascending cross sections of the abdomen show long ascending retrocecal appendix(arrows), with stranding of the surrounding fat and fluid collection in the subhepatic region(arrowhead), surrounding the tip of the right liver lobe.


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Conclusion

The radiologists must be familiar with the spectrum of conditions that may manifest asacute right upper quadrant pain. Ultrasonography is the pivotal imaging modality to helpexplain the clinical picture, which in turn is fundamental to select the prompt and adequatetreatment. Nevertheless, there are some clinical situations that computed tomographymay be a reliable tool to a best evolution, improving the accuracy in the final diagnosis.

Personal information

References

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