plain picture in acute abdomen
TRANSCRIPT
Plain picture in acute abdomen
Moderator-Dr (Prof) R K Gogoi
Presenter Dr Sarbesh Tiwari
INTRODUCTION
bull Acute abdomen refers to presence of severe abdominal pain developing suddenly or over a period of several hours
bull Most frequent reasons for presentation at the emergency department (ED)
bull It requires a clinician to make an urgent therapeutic decision
Plain Radiography
bull Plain abdominal radiography is traditionally the first radiological investigation in acute abdomen
bull Interpretation of plain films presents with formidable challenge because though specific diagnosis can be made not infrequently the appearance are non specific and misleading
Basic radiographs
amp
Erect abdomen
Left lateral decubitus (right side raised) are taken to add information
Patient to remain in given position ndash 10 minutes
A supine Abdomen radiograph
Erect Chest x ray
Basic standard radiographs
Erect chest radiograph
o Small pneumoperitoneum can be detected
o Various chest conditions may mimic an acute abdomen
o Acute abdominal conditions may be complicated by chest pathology
o Even a normal chest radiograph acts as a baseline and helps in detection of post operative complication
Chest Conditions that mimic acute abdomen
1 Pneumonia
2 Myocardial Infarction
3 Pulmonary Infarction
4 Congestive cardiac failure
5 Pericarditis
6 Leaking or dessecting thoracic aortic aneurysm
7 Pneumothorax
8 Pleurisy
Abdominal radiographs (kv60-65 short exposure time)
o Supine abdominal radiograph- Distribution of gas Calibre of bowel Displacement of bowel Obliteration of fat lines
o Erect abdominal radiograph- fluid level and free gas
o Horizontal-ray films( erect or lateral decubitus)- free intra- abdominal air fluid levels
TECHNIQUE standard projection
bull supine with knee slightly flexed
bull centered at iliac crest
bull Exposure during expiration
bull Low kV (60-75 kV)
bull Short exposure time to avoid motion
bull Both the lung bases and the pubic symphysis included
Anteroposterior supine
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
Plain Radiography
bull Plain abdominal radiography is traditionally the first radiological investigation in acute abdomen
bull Interpretation of plain films presents with formidable challenge because though specific diagnosis can be made not infrequently the appearance are non specific and misleading
Basic radiographs
amp
Erect abdomen
Left lateral decubitus (right side raised) are taken to add information
Patient to remain in given position ndash 10 minutes
A supine Abdomen radiograph
Erect Chest x ray
Basic standard radiographs
Erect chest radiograph
o Small pneumoperitoneum can be detected
o Various chest conditions may mimic an acute abdomen
o Acute abdominal conditions may be complicated by chest pathology
o Even a normal chest radiograph acts as a baseline and helps in detection of post operative complication
Chest Conditions that mimic acute abdomen
1 Pneumonia
2 Myocardial Infarction
3 Pulmonary Infarction
4 Congestive cardiac failure
5 Pericarditis
6 Leaking or dessecting thoracic aortic aneurysm
7 Pneumothorax
8 Pleurisy
Abdominal radiographs (kv60-65 short exposure time)
o Supine abdominal radiograph- Distribution of gas Calibre of bowel Displacement of bowel Obliteration of fat lines
o Erect abdominal radiograph- fluid level and free gas
o Horizontal-ray films( erect or lateral decubitus)- free intra- abdominal air fluid levels
TECHNIQUE standard projection
bull supine with knee slightly flexed
bull centered at iliac crest
bull Exposure during expiration
bull Low kV (60-75 kV)
bull Short exposure time to avoid motion
bull Both the lung bases and the pubic symphysis included
Anteroposterior supine
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
Basic radiographs
amp
Erect abdomen
Left lateral decubitus (right side raised) are taken to add information
Patient to remain in given position ndash 10 minutes
A supine Abdomen radiograph
Erect Chest x ray
Basic standard radiographs
Erect chest radiograph
o Small pneumoperitoneum can be detected
o Various chest conditions may mimic an acute abdomen
o Acute abdominal conditions may be complicated by chest pathology
o Even a normal chest radiograph acts as a baseline and helps in detection of post operative complication
Chest Conditions that mimic acute abdomen
1 Pneumonia
2 Myocardial Infarction
3 Pulmonary Infarction
4 Congestive cardiac failure
5 Pericarditis
6 Leaking or dessecting thoracic aortic aneurysm
7 Pneumothorax
8 Pleurisy
Abdominal radiographs (kv60-65 short exposure time)
o Supine abdominal radiograph- Distribution of gas Calibre of bowel Displacement of bowel Obliteration of fat lines
o Erect abdominal radiograph- fluid level and free gas
o Horizontal-ray films( erect or lateral decubitus)- free intra- abdominal air fluid levels
TECHNIQUE standard projection
bull supine with knee slightly flexed
bull centered at iliac crest
bull Exposure during expiration
bull Low kV (60-75 kV)
bull Short exposure time to avoid motion
bull Both the lung bases and the pubic symphysis included
Anteroposterior supine
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
Erect chest radiograph
o Small pneumoperitoneum can be detected
o Various chest conditions may mimic an acute abdomen
o Acute abdominal conditions may be complicated by chest pathology
o Even a normal chest radiograph acts as a baseline and helps in detection of post operative complication
Chest Conditions that mimic acute abdomen
1 Pneumonia
2 Myocardial Infarction
3 Pulmonary Infarction
4 Congestive cardiac failure
5 Pericarditis
6 Leaking or dessecting thoracic aortic aneurysm
7 Pneumothorax
8 Pleurisy
Abdominal radiographs (kv60-65 short exposure time)
o Supine abdominal radiograph- Distribution of gas Calibre of bowel Displacement of bowel Obliteration of fat lines
o Erect abdominal radiograph- fluid level and free gas
o Horizontal-ray films( erect or lateral decubitus)- free intra- abdominal air fluid levels
TECHNIQUE standard projection
bull supine with knee slightly flexed
bull centered at iliac crest
bull Exposure during expiration
bull Low kV (60-75 kV)
bull Short exposure time to avoid motion
bull Both the lung bases and the pubic symphysis included
Anteroposterior supine
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
Chest Conditions that mimic acute abdomen
1 Pneumonia
2 Myocardial Infarction
3 Pulmonary Infarction
4 Congestive cardiac failure
5 Pericarditis
6 Leaking or dessecting thoracic aortic aneurysm
7 Pneumothorax
8 Pleurisy
Abdominal radiographs (kv60-65 short exposure time)
o Supine abdominal radiograph- Distribution of gas Calibre of bowel Displacement of bowel Obliteration of fat lines
o Erect abdominal radiograph- fluid level and free gas
o Horizontal-ray films( erect or lateral decubitus)- free intra- abdominal air fluid levels
TECHNIQUE standard projection
bull supine with knee slightly flexed
bull centered at iliac crest
bull Exposure during expiration
bull Low kV (60-75 kV)
bull Short exposure time to avoid motion
bull Both the lung bases and the pubic symphysis included
Anteroposterior supine
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
Abdominal radiographs (kv60-65 short exposure time)
o Supine abdominal radiograph- Distribution of gas Calibre of bowel Displacement of bowel Obliteration of fat lines
o Erect abdominal radiograph- fluid level and free gas
o Horizontal-ray films( erect or lateral decubitus)- free intra- abdominal air fluid levels
TECHNIQUE standard projection
bull supine with knee slightly flexed
bull centered at iliac crest
bull Exposure during expiration
bull Low kV (60-75 kV)
bull Short exposure time to avoid motion
bull Both the lung bases and the pubic symphysis included
Anteroposterior supine
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
TECHNIQUE standard projection
bull supine with knee slightly flexed
bull centered at iliac crest
bull Exposure during expiration
bull Low kV (60-75 kV)
bull Short exposure time to avoid motion
bull Both the lung bases and the pubic symphysis included
Anteroposterior supine
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
Supplemental projectionsbull Ideally tilting x ray
table with potter Bucky diaphragm used to reduce distress to patient
bull 14rdquo- 17rdquo film high mA short exposure time increased 7-10 kVp over supine
bull Centered just above umbilicus in midline
Abdomen AP erect
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
ADDITIONAL PROJECTIONS
bull Prone Oblique Lateralbull For better definition and localization of
bull mass lesionsbull calcificationsbull herniations
bull A prone radiograph is useful when distal colonic obstruction is suspected
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
11
RADIATION EXPOSURE
bull One PP abdomen exposes a patient to 07 mSv of radiation equivalent to 35 chest radiograph
bull Gonadal shielding should be used if gonads lie within 5 cm of the primary beam if clinical objective is not compromised
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
12
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
NORMAL GAS PATTERN
bull Stomach
- alwaysbull Small bowel
- 2 or 3 loops of non-distended bowel
- normal diameter = 25 cmbull Larger bowel
- in rectum or sigmoid colon - always
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
NORMAL FLUID LEVELS
bull Stomach- always (except supine film)
bull Small bowel- 2 or 3 levels possible
bull Large bowel- none normally
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
DISEASE ENTITY
PNEUMOPERITONEUM
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
bull Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity
bull Almost always caused by perforation of hollow viscus
bull Perforated duodenal ulcer is the most frequent cause
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
19
CAUSES1 Perforationbull Peptic ulcer diseasebull Inflammation- Diverticulitis toxic megacolonnecrotizing
enterocolitisbull Infractionbull Pneumatosis coli- The cyst may rupturebull Maliganacybull Mechanical perforation following trauma
2 Iatrogenicbull Abdominal surgerybull Peritoneal dialysis
3 Pneumothorax- due to congenital pleuroperitoneal fistula
4Introduction per vaginum- eg douching
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
20
RADIOGRAPHY
bull Optimal radiographic technique is important
bull At least 2 radiographsbull a supine abdominal radiograph and bull either an erect chest image or a left lateral decubitus
image
bull The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired
bull As minimal as 1ml of free gas could be detected by proper technique
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
21
Signs in pneumoperitoneum
Erect chest radiograph reveals free gas between the liver and both does of diaphragm
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
22
Left lateral decubitus film showing gas between the liver and abdominal wall
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
23
Signs of pneumoperitoneum of supine radiographbull Right upper quadrant gas
Peri hepatic
Sub hepatic
Morrisonrsquos pouch
bull Fissure for ligament teres
bull Riglerrsquos (double wall sign)
bull Ligament visualization
Falciform
Umbilical inverted lsquoVrsquo sign
bull Triangular air
bull The cupola sign
bull Football or air dome
bull Scrotal air in children
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
24
Gas in subhepatic space
Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
25
Doges cap sign
bull Doges Cap sign refers to free air in Morrisons pouch
bull Morrisons pouch is normally a potential space between the right kidney and the liver
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
26
Triangular gas shadow superior to kidney and postero-inferior to 11th rib
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
27
Riglerrsquos sign
Riglers sign refers to the appearance of the bowel wall on plain film when it is outlined by intraluminal and extraluminal air The extra luminal air is free peritoneal gas
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
28
Falciform ligament visualization
Visualization of Falciform ligament by free gas on either side of the ligament
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
29
Football sign
bull The football sign likens the massively air-filled peritoneum to an American football
bull In the supine position free air collects anterior to the abdominal viscera producing a sharp interface with the parietal peritoneum and thereby creating the football outline
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
30
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
31
Double Bubble Sign
Two collections of overlapping gas- one of these collections is sub diaphragmatic free gas and the other is normal gas within the fundus of the stomach
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
32
The Cupola Sign
An arcuate collection of free intraperitoneal air beneath the central tendon of diaphragm The superior border is well defined (arrows)
compared with the inferior extent of the collection
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
33
The Triangle Sign
The triangle sign refers to small triangles of free gas that can typically be positioned between the large bowel and the flank(black arrow)
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
34
CONDITIONS SIMULATING PNEUMOPERITONEUM
1 Chilaiditirsquos syndrome-intestine between liver and diaphragm
2 Subphrenic abscess
3 Curvilinear supradiaphragmatic pulmonary collapse
4 Subdiaphragmatic fat
5 Cyst in pneumatosis intestinalis
6 Sub pulmonary pneumothorax
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
35
CONDITIONS SIMULATING PNEUMOPERITONEUM
Chilaiditirsquos syndrome-intestine between liver and diaphragm
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
36
CONDITIONS SIMULATING PNEUMOPERITONEUM
Right sided subphrenic abscess
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
37
CONDITIONS SIMULATING PNEUMOPERITONEUM
Large bulla at the base of the right lung mimics a
large pneumoperitoneum
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
38
INTESTINAL OBSTRUCTION
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
39
GASTRIC DILATATION
Causes
1 Mechanical gastric outlet obstruction
2 Paralytic ileus
3 Gastric volvulus
4 Air swallowing
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
40
GASTRIC VOLVULUSo Twisting of the stomach around its longitudinal or
mesenteric axis
o Organoaxial volvulus - Stomach rotates along its long axis and becomes obstructed with the greater curvature being displaced superiorly and the lesser curvature located more caudally in the abdomen
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
41
bull Mesenteroaxial volvulus --less common occurs when the stomach rotates along its short axis with resultant displacement of the antrum above the gastroesophageal junction
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
42
SMALL BOWEL OBSTRUCTION
bull Small bowel obstruction refers to any condition where the lumen of the small bowel is obstructed
bull The obstruction may be intrinsic (as with intussusception) or extrinsic (as with abdominal adhesions)
bull A small bowel diameter on plain film greater than 30mm is considered dilated
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
43
Clinical Presentation of SBO
Abdominal pain
Rapid onset of nausea and vomiting
Belching
Abdominal swelling
Constipation and obstipation
Squealing bowel sounds (early obstruction)
No bowel sounds (bowel wall muscular
exhaustion)
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
44
SMALL BOWEL OBSTRUCTION
bull Extrinsic causes - adhesions( most common)
- hernias
- masses
- congenital malrotations
bull Intramural causes - inflammatory strictures
- ischaemia
- primary small bowel tumours
bull Intraluminal causes - gall stones
-foreign bodies
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
45
PLAIN RADIOGRAPHbull Plain film
bull Supine abdominal X-rays-
bull Erect films shows-
bull lsquolsquoString of pearls signrsquorsquo-
Signs appear after 3-5 hoursmarked after 12 hours
dilated gas filled bowel loops (more than 25 cm) with little or no gas in
colon
multiple fluid level assuming a lsquolsquostep-ladder apperancersquorsquo
- Seen in decubitus or upright film and is virtually diagnostic of SBO
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
46
markedly distended loops of small bowel with effacement
of the Valvulae in the mid abdomen
Step ladder pattern produced by air fluid levels in erect film
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
47
Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows) which represents air trapped between the Valvulae Conniventes
STRING OF PEARL SIGN
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
48
The coiled spring appearance only occurs in the dilated air-filled small bowel It is most noticeable in the jejunum where
the valvulae conniventes are closely spaced
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
49
GASLESS SMALL BOWEL OBSTRUCTION
Gasless fluid filled dilated small bowel
All the air is absorbed
Difficult to differentiate with normal bowel loops
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
50
PARALYTIC ILEUS
bull lleus occurs from hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction
bull Causes- 1 Post operative ileus
2 Electrolyte imbalance
3 Sepsis
4 Generalised peritonoitis
5 Blunt abdominal trauma
6 Infiltration of mesentry by tumor
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
51
PARALYTIC ILEUS
bull Difficult to distinguish adynamic ileus from mechanical obstruction based on single radiograph
bull Degree of distension varies and features are not specific
bull Generalized distension- difficult to distinguish from low large bowel obstruction
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
52
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
53
Differentiating SBO from Paralytic Ileus
SBO Ileus
EtiologyPatient with prior
surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent May not be apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
54
STRANGULATING OBSTRUCTION
bull Occurs when two limbs of a loop are incarcerated by a band or in a hernia compromising the blood supply
bull Plain radiograph
- soft tissue mass or pseudotumour
-gas filled loops separated by thickened walls may resemble a large coffee bean
- if gangrene occurs lines of gas seen in the wall of the small bowel
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
55
Dilated small bowel loops with an obstructed bowel in the right inguinal canal
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
56
GALLSTONE ILEUS
bull Mechanical intestinal obstruction due to impaction of gall stones in the intestine
bull Comprises about 2 of small bowel obstruction
bull Unusual complication of chronic cholecystitis
bull Impaction of gallstone in terminal ileum after passing through a biliary-enteric fistula
bull Average age of diagnosis is 70 years
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
57
bull The classic radiographic signs described by Rigler
bull Riglerrsquos traid-
1 Incomplete or complete SBO
2 Gas within gall bladderbile duct
3 Ectopic location of gall stone
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
58
INTUSSUSCEPTION
bull It is the invagination of a segment of bowel ( intussusceptum) into the contiguous segment ( intussuscipiens)
bull Commonly seen in children below 2 years
bull Ileocolic segment involved in 90 cases
bull Colocolic and ileoileal intussusception may occur
bull Common in the ileum due to inflammation of the lymphoid tissue in Peyerrsquos patches
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
59
INTUSSUSCEPTION
bull In adults usually secondary to tumor of the bowel
bull Results in small bowel obstruction
bull Crescent sign-Soft tissue mass sometimes surrounded by a crescent of gas most commonly in Rthypochondrium
bull Target sign- two concentric circles of fat density lying to the rt of spine
bull Target sign twice as common as crescent sign
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
60
There is a prominent crescent sign in the left upper quadrant with a subtle target sign in right upper quadrant
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
61
Intussusceptions in the left upper quadrant on this plain film of an infant with pain vomiting
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
62
SMALL INTESTINAL INFARCTIONbull Thrombosis or embolism of superior mesentric artery
bull FEATURES
1 Gas filled dilated loops with multiple fluid levels
2 Thickened bowel loops owing to submucosal edema or hemorrhage
3 Linear gas in wall streaks suggest gangrene
4 Free gas if perforation
5 Intra luminal gas in mesentric veins or portal
vein in advanced cases
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
63
Intramural gas with positive rigler sign (due to intraperitoneal gas) suggests possibilty of intestinal infarction
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
64
bull LARGE BOWEL OBSTRUCTION
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
65
Large Bowel Obstruction
bull Dilated colon to point of obstruction
bull Little or no air in rectumsigmoid
bull Little or no gas in small bowel if ileocecal valve remains competent
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
66
Etiology
bull Mechanical obstruction
1 Carcinoma of colon (60)
2 Diverticulitis (second most common)
3 Volvulus
4 Extrinsic compression
bull Paralytic ileus AKA acute colonic psudo-obstruction was first described by Ogilvie
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Abull Large bowel distension
only-bull Owing to competent
ileocaecal valvebull Caecum at risk of
perforation
67
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
LARGE BOWEL OBSTRUCTION-types
bull TYPE 1 Bbull Competent ileocaecal
valve leading to caecal distension but also as a mechanical obstruction to small bowel
bull Caecum at risk of perforation
68
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
LARGE BOWEL OBSTRUCTION-types
bull TYPE IIbull Large and small
bowel distensionbull Incompetent valve
69
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
70
Large bowel Volvulusbull Sigmoid colon and caecum - most common
sites
bull If twist greater than 360 degrees unlikely to resolve spontaneously
bull The risk of vascular compromise more important than mechanical effects
bull Compound volvulus involving interwining of two loops of bowel is rare such as ileosigmoid knot
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
71
CAECAL VOLVULUS
bull Torsion of the bowel around its own mesentery and often results in a closed-loop obstruction
bull Occurs due to development failure of peritoneal fixation
bull Accounts for 2-3 case of intestinal obstruction and 11 cases of colonic volvulus
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
The cecum twists in the axial plane rotating clockwise or counterclockwise around its long axisAt times caecum twists and inverts and occupy left upper quadrant
72
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
73
PLAIN RADIOGRAPH
bull Plain film diagnostic in about 75
bull Dilated air filled caecum in an ectopic location usually with the caecal apex in left upper quadrant
bull Kidney or coffee bean appearence due to medially placed ileo caecal valve producing a soft tissue indentation
bull Little gas in distal colon and usually collapsed
bull Refluxed gas may erroneously suggest a small bowel obstruction
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
74
Even though there is considerable distension of the caecumone or two haustral markings can be usually seenunlike sigmoid volvulus
Identification of attached gas filled appendix confirms diagnosis
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
75
SIGMOID VOLVULUS
bull Accounts for 60-70 of colonic volvulus
bull Classically occur in old age psychiatrically disturbed mentally retarded or institutionalised people
bull Twists around mesenteric axis rarely with axial torsion
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
SIGMOID VOLVULUS-findingsbull Dilated loop of sigmoid colon that has a inverted U
configuration with absent haustral margin is an important diagnostic point
bull Left flank overlap sign
bull Liver overlap sign
bull Apex under left hemidiaphram
bull Apex above 10th thoracic vertebra
bull Inferior convergence on left76
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
77
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
78
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
79
COLONIC PSEUDO OBSTRUCTION
bull Also known as OGILVIE syndrome
bull Due to autonomic imbalance
bull Acute abd distension within10 days of precipitating pathology
bull Contrast enema CT required to exclude mechanical obstruction
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
80
DISTINCTION BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION
Small bowel Large bowel
Valvulae Conniventes
Present in jejunum
Absent
Number of loops Many Few
Distribution of loops
Central Peripheral
Haustra Absent Present
Diameter 3-5 cm gt5cm
Radius of curvature
small large
Solid faeces Absent Present
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
81
Acute colitis
bull An assessment of the extent of colitis state of mucosadepth of ulcerationpresence or absence of toxic megacolon and perforation can be made
bull The extent of faecal residue related to the extent of colitis
bull lsquoEmpty abdomenrsquo-no faecal residue or gas so active total colitis
bull Intra luminal gas tend to accumulate as colitis progress
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
82
Acute ulcerative colitis- descending colon with irregular outline absent haustrations absent faecal residue
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
TOXIC MEGACOLON
bull Fulminating form of colitis with trans mural inflammation
bull Perforation and peritonitis common
bull Radiologically-dilatation and nodular mucosa
bull Dilatation gt55mm- significant and sufficient
bull Changes most frequent in transverse colon
bull Gaseous distension of small bowel- severe colitis ndash poor prognosis
83
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
TOXIC MEGACOLON
bull Plain abdominal radiograph shows distention of the transverse colon associated with mucosal edema
bull The maximum transverse diameter of the transverse colon is 6 cm
84
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
85
bull ISCHAEMIC COLITISo Disorder caused by vascular insufficiency and bleeding
into the wall of the colon
o Preferentially involves the splenic flexure and the proximal descending colon
o Radiographically difficult to identify unless some intra luminal gas present
o Submucosal thickening with cresentic margins (thumb-printing)
o Involved area acts as a functional obstruction so proximal parts frequently distended
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
86
Ischemic colitis
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
87
PSEUDOMEMBRANOUS COLITIS
bull Common cause of antibiotic associated diarrohea
bull Clostridium difficile is usually involved
bull 13 rd cases shows positive findings on plain films
bull Colonic dilatation (32 )
bull Thumb printing thickened haustra abnormal mucosa (18 )
bull Untreated cases develops toxic megacolon and subsequent perforation
bull Associated small bowel dilation(20 ) ascites (7 ) may be seen
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
88
extensive haustral thickening (arrows) in a patient with pseudomembranous colitis
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
INFLAMMATORY DISORDERS
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
90
ACUTE APPENDICITIS
o Commonest acute surgical condition in the developing country
o Radiological signs-
Appendix calculus(05-06)cm Right lower quadrant mass indenting the caecum Dilated caecum Sentinel loop Widening blurring extraperitoneal fat line Scoliosis concave to the right Right lower quadrant haze Gas in the appendix
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
91
Appendicoliths are found in 10 of cases Its presence with pain in rt lower abdomen is highly suggestive of diagnosis
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
ACUTE CHOLECYSTITISbull Gall stones- in 20 only
bull Porcelein GB
bull Right hypochondrial mass due to enlarged gall bladder
bull Duodenal ileus
bull Ileus of hepatic flexure of colon
bull Gas within biliary system
92
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
93
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
94
ACUTE PANCREATITISbull Acute pancreatitis refers to acute inflammation of the pancreas
bull Causesbull Gallstones (most common)bull Alcohol abuse usually chronicbull Trauma more often penetratingbull Drug-inducedbull Anatomic abnormalitybull ERCP-inducedbull Infectious especially post-viral in childrenbull Vasculitisbull Idiopathic
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
95
ACUTE PANCREATITISbull Pathological changes are edema
hemorrhegelnfarctionfat necrosis followed by acute suppuration
bull Inflammatory processes tend into gastro colic ligament or paraduodenal areas- follow route of mesentry or extend out of peritoneum into perirenal space
bull Lot of radiological signs described but many are of little value in diagnosing individual cases
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
96
Plain film changes-
Chest x-ray-o Left sided pleural effusiono Splinting of left hemidiaphragmo Basal atelactasis
Abdominal film-o Duodenal ileuso Gasless abdomeno ldquocolon cut offrdquo signo Renal ldquohalordquo signo Absent left psoas shadowo Indistinct mottled shadowingo Sentinel loopo Intrapancreatic gas-abscess enteric fistula
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
97
The abrupt termination of gas within the proximal colon at the level of the radiographic splenic flexure usually with decompression of the distal colon
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
98
A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process The sentinel loop sign may aid in
localizing the source of inflammation
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
99
bull Later stages- pancreatic pseudocyst visible on plain film as large soft tissue mass
bull Pleural effusions mainly left sided
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
INTRA-ABDOMINAL ABSCESSbull Abscesses are collections
of pus that may displace adjacent structures
following their involvement by inflammatory process
bull Usually of soft tissue density on plain filmsbut frequently contain gas
bull Recognition of small gas bubbles outside bowel lumenunchanged in position on sequential films strongly so abscess 100
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
101
SUBPHRENIC ABSCESS
bull Nearly always occurs as a result of surgery
bull Chest X-ray - raised hemidiaphragm
- basal consolidation
- pleural effusion
Abdominal radiographs
- gasfluid level
- Irregular gas pocket
- Scoliosis towards the lesion
- localised paralytic ileus
Fluoroscopy- decrease diaphragmatic movement
- locates small gas-fluid level irregular gas pockets
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
INTRA-ABDOMINAL ABSCESS
Subhepatic abscess
bull A gasfluid level is seen beneath the right hemidiaphragm Note also the pleural effusion The abscess developed in a 45-year-old woman following a cholecystectomy
102
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
103
PARACOLIC ABSCESS
Lies close to the site of causative lesion
Diverticulosis and appendicitis are the commonest causative lesions
Soft tissue mass often containing gas bubbles and displacing colon ndash mc radiographic presentation
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
104
INTRAMURAL GAS
bull Gas within walls of hollow viscus
bull Classification
Cystic pneumatosis
Interstitial emphysema
Gas-forming infections
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
105
Cystic pneumatosis (Pneumatosis cystoides intestinalis)
bull Cyst like collections of gas in the walls of the hollow viscera
bull Left half of colon most frequently involved- pneumatosis coli
bull Plain abdominal radiographs-
Gas containing cyst
Pneumoperitoneum
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
106
INTERSTITIAL EMPHYSEMA
bull Linear gas in single or double streaks is found in the bowel wall
bull Common site- stomach amp colonbull Associated with toxic megacolon
Emphysematous gastritis- - contracted stomach - mottled lucency in the left upper abdomen
Emphysematous cholecystitis -occurs in absence of gallstones
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
107
Necrotizing enterocolitis- in premature babies
- generalised bowel distension
- bowel wall thickening
- pneumatosis
- associated with gas in the portal vein
Emphysematous cystitis-
- linear gas streaks and gas cysts within
the wall of the urinary bladder amp within
the lumen of the bladder
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
108
Linear or curvilinear lucencies are seen in the walls of the bowel
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
109Emphysematous gastritis Emphysematous cysytitis
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
110
Emphysematous Cholecystitis
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
111
OTHER CONDITIONS
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
112
RENAL COLIC
bull A high proportion of patients with acute ureteric obstruction due to calculus present with an acute abdomen
bull About 90 of renal stones are radio-opaque Uric acid stones especially may be missed
bull Plain abdominal radiograph-
Calculi (90) Meteorism Paralytic ileus Urinoma- soft tissue mass with loss of renal and psoas outines
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
113
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
114
Emphysematous Pyelonephritis
bull Recognised by gas bubbles within the kidney or linear gas beneath the renal capsule
bull Occurs in uncontrolled Diabetes or Obstructive uropathy
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
115
ACUTE GYNAECOLOGICAL DISORDERS
bull Torsion of an ovarian cyst- pelvic mass
bull Dermoid cyst- contains calcification teeth or fat
bull Ruptured ectopic pregnancy-
- pelvic mass
- paralytic ileus
- free intrapeitoneal fluid
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
116
Pop corn like cauliflower ndash uterine leiomyoma
Ovarian teratoma
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
117
Abdominal Aortic Aneurysm
bull Presents as acute abdomen with shock and simulated renal colic
bull Curvilinear calcification seen on AP radiograph but is best detected on a lateral view
bull Calcified walls of aorta can allow measurement of lumen
bull AAA if over 3 cm AP diameter
bull Ultrasound and CT are much more sensitive
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
118
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
119
ASCITESbull Only large amount of Ascites can be recognized on
abdominal radiograph
bull Signs
1Obliteration of the inferior edge of the liver
2Widening of the distance between the flank stripe and ascending colon Normal is 2-3 mm
3 Fluid accumulation in the pelvis
4 centrally located bowel loops with bulging flanks
5 Ground glass appearnace_ requires large amount of fluid
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
120
Supine view of the abdomen shows central displacement of the loops of bowela uniform grayness to the abdomen loss of any definition of the edge of the spleen or liver and displacement of the bowel loops out of the pelvis all suggestive of ascites
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
121
Hydatid cyst in the Liver
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
FOREIGN BODY
122
IRON TABLETS BUTTON BATTERIES
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
123
bull PAEDIATRICS
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
124
DUODENAL ATRESIA JEJUNAL ATRESIA
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
125
NECROTIZING ENTEROCOLITIS
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
126
Conclusion
bull Following the history and clinical examination plain film radiographs have been one of the first and most useful methods of further investigation
bull Plain picture continues to be initial imaging modility in acute abdomen particularly in perforation and intestinal obstruction
bull In cases where definite diagnosis cannot be reached further evaluation with USG and CT scan is required
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-
127
- Plain picture in acute abdomen Moderator- Dr (Prof) R K Go
- INTRODUCTION
- Plain Radiography
- Basic radiographs
- Slide 5
- Chest Conditions that mimic acute abdomen
- Slide 7
- TECHNIQUE standard projection
- Supplemental projections
- ADDITIONAL PROJECTIONS
- RADIATION EXPOSURE
- Slide 12
- NORMAL GAS PATTERN
- Slide 14
- NORMAL FLUID LEVELS
- Slide 16
- DISEASE ENTITY
- Slide 18
- CAUSES
- RADIOGRAPHY
- Signs in pneumoperitoneum
- Slide 22
- Signs of pneumoperitoneum of supine radiograph
- Gas in subhepatic space
- Doges cap sign
- Slide 26
- Riglerrsquos sign
- Falciform ligament visualization
- Football sign
- Slide 30
- Double Bubble Sign
- The Cupola Sign
- The Triangle Sign
- CONDITIONS SIMULATING PNEUMOPERITONEUM
- CONDITIONS SIMULATING PNEUMOPERITONEUM (2)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (3)
- CONDITIONS SIMULATING PNEUMOPERITONEUM (4)
- Slide 38
- GASTRIC DILATATION
- GASTRIC VOLVULUS
- Slide 41
- SMALL BOWEL OBSTRUCTION
- Clinical Presentation of SBO
- SMALL BOWEL OBSTRUCTION (2)
- PLAIN RADIOGRAPH
- Slide 46
- Slide 47
- Slide 48
- GASLESS SMALL BOWEL OBSTRUCTION
- PARALYTIC ILEUS
- PARALYTIC ILEUS (2)
- Slide 52
- Slide 53
- STRANGULATING OBSTRUCTION
- Slide 55
- GALLSTONE ILEUS
- Slide 57
- INTUSSUSCEPTION
- INTUSSUSCEPTION (2)
- Slide 60
- Slide 61
- SMALL INTESTINAL INFARCTION
- Slide 63
- Slide 64
- Large Bowel Obstruction
- Etiology
- LARGE BOWEL OBSTRUCTION-types
- LARGE BOWEL OBSTRUCTION-types (2)
- LARGE BOWEL OBSTRUCTION-types (3)
- Large bowel Volvulus
- CAECAL VOLVULUS
- Slide 72
- PLAIN RADIOGRAPH (2)
- Even though there is considerable distension of the caecumone
- SIGMOID VOLVULUS
- SIGMOID VOLVULUS-findings
- Slide 77
- Slide 78
- COLONIC PSEUDO OBSTRUCTION
- DISTINCTION BETWEEN SMALL AND LARGE BOWEL
- Acute colitis
- Slide 82
- TOXIC MEGACOLON
- TOXIC MEGACOLON (2)
- Slide 85
- Slide 86
- PSEUDOMEMBRANOUS COLITIS
- Slide 88
- Slide 89
- ACUTE APPENDICITIS
- Slide 91
- ACUTE CHOLECYSTITIS
- Slide 93
- ACUTE PANCREATITIS
- ACUTE PANCREATITIS (2)
- Plain film changes-
- Slide 97
- Slide 98
- Slide 99
- INTRA-ABDOMINAL ABSCESS
- SUBPHRENIC ABSCESS
- INTRA-ABDOMINAL ABSCESS (2)
- PARACOLIC ABSCESS
- INTRAMURAL GAS
- Cystic pneumatosis (Pneumatosis cystoides intestina
- INTERSTITIAL EMPHYSEMA
- Slide 107
- Slide 108
- Slide 109
- Slide 110
- Slide 111
- RENAL COLIC
- Slide 113
- Emphysematous Pyelonephritis
- ACUTE GYNAECOLOGICAL DISORDERS
- Slide 116
- Abdominal Aortic Aneurysm
- Slide 118
- ASCITES
- Slide 120
- Slide 121
- FOREIGN BODY
- Slide 123
- Slide 124
- Slide 125
- Conclusion
- Slide 127
-