IMAGING IN ACUTE ABDOMEN

Acute onset abdominal pain that develops over a period of hours is a common clinical
scenario requiring emergency admission. The conditions that present in this fashion are
numerous, many of which require an emergency surgical intervention. The diagnosis in
these patients has to be established quite early and appropriate treatment whether in the
form of medications or a surgical operation has to be performed expediently as many of
these conditions are life threatening. Moreover most of these conditions present with
almost similar symptoms of abdominal pain, vomiting, abdominal distension etc., causing
a great deal of diagnostic confusion. Although a careful history taking and examination
are very important in arriving at or more often short listing the possibilities, they need a
confirmation by one or more imaging methods in order to plan and execute the right
treatment. Hence the importance of urgent imaging in acute abdominal pain. The various
modalities like Plain x-Rays, ultrasound (Sonar), CT scans, MRI and scintigraphy
(nuclear medicine imaging) are all used at present .The relative merits and limitations of
various imaging techniques are outlined below:
How do plain x-rays help in diagnosing acute abdominal pain?
Plain x-rays are commonly used and are usually the first imaging modality as they are
easy to perform, have a low radiation dose and can give vital information. An upright
chest film may show free air that indicates a perforation of the hollow viscus like
stomach or intestine (see Fig1). Frank pneumonia can present with abdominal pain and a
plain chest film can be diagnostic (Fig2.)

Fig2
Fig1

x-ray picture of Lt.Basal

Pneumonia presenting
With abdominal pain

Kidney stones are picked up in about 90% of cases. Small Bowel Obstruction is depicted
by dilatation of small bowel loops and presence of fluid levels. However plain x-rays
cannot diagnose important conditions like appendicitis, cholecystitis (inflamed gall
bladder), Pancreatitis (inflamed pancreas) etc.
What conditions can be diagnosed by Ultrasound (Sonar)?
Ultrasound is an extremely popular method of imaging in acute abdomen as it is simple
and can be performed with ease and quickly .Theres no radiation exposure and can be
repeated over some time to show the interval change as in continuing bleeding .The so
called FAST (Focused abdominal sonar for Trauma) is used routinely in patients
following injuries to detect internal bleeding. Ultrasound is the modality of choice in
diagnosing Ac. Cholecystitis (Inflamed Gall bladder) and gall bladder stones. Moreover
conditions like kidney stones , blocked kidneys, Liver cysts, abscesses(collections of
pus).,Collections of fluid or pus inside the abdomen ,ovarian cysts in females are readily
picked up on Ultrasound(U/S).U/S is particularly useful in pregnancy and in other
conditions in which CT or MRI cannot be performed safely eg. Kidney failure.
Ultrasound can diagnose Ac.appendicitis but this requires considerably experienced
radiologist, otherwise CT is the modality of choice. U/S is not very helpful in obese
people and when theres gaseous abdominal distension as ultrasonic waves do not pass
easily through fat and air. U/S of the gall bladder requires the patient to be fasting as after
meals the contracted gall bladder is not easily seen on U/S.

Whats the advantage of CT abdomen over U/S? What are its limitations?
CT abdomen is the most valuable imaging modality as it not only images the solid organs
like liver ,spleen ,pancreas ,kidneys etc.but shows the bowel as well and the state of
abdominal blood vessels. CT is very helpful in diagnosing a large variety of abdominal
emergencies and influences the plan of management in about 60% of cases. Moreover
unlike U/S its not operator dependant .Advanced software technology has made it
possible to construct the three dimensional images of different organs. CT improves
diagnostic accuracy. The disadvantage is that it involves a lot of radiation exposure.
Radiation dose of one abdominopelvic CT equals to that of 100 chest x-rays. The
estimated risk of cancer death for those undergoing CT is 12.5/10000 for each pass of CT
scan through the abdomen. So theres a strong case against CT without a justified
reason .Usually a dye (Contrast Medium) is required to be injected into the blood to
delineate the structure of various organs (Contrast Enhanced CT). This contrast has toxic
effect on the kidneys and cannot be used in patients having compromised kidney
function. This is a limitation of CT. Patients who are taking Metformin(Glucophage) for
diabetes also have to stop the medication 48 hrs before contrast injection particularly
patients with compromised kidney function to prevent Metformin associated lactic
acidosis(MALA).Allergy to contrast is rare but asthmatics need to receive steroids before
CT to minimize the effects of any such allergic reactions.
Is MRI done in acute abdomen .How does it compare with other imaging methods?
MRI is performed but not as commonly as CT.

Image resolution is good, theres no x-ray exposure and can be performed on pregnant
patients. However it is more time consuming than CT .There is no scientific evidence
regarding the usefulness of MRI in acute abdomen as compared to CT. Therefore it is
used in special circumstances .It cannot be performed in patients having pacemakers and
prosthesis made of magnetic metals and people having fear of living in enclosed spaces
(Claustrophobia).

What is Nuclear Medicine imaging (Scintigraphy)?

Here substances (Radionuclides) which release rays like gamma rays, beta rays etc. are
injected and the organs are imaged where these get accumulated to pickup abnormal
conditions. These are done in Nuclear medicine departments as many of these compounds
are isotopes .Commonly used scans are V/Q scans to detect Pulmonary embolism(block
of artery of the lung), HIDA scan for detecting acute cholecystitis (inflammation of gall
bladder)Tcm Labeled RBC scan for gastrointestinal bleeding.
The major problems with these nuclear medicine scans are that they are time consuming,
require a special team of personnel to be called in to perform them and have poor

localization .For these reasons they are not considered appropriate as modality of choice
and are rarely performed.

Fig

showing HIDA Scan

As we have seen imaging is an important part of the management of acute abdomen.

There is no doubt that an accurate diagnosis not only helps in the correct surgical
management but also avoids unnecessary surgeries and hence their complications. Plain
x-rays of the abdomen ,U/S and CT scans complement each other in arriving at the
diagnosis .MRI and scintigraphy are used rarely in acute abdomen in special
circumstances.