Joel P. Thompson, M.D., MPH, Dhana Selvaraj, M.D., Refky Nicola, D.O.
Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY
Diverticulitis Thick-walled diverticulum with adjacent infiltrative changes; short or long Medical. Surgical intervention may be
-segment bowel wall thickening. Abscesses may form. necessary for medically refractory cases,
large abscesses, and fistula formation.
Mesenteric Adenitis Cluster of 3 or more right lower quadrant lymph nodes >5 mm in shortest Medical.
diameter, without identifiable cause.
Neutropenic Colitis Distended and thick-walled cecum, infiltrative changes, pericolic fluid. Medical. High risk of bowel perforation; CT
(Typhlitis) may be used to monitor treatment response.
Meckels Blind-ending tubular structure in the right lower quadrant arising from Surgical resection.
Diverticulitis the distal ileum; infiltrative changes, wall thickening, and
hyperenhancement may be seen.
Epiploic Appendagitis Pericolic fatty mass with surrounding inflammatory changes, most Medical.
commonly in the transverse and descending colon. A central thrombosed
vein may be identified.
Omental Infarct Pericolic fatty mass with surrounding inflammatory changes, most Medical.
commonly in the right hemiabdomen between the colon and the anterior
abdominal wall.
Genitourinary/Gynecological
Urolithiasis Obstructing calculus with hydronephrosis +/- hydroureter. Medical, unless calculus large.
Pyelonephritis Imaging most often normal. May see striated nephrogram or delayed Medical.
contrast excretion on CT. US may show loss of corticomedullary
differentiation.
Ovarian Torsion US: Enlarged and heterogeneous ovary; may be midline. May see Surgical detorsion.
reduced or absent venous flow.
Hemorrhagic Ovarian US: Finely septated fishnet pattern of fibrin bands; retractile clot or None.
Cyst avascular peripheral nodule non-acutely.
Pelvic Inflammatory Dilated tubular structures representing Fallopian tubes with wall Medical.
Disease thickening. Ipsilateral ovary may be enlarged.
Ectopic Pregnancy Non-visualization of an intrauterine pregnancy with positive beta-hCG. Medical but may require surgical
US: May see yolk sac, detect fetal heartbeat, or see ring of fire sign of intervention.
peripheral hypervascularity around adnexal mass.
Table 1. Overview of gastrointestinal and genitourinary causes of right lower quadrant pain.
A B
A B C
Figure 2. Acute Appendicitis.
Axial MDCT image with oral contrast (A) demonstrates an enlarged appendix, measuring up to 14 mm in diameter (white arrow), wall
thickening, and adjacent inflammatory changes with phlegmon formation (yellow arrow). Surgical pathology demonstrated appendicitis.
Longitudinal ultrasound images in a different patient (B) demonstrate an enlarged appendix, measuring up to 10 mm, that is
noncompressible, consistent with appendicitis. Ultrasound image at a different level in the same patient demonstrates a hyperechoic focus
with posterior shadowing, consistent with an appendicolith (C).
Infectious Enterocolitis
Infectious enterocolitis can present clinically similar
to appendicitis, particularly if caused by pathogens
such as Yersinia, Campylobacter, or Salmonella, which
may cause ileocecitis.12,14 The imaging findings on
MDCT involve a long-segment circumferential wall
thickening with homogenous enhancement, usually
without stranding of the adjacent fat. In addition,
mesenteric adenopathy and surrounding free fluid
may be present.
Neutropenic Colitis (Typhlitis) and sigmoid colon, diverticula may also form along the
Neutropenic colitis has a similar presentation of ascending colon and present with right-sided
acute appendicitis, but occurs particularly in abdominal pain. Diverticulitis is thought to be caused
immunosuppressed patients with leukemia, post- by microperforation of a diverticulum.
transplantation status, or acquired immunodeficiency.
Mucosal damage secondary to both infection and
ischemia is typically confined to the cecum and
ascending colon.16 A prompt diagnosis is necessary
due to the high risk of perforation. MDCT findings
includes a distended cecum with circumferential wall
thickening, peri-colonic infiltration, and peri-colic fluid
(Fig. 5).6,16,17 Pneumatosis can also be present.6
Treatment includes bowel rest and antibiotics. MDCT
is used to follow the progression of therapy, as
evidenced by the improvement in the thickening of
cecal wall.6 The extent of cecal wall thickening into
the ascending colon as well as the patients history
helps to differentiate neutropenic colitis from cecal Figure 6. Diverticulitis.
wall thickening associated with appendicitis. 83-year-old woman with acute leukocytosis and right lower
quadrant abdominal pain. Axial MDCT image with oral
contrast shows diverticular wall thickening with infiltration
of the adjacent fat (white arrow) in the ascending colon just
above the cecum, consistent with acute diverticulitis.
Epiploic Appendagitis
Epiploic appendages are small fat protrusions
arising from the serosal surface of the colon; these are
not usually identifiable on cross sectional imaging. Figure 8. Epiploic appendagitis.
Torsion of an epiploic appendix causes vascular 63-year-old man with a history of diverticulitis presents with
occlusion, ischemia, and acute onset abdominal pain. right-sided abdominal pain that is worse with movement
and deep breathing; no leukocytosis. Axial MDCT image
An inflammatory process within the abdomen can also demonstrates a focus of inflammatory changes just superior
extend to the epiploic appendages, causing secondary to the transverse colon with a high attenuation central dot
epiploic appendagitis. Since the number and size of (white arrow), consistent with epiploic appendagitis.
Pyelonephritis
Pyelonephritis is most commonly associated with an
ascending genitourinary tract infection and is a clinical
diagnosis; often times, the sonographic and MDCT
findings are normal.27 However, imaging is useful in
excluding complications, such as abscess formation,
emphysematous pyelonephritis (typically in diabetics
and immunocompromised patients), or
Figure 9. Omental infarct. xanthogranulomatous pyelonephritis. Findings of
72-year-old man presents with 3 days of right lower
pyelonephritis on CT include nephromegaly due to
quadrant pain. Axial MDCT demonstrates infiltrative
changes with central fat density between the cecum and the edema, a striated or delayed nephrogram, perinephric
anterior abdominal wall (white arrow), consistent with the fat stranding, and wall-thickening and enhancement of
appearance of omental infarct. The appendix was normal. the renal collecting system (Fig. 11).28 Delayed
appearance of the calices may also be seen; however,
since pyelonephritis is often bilateral, comparison
between the two kidneys may not be helpful.
A B
A B C
Figure 13. Hemorrhagic cyst.
28-year-old woman with acute right lower quadrant and pelvic pain. Transvaginal ultrasound with Doppler of the right ovary (A) shows a
complex cyst (arrow) with fine reticular pattern and echogenic areas; no internal vascularity is seen. Transvaginal ultrasound image of the
same patient superior to the uterus (B) demonstrates hemoperitoneum with debris (arrow) from rupture of the hemorrhagic cyst.
Pregnancy test was negative, excluding the possibility of ectopic pregnancy. Follow up transvaginal ultrasound at a 2 week interval (C)
shows decrease in the size of the cyst with changes in the internal architecture from retraction of the clot (arrow).
cysts, tumors, enlarged corpus luteum, or ovulation vascularity. Echogenic fluid can be seen in the cul-de-
induction for infertility. Ultrasound is performed as the sac in cases of ruptured cyst (Fig. 13B). In
first line of imaging, demonstrating increased size (>4 indeterminate cases, MRI may be performed to show
cm in greatest diameter) and volume of the involved the blood products, or a follow-up sonogram can show
ovary, heterogeneous appearance from edema and change in the echo pattern or resolution of the cyst
hemorrhage, and typically an associated cyst or mass (Fig. 13C). Correlation with menstrual history is
(Fig. 12). Multiple small follicles can be seen in the helpful as these typically occur in the luteal phase.
periphery of the enlarged ovary due to displacement Treatment is typically supportive.
from stromal edema, described as string of pearls
sign.29 On Doppler, venous flow is often reduced or
absent, but this is less sensitive than gray-scale Pelvic Inflammatory Disease
findings. The arterial blood flow may be dampened or Acute pelvic inflammatory disease can present with
absent as well, but this finding is variable due to dual fever and lower abdominal pain, similar to that of
blood supply (ovarian artery and uterine branch acute appendicitis. Neisseria gonorrhoeae and
artery). Comparison with the normal unaffected ovary Chlamydia trachomatis are the most commonly
is often helpful. Treatment is surgical detorsion and implicated organisms. Patients may have additional
removal of necrotic tissue. symptoms relating to the urogenital tract, including
dysuria, dyspareunia, and vaginal discharge. On
transvaginal ultrasound, enlarged and heterogeneous
Hemorrhagic Ovarian Cyst appearing ovaries, thickened adnexal structures,
Hemorrhage into an ovarian cyst can cause abrupt dilated fallopian tubes containing simple fluid or
lower abdominal or pelvic pain. Hemorrhagic cysts echogenic contents, and pelvic fluid collections can be
have a thin wall with posterior through transmission. seen (Fig. 14). CT findings include enlarged ovaries
The internal architecture depends on the stage of with abnormal enhancement, dilated and fluid filled
evolution of the hemorrhage, from anechoic fluid in fallopian tubes with enhancing wall from pyosalpinx,
the acute stage to echogenic clot in later stages, giving stranding of the pelvic fat, enhancement of the
rise to varied sonographic appearances.30 The most adjacent peritoneum, and pelvic abscesses in
common appearance is a finely septated fishnet advanced cases (Fig 14C).31 Similar findings can be
pattern resulting from fibrin bands (Fig. 13A). seen involving the endometrium and cervix in
Additional findings include a fluid-debris level, a endometritis and cervicitis. Treatment is supportive,
nodule from retracting clot, or a completely echogenic including antibiotic therapy.
lesion. These typically do not show internal
A B
Figure 14. Tubo-ovarian abscess.
26-year-old woman with acute right lower quadrant pain.
Transvaginal ultrasound image with Doppler (A) shows an
enlarged, complex appearing, and hyperemic right ovary (arrows)
from tubo-ovarian abscess. Transvaginal ultrasound with Doppler
(B) reveals thickened and hyperemic left adnexal structures
(arrow) with adjacent fluid collection. Axial post-contrast CT
image of the pelvis (C) shows a heterogeneously enhancing right
ovary (long arrow) and thickened adherent left adnexal
structures with pyosalpinx (short arrow). The patient improved
on antibiotics.
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