IMAGING OF

ACUTE ABDOMEN
 INTRODUCTION
• “Acute abdomen” is a term used to encompass a
spectrum of surgical, medical and gynecological
conditions (intra-abdominal process), ranging from the
trivial to the life threatening, which require hospital
admission, investigation and treatment
• Assesing the patient with an acute abdomen need many
investigation including laboratory test and imaging
studiesplain photo, US, CT and contrast study .
 Imaging studies
• Plain abdominal films: erect chest film, supine, and
upright (optional:left lateral decubitus)
• Abdominal US
• Abdominal CT
Plain abdominal film
Table 1 Plain abdominal film

Left Lateral Decubitus

Erect Chest Supine Abdomen Erect Abdomen
Abdomen
Best for abdominal
detail: Organs, bones
Best for free air under For air-fluid levels and For free air and air-
and joints,
right diaphragm little else fluid levels
calcifications, fat and
gas pattern
 Supine abdomen
• Looking for
• Gas pattern
• Calcifications
• Soft tissue masses
• Substitute – none
 Erect abdomen
• Looking for
• Free air
• Air-fluid levels
• Substitute – left lateral
decubitus
 Etiologies
• Hemorrhage
• GI perforation
• Bowel obstruction
• Inflammatory disorder
• Circulatory impairment
 HEMORRHAGE
• Intraperitoneal hemorrhage
• Rupture:
• hepatoma
• aortic anuerysm
• ectopic pregnancy
• ovarian bleeding
• Gastrointestinal hemorrhage
• Upper GI hemorrhage
• Duodenal ulcer
• Gastric ulcer
• Hemorrhagic gastritis
• Esophageal or gastric varices ect.
• Lower GI hemorrhage
• Bleeding of colon cancer
• Ischemic colitis ect.
 Imaging
• US finding
• Free peritoneal fluid accumulation on the Morison’s pouch, the
rectovesical pouch, the pouch of Douglas, and the bilateral
subphrenic space
• Abdominal CT
• CTgold standars for specific intraabdominal pathology
US
CT
 Gastrointestinal
perforation
• Gastrointestinal perforation are serious disorder requiring
rapid diagnosis and treatment
• Since they may be severe enough to produce septic or
hypovolemic shockrapid decision-making for urgent
laparotomy is crucially important
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● Radiological appearances:

Plain abdominal film:

- Oval/linear collection of gas:
♠ Subhepatic space
♠ Morison’s pouch
♠ Beneath the diaphragm (the cupola sign)
♠ In the centre of the abdomen over a fluid
collection (the football sign)
♠ Fissure for ligamentum teres
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- Small triangular collections of gas between loops of

bowel.

- Visualisation of the outer as well as the

inner wall of a loop of bowel (Rigler’s sign).

USnot as sensitive as plain radiography for

demonstating pneumoperitoneum

CT:
Free gas over the liver, anteriorly in the mid
abdomen, & in the peritoneal recesses.
Plain photo
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Pneumoperitoneum

Fissure for ligamentum teres Rigler’s sign

Football
sign
 BOWEL OBSTRUCTION
• The first investigation when bowel obstruction is
suspected is the supine plain abdominal X-ray, together
with an erect chest film if perforation is a possibility
• Occasionally, all the dilated bowel may be fluid fill and not
visible on a plain X-ray and further imaging with contrast
studies, CT or US may be needed to demonstrate dilated
bowel
• Imaging aims: to confirm the presence of bowel
obstruction, define the level obstruction, identify the cause
and detect complications such as perforation
 Table 2. Cause of bowel obstruction

Extrinsic Bowel wall Intraluminal

Adhesions Neoplasia Intussusception

Hernia Strictures:inflamma Foreign body

tory,
radiation,chemical
Volvulus Intestinal Gallstone ileus
ischaemia

Inflammation/abscess

Malignant infiltration
(e.g. peritoenal
deposits)
 Small-Bowel Obstruction:

 Etiology:
- Adhesions due to previous surgery
- Strangulated hernias
- Volvulus
- Gallstone ileus
- Intussusception
- Neoplastic, etc.
 Small bowel obstruction (SBO)
• Plain filmprimary investigation of choice
• Plain film of SBO:
Dilated small bowel loops:
• Tend to the central
• Numerous
• 2.5-5.0 cm diameter
• Have a small radius of curvature
• Valvulae conniventes: thin, numerous, and
extend right across the bowel
• Do not contain solid faeces
• Multiple fluid levels on the erect film
• String of beads sign on the erect film
• Absent or little air in the large bowel
SBO: valvulae conniventes
SBO:stepladder pattern
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Small-Bowel Obstruction:
String of beads sign
 29

♥ Ultrasound:

- Dilated fluid-filled loops of small-bowel

obstruction.
- Assessment of the peristaltic activity.
US:SBO
• CT sign of SBO
• Small bowel loops measuring>2.5 cm in diameter
• Identifiable focal transition zone from prestenotic dilated bowel to
post-stenotic collapsed bowel loops
CT:SBO

Fluid-filled loops Bowel calibre change

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LARGE-BOWEL OBSTRUCTION
• Etiology:
- Neoplastic (benign & malignant)
- Volvulus (caecal & sigmoid), etc.

• Radiological appearances:
Depends on the state of competence
of the ileocaecal valve:
 Large bowel
obstruction (LBO)
 Plain-film signs of LBO:
› Dilated large bowel loops which:
 Tend to be peripheral
 Few in number
 Large: above 5.0 cm diameter
 Wide radius of curvature
 Haustra: thick and widely separated and may or may not extend
right across the bowel (compare these features with the valvulae
conniventes found in the small bowel
 Contain solid faeces
 • Caecum maybe dilated
• Small bowel may be dilated
• Contrast enema maybe helpful:
• To differentiate pseudo-obstruction and may be indistinguishable on
plain film from mechanical of obstruction
• To localized the point of obstruction
• To diagnose the cause of obstruction e.g. tumour, inflamatory mass
Contrast-enema
Plain film:Sigmoid volvulus

coffee bean sign

Plain film: Caecal Volvulus
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PARALYTIC ILEUS
 Generalised paralytic ileus:
 ●Etiology:
 - Peritonitis
 - Post-operative
 - Hypokalaemia
 - General debility or infection
 - Drugs: morphine
 - Congestive cardiac failure, renal colic, etc.

 ●Radiological appearances:
- Both small & large-bowel dilatation
- Horizontal-ray films: multiple fluid levels
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PARALYTIC ILEUS
 INFLAMMATORY
DISSORDERS
• Acute appendicitis
• Acute pancreatitis
• Acute cholecystitis
• Abdominal absces
• Peritonitis
 Acute appendicitis
• Abdominal x-ray (AXR)
• Non-specific finding
• Approximately 10%a calcified appendicolith
• US
• Generally, the normal cannot be defined with US, clear
visualization of the appendix is suggestif of inflammation
• Swollen, non compressible appendix greater than 7 mm in
diameter with a target or bulls-eye configuration is produced by
the hypoechoic dilated appendiceal lumen
• Assymetrical wall thickening due to phlegmonous infiltration, an
appendicolith with acoustic shadowing
• US finding
• Echogenic hallo form by omental tissues draped over the appendix
• Free fluid in the culdesac
• Atony in the terminal ileum with compression US
• CT finding
• 90% diagnostic accuracy to detect acute appendicitis
• With the good contrastfilling of the terminal ileum and
the cecum (oral contrast given 1 hour before
examination)
• Tubular structure 4 mm to 20 mm in diameter with a
thickened wall that enhance after administration IV
contrast medium
• Pericecal fluid collection and calcified appendicolith
Plain film:apendicolith
CT
 Acute pancreatitis
 Severity of acute
pancreatitis
rangesmild edema
with minimal symptoms
to a severe necrotizing
process that culminates
in multiple organ failure
 US and CT most
precisely define the
anatomic extent of the
lesions and the detect
local complications
 Imaging
• Plain filmsno significant plain film findings in up to two-
thirds of patients wih acute pancreatitis
• Plain-film signs may include:
• Paralytic ileus in the left upper quadrant
• Generalized ileus
• Loss of left psoas outline
• Separation of greater curve of stomach from tranverse colon
• CXR signs that may be seen include:
• Left pleura effusion
• Atelectasis of left lower lobe
• Elevated left hemidiaphragm
• US finding:
• The acutely inflamed pancreasenlarged with
decreased echogenicity and blurred irregular margin
• Fluid collection are seen as hypoechoic areas
• US can be used to guide aspiration and the drainage
procedures, and for follow up
• CTimaging investigation of choice for acute
pancreatitis, and is particularly useful for the
following:
• Confirmation of the diagnosis
• Identification of necrotic gland tissue
• Diagnosis of complication
• Guidance of interventional procedures
• CT signs of acute pancreatitis include:
• Diffuse or focal pancreatic enlargement with decreased density and
indistinct gland margins
• Thickening of surrounding fascial planes e.g. left paranephric fascia
• Acute fluid collections, most commonly related to pancreas though
also in the lesser sac and in the left pararenal space
• Phlegmon appears as an irregular mass spreading along fascial
planes and can be quite extensive
• Abscess
• Pseudocyst
US
CT
 Acute cholecystitis
 Approximately 85%-90% of
cases with acute cholecystitis
(AC) develop as a
complication of cholelithiasis
 Conversely, approximately
10%-20% of patients with
gallstone will require surgery
for complication, usually
cholecystitis, within 15 years
after their stone disease is
diagnosed
 Acalculous cholecystitis
account for 5%-15% of cases
of acute cholecystitis
(immunocompromize,
critically ill,iatrogenic,
congenital etc)
 Imaging
• Plain filmsinsensitive for acute cholecystitis
• Plain films signnonspesific and include:
• Gallstone (only seen in 10%)
• Soft tissue mass in the right upper quadrant due to distended
gallbladeer
• Paralytic ileus in the right upper quadrant
 Imaging
• USinvestigation of choice for suspected acute
cholecystitis
• US signs of acute cholecystitis include:
• Gallstones:hyperechoic lesions with acoustic shadowing
which are mobile
• Thickening of gallbladder wall to greater than 4 mm
• Hypoechoic gallblader wall due to oedema
• Surrounding fluid or localized fluid collection
• Distended gallbladder
• Localized tenderness to direct probe pressure
• CTscanning contribute little to diagnosis of
cholecystitis
• CTinvestigation of complicatiosbiliary or
pericholecystic abscess
US:Acute cholecystitis
US:Acute cholecystitis
US:Acute cholecystitis
 Peritonitis
• Peritonitisan inflammatory or suppurative reaction of the
peritoneum to direct irritation
• Cause:
• Inflammatory
• Infectious
• Ischemic
Exudation,
Hematogenous,
Contiguous extension,
Iatrogenic manipulation
 Imaging
• Plain abdominal radiograph: cannot provide
specific
• Air-fluid Levels
• Stones
• Ascites
• Eggshell calcification
• Air in Biliary tree.
• Obliteration of psoas-shadow in retro- peritoneal
disease
• Right lower quadrant sentinel loops in acute
appendicitis
• USnonspecific
• Abdominal CT
• CT signs 
• Ascites (free or encapsulated)
• Infiltration of the omentum and/or mesentery
• Thickening of the parietal peritoneum

• Angiography for ischaemia, hemorrhage

 66

ACUTE COLITIS
• Acute inflammatory colitis
• Toxic megacolon
• Pseudomembranous colitis
• Ischaemic colitis
 67

Acute inflammatory colitis

• Plain film can assess :
♠ the extent of the colitis
♠ the state of mucosa:
It can be assessed from :
- the faecal residue:
In left-sided disease, the proximal limit of
faecal residue will indicate the extent of
active mucosal lesion.
- the width of the bowel lumen
- the mucosal edge
- the haustral pattern
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Toxic megacolon
• A fulminating form of colitis with transmural inflammation,
extensive & deep ulceration & neuromuscular
degeneration.
• Involve the transverse colon
• Ro. Findings:
Mucosal islands (=pseudopolyps) & dilatation (8 cm)
• Common complication:
Perforation in the sigmoid & peritonitis
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Toxic megacolon
 70

Ischaemic colitis
 Etiology:
Vascular insufficiency & bleeding into the wall
of the colon.
 Sudden onset of severe abd.pain in the early hours
of the morning, followed by bloody diarrhoea.
 In middle-aged & elderly patients.
 The wall of splenic flexure & descending colon is
greatly thickened→ thumb printing (plain films).
 The right side of colon is frequently distended.
Pathophysiology of mesenteric ischaemia
 72

Ischaemic colitis

thumb printing
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