EMERGENCY SURGERY
CT remains the workhorse in the radiology department e it is
Imaging and radiological
interventions for the acute
abdomen
Nikhil K Patel
Andrew Hatrick
Abstract
The acute abdomen presents a diagnostic challenge encompassing a
wide range of possible pathologies that may have substantial overlap
in their clinical presentation. The choice of imaging modality and char-
acteristic appearances of frequently encountered causes of an acute
abdomen will be discussed. Interventional radiological techniques
and their importance in supporting the surgical management of a pa-
tient will also be covered.
Keywords Abdominal aortic aneurysm; appendicitis; cholecystitis;
diverticulitis; embolization; mesenteric haemorrhage; mesenteric
ischaemia; pancreatitis; perforation
Introduction
The acute abdomen encompasses a range of pathologies from
those that are self-limiting and require little intervention to
potentially life-threatening conditions. Accurate and prompt
diagnosis is critical and relying solely on clinical history, physical
examination and biochemical workup may only identify a small
percentage of cases.
Imaging plays a vital role in the diagnosis and subsequent
management of patients presenting with an acute abdomen.
Plain film radiography is usually the first investigation organized
due to its ease of acquisition e although its role is now limited
due the wide availability and diagnostic superiority of computed
tomography (CT).
Ultrasound is commonly used to assess the solid abdominal
viscera and, to some extent, the alimentary canal. It is highly
user dependent and hampered by large body habitus and excess
bowel gas. Its advantage lies in the lack of ionizing radiation and
its potential functional assessment of vascular structures. It is
also a dynamic tool eliciting sites of tenderness that can be
correlated with the sonographic appearances. Intravenous
microbubble contrast enhanced ultrasound is largely employed
to characterize solid organ lesions but emerging applications
include assessment of non-acute inflammatory bowel disease
and aortic stent grafts for endoleaks.
Nikhil K Patel BSc MBBS is a Specialist Registrar at Frimley Park
Hospital NHS Foundation Trust, Frimley, UK. Conflicts of interest:
none.
Andrew Hatrick MA MB Bchir MRCP FRCR EBIR is an Interventional
Consultant Radiologist at Frimley Park Hospital NHS Foundation
Trust, Frimley, UK. Conflicts of interest: none.
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accurate, reproducible, widely available and relatively quick to
obtain which makes it ideal in the acute setting. Intravenous
contrast is usually timed to the portal venous phase for optimal
assessment of the solid abdominal viscera. Coverage starts a little
above the hepatic dome to the proximal thigh. This allows
assessment of the lung bases as infection here can mimic upper
quadrant pain. Multiphasic imaging is possible depending on the
clinical question at hand.
Non-contrast CT is ideal for assessment of renal tract calculi
or in cases where contrast is contraindicated (e.g. renal failure or
contrast allergy). Unlike ultrasound, a paucity of intra-abdominal
fat inhibits the assessment of the abdominal viscera due to lack
of fat planes, which help differentiate tissues. Enteral, oral or
rectal contrast in the acute setting tends not to be practical but
can help differentiate bowel loops from intra-abdominal collec-
tions. In specific cases, enteric contrast is used outside of the
acute setting as a problem-solving tool e for example, delin-
eating fistulous tracts or anatomy after complex bariatric surgery.
Suggested CT protocols are listed in Table 1 that may be tailored
to individual cases in order to achieve a high diagnostic outcome.
Ionizing radiation remains the biggest draw back to CT fol-
lowed by contrast nephropathy e particularly in patients with
multiple comorbidities. The average effective dose of a CT
abdomen and pelvis with contrast is 8e10 mSv while a plain
chest radiograph is 0.02 mSv and an abdominal radiograph is 0.1
e1 msV. For comparison, the average background radiation dose
in the UK is 2.7 mSv/year and a transatlantic flight is 0.08 mSv.
Magnetic resonance imaging (MRI) in the acute setting is
limited by its availability and lengthy time to image. It provides
excellent soft tissue differentiation with no ionizing radiation and
may be considered in select patient groups, for example, children
and pregnant women presenting with possible appendicitis.
Compared to CT, it is has a lower spatial resolution, a longer
scanning time and is more prone to artefact.
Appendicitis
Acute appendicitis is a common clinical diagnosis in the setting
of acute right iliac fossa pain. Diagnosis is often a clinical chal-
lenge as the presentation is often atypical and the list of differ-
entials diagnoses is wide and includes many mimics such as
diverticulitis, pelvic inflammatory disease, inflammatory bowel
disease and renal colic to name a few. While the gold standard
for diagnosis remains pathological confirmation after appendec-
tomy, improved diagnostic imaging techniques and availability
has reduced the number of negative appendectomies.
Ultrasound is widely used as a first-line imaging modality in
the paediatric population, given the absence of ionizing radia-
tion, and in the young female population with a high suspicion of
gynaecological pathology. There are inherent limitations with
ultrasonography due to artefact from bowel containing gas that
can obscure a retrocaecal appendix. Published literature on the
diagnostic sensitivity and specificity ranges from 44% to 100%
and 47% to 99% respectively.1 This is due to a multitude of
reasons not limited to operator skill, obesity and anatomic
variants.
Visualization of the appendix is best approached with a linear
high-frequency transducer using the graded compression
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 EMERGENCY SURGERY

Appropriate CT protocols for various suspected underlying pathologies

Indication Phase of intravenous contrast Enteric contrast

Acute abdominal pain, Portal venous phase Oral water prior to scan if possible
e.g. appendicitis/collection (65e70 seconds)
Post-small bowel surgery, Portal venous phase 20 ml water-soluble contrast in 1 litre water,
e.g. leak/fistula/stricture (65e70 seconds) 1.5 hours before scan
Post-colonic surgery, Portal venous phase 20 ml water-soluble contrast in 1 litre water,
e.g. leak (65e70 seconds) instilled via large Foley catheter and enema
giving set
Bariatric patients post-surgery, Portal venous phase 10e20 ml water-soluble contrast in 200 ml
e.g. leak/stricture (65e70 seconds) water, 30 minutes before scan
Mesenteric angiogram, Pre-contrast, arterial phase (25e35 seconds) None
e.g. acute haemorrhage and portal venous phase studies. Axial,
coronal and sagittal reformats

Table 1

technique; this displaces overlying gas-filled bowel loops during
continuous imaging. Typically the normal appendix appears as a
compressible, layered structure. The sonographic appearances
that indicate appendicitis are a non-compressible, blind ending,
non-peristalsing luminal structure that has diameter of greater
than 6 mm (outer wall to outer wall) and a wall thickness of
greater than 3 mm (Figure 1). Mural hypervascularity, peri-
appendicial fluid and echogenic mesenteric fat also contribute to
the diagnosis.2
CT is superior to ultrasound in diagnostic accuracy and its use
is now widespread in the diagnosis of appendicitis. The major
disadvantage is an increased lifetime risk of cancer with some
studies estimating the development of one radiation induced
cancer for every 620 males and 470 females who undergo CT
with contrast at age 20.3 It is for this reason that CT is largely
employed as a second-line investigation following a negative
or equivocal ultrasound in patients with ambiguous clinical
symptoms. Advances in dose reduction technology and individ-
ual scanning protocols, such as focused CT and low-dose ac-
quisitions, can mitigate the risk to some degree although are not
widely adopted.
Specific CT findings of acute appendicitis include appendiceal
thickening greater than 6 mm, which should be interpreted in the
clinical context and presence of other findings, wall thickening
greater than 3 mm and mural hyper-enhancement often seen as a
bull’s eye sign due to submucosal oedema. The presence of an
appendicolith is not diagnostic as an isolated finding although it
may have a prognostic importance: its presence is associated
with an increased risk of perforation.4
Additional peri-appendiceal findings include mesenteric fat
stranding, thickening of the lateral conal fascia, extraluminal fluid,
phlegmon or abscess formation. These findings can be seen in other
pathological processes involving the right lower quadrant and are
not specific to appendicitis. In addition, the sensitivity of these signs
may be decreasing due to imaging earlier in the disease process.5
The major complication of appendicitis, if allowed to prog-
ress, is perforation secondary to a necrotic or ischaemic wall
leading to peri-appendiceal abscess formation. This is commonly
managed with percutaneous drainage if greater than 4 cm fol-
lowed by delayed appendectomy.
MRI is reserved pregnant patients e where it is the most
common non-obstetric surgical condition during pregnancy e
and the paediatric population. There is no ionizing radiation and
although the safety of MRI to the fetus has not been proved, no
teratogenic or carcinogenic effects have been described in the
literature.6 There is wall thickening, which appears hypointense
on T1-weighting imaging and hyperintense on T2-weighted im-
aging. T2-weighted sequences also demonstrate hyperintense
signal where there is peri-appendiceal mesenteric fat stranding.
Intravenous gadolinium contrast material is not required and is
contraindicated in the first trimester.

Cholecystitis

Figure 1 Ultrasound depicting a thick-walled, blind-ending, non- Ultrasound is the modality of choice in the diagnosis of acute
compressible luminal structure in keeping with an inflamed appendix. cholecystitis. It is able to depict gallbladder wall thickening and

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oedema, pericholecystic fluid and hypervascularity. Potential

complications such as gallbladder perforation may be recognized
early by the presence of intramural fissuring which necessitates
prompt intervention.
Potential aetiologies such as gallstones and complications
including biliary tree dilatation are readily depicted with ultrasound.
Gallstones appear as mobile hyperechoic foci with posterior
acoustic shadowing (Figure 2). Identifying the presence of gall-
stones within the biliary tree is important given the sequelae of
ascending cholangitis, acute pancreatitis and obstructive jaundice.
Sonographic evidence of biliary tree obstruction include a
common bile duct (CBD) diameter of greater than 7 mm and a
tram track appearance to the intrahepatic biliary ducts. CT may
provide additional information such as intraluminal gas and
intraluminal membranes suggesting emphysematous cholecys-
titis and gangrenous cholecystitis. It is also useful in cases where
the clinical presentation presents a diagnostic dilemma or where
obesity and gaseous bowel distension limits the use of
ultrasound.7
Magnetic resonance cholangiopancreatography (MRCP) is
superior to ultrasound in depicting cystic duct and gallbladder Figure 3 Tubogram following cholecystostomy. Contrast outlines
multiple gallstones with subsequent emptying into the common bile
neck calculi as well as ruling out distal CBD stones e it is usually
duct and duodenum.
employed after ultrasound has failed.
Plain radiography is of limited use as only 15% of gallstones
are radio-opaque and the identification of pneumobilia has his- procedure in ITU patients with unexplained sepsis who are at
torically been used to identify a gallstone ileus. risk of acalculous cholecystitis.
A PC also affords access for non-surgical procedures such as
Radiological interventions for cholecystitis dissolution of stones, percutaneous cholecystolithotomy and
Percutaneous cholecystostomy (PC) is a radiologically inserted endoscopic lithotripsy.
drain performed under local anaesthetic using the Seldinger
technique (Figure 3). Transhepatic and transperitoneal routes are Pancreatitis
described, although a transhepatic route may reduce the risk of Imaging with CT is recommended to confirm the diagnosis and
bile leak post-drain removal. identify complications of acute pancreatitis; particularly as the
PC is indicated in critically ill patients with acute cholecystitis, clinical signs and biochemical markers can be non-specific and
cholangitis and biliary obstruction where reducing the infective correlate poorly with disease severity. The optimum time frame
burden is necessary until an elective cholecystectomy can be for imaging ranges from within 24 hours by some authors, in
performed. It may also be used as a diagnostic and therapeutic order to facilitate ERCP and sphincterotomy within 72 hours, to 3
e7 days post-onset of symptoms which offers a better assess-
ment of the degree of pancreatic necrosis.8 The role of ultrasound
is limited to detecting the likely aetiology of gallbladder and CBD
stones as well as peritoneal fluid collections as it cannot assess
pancreatic necrosis.
In the acute setting, on a portal venous phase CT, the
pancreas appears oedematous and there is peri-pancreatic fat
stranding (Figure 4). Peri-pancreatic fluid collections may be
present as well as complications such as portal and splenic vein
thrombosis. Pancreatic necrosis appears as areas of absent
enhancement. A three-phase CT (unenhanced, parenchymal
phase (40 seconds) and portal venous phase) may be used in the
initial assessment of acute pancreatitis; this can depict calcifica-
tions consistent with chronic pancreatitis and offer optimum
assessment of the pancreatic parenchyma.

Radiological interventions for pancreatitis

Figure 2 Ultrasound demonstrating an oedematous gallbladder with
an echogenic calculus (between crosshairs) and posterior acoustic
shadowing consistent with acute calculous cholecystitis.
Ultrasound- or CT-guided intervention is reserved for those patients
who develop pancreatic abscesses, pseudocysts or areas of liq-
uefied necrosis. Access depends on the target area and may
require transgastric, transduodenal, transhepatic, retroperitoneal or
transperitoneal routes. The insertion of multiple large-bore drains

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Figure 4 Axial CT demonstrating an oedematous pancreas with peri-
pancreatic fluid and stranding.
into the retroperitoneum allows irrigation and potential access for
percutaneous retroperitoneal endoscopic necrosectomy. Chronic
symptomatic pseudocysts can be drained into the stomach via a
radiologically placed transgastric cystogastrostomy stent.
Diverticulitis
Acute diverticulitis on CT characteristically appears as a segment
of thickened bowel with accompanying diverticulae and peri-
enteric stranding. Colorectal cancer can appear similar with the
presence of a short segment of involvement and luminal mass
further raising the possibility. A segment greater than 10 cm is
more commonly seen in acute diverticulitis while the presence of
mesocolic lymph nodes can be seen in both conditions. It is
therefore prudent to directly visualise the colonic mucosa after
the acute episode has resolved to exclude malignancy.9
Complications of acute diverticulitis include perforation,
bowel obstruction, abscess and fistulous communication; this is
best appreciated on CT (Figure 5). The Modified Hinchey
Figure 5 Coronal CT showing fistulous connection between thickened
bowel, secondary to diverticulitis, and the urinary bladder which con-
tains air.
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classification is a well-recognized severity and management al-
gorithm that utilizes CT.
Perforation
Perforation of an abdominal viscus may be secondary to a variety
of underlying aetiologies e the presentation can be variable
rending it difficult to diagnose on purely clinical grounds. Im-
aging has a vital role in confirming perforation as well as iden-
tifying the causative process and aiding in the surgical approach.
The most common cause is due to gastroduodenal peptic ulcer
disease or diverticulitis with carcinoma and bowel ischaemia
occurring less frequently.9
The key to establishing whether a perforation has occurred
is the identification of extraluminal air. Erect chest and abdom-
inal radiographs are traditionally the first imaging the patient
may receive. A crescent of increased transradiancy below the
hemi-diaphragms indicates intra-abdominal free air; this should
not be confused with interposed large bowel in the hep-
atodiaphragmatic space that can mimic pneumoperitoneum. The
distinguishing feature is the presence of haustra. This can be seen
in Chilaiditi syndrome where interposed large bowel associated
with abdominal pain can mimic pneumoperitoneum and hence
perforation.
On abdominal supine radiographs free air manifests as: tri-
angles between closely opposed loops of bowel, the continuous
diaphragm sign, football sign and Rigler’s sign (Figure 6). Rigler’s
sign describes the sharp delineation of bowel wall due to gas
either side, similarly the falciform ligament become visible due to
air outlining the structure. In cases of duodenal and sigmoid
perforation, free air collects in the retroperitoneum and may
outline the kidneys and psoas muscle.
CT is far superior to plain radiography in detecting small
amounts of intra-abdominal free air. It has the added advantage
of being able to identify the likely site of perforation and
possible complications, such as abscess formation. Clues as to
the site of perforation include a concentration of locules of air,
Figure 6 Erect radiograph demonstrating right subdiaphramatic free
air and Rigler’s sign in the left upper quadrant of the abdomen in
keeping with perforation.
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focal bowel thickening and bowel wall defect. Free air collect-
ing around the liver and stomach indicates a gastroduodenal
site whereas free air located in the pelvis and mesocolic regions
suggests the colon or appendix as the likely site of perforation
(Figure 7).
Radiological interventions in intra-abdominal
collections and perforations
Image-guided percutaneous drainage forms part of the routine
care in an ever-increasing number of surgical patients with a
wide range of indications. Complicating collections in patients
who are unsuitable or unfit for surgery may be treated with
radiological guided drainage; this also includes patients who
require temporization until definitive surgical treatment, for
example, patients who are haemodynamically unstable.
The choice of ultrasound- or CT-guided intervention depends
on the location, size and presence of gas within a collection that
can be difficult to differentiate from adjacent gas containing
bowel on ultrasound. In practice, superficial fluid collections are
readily characterized and amenable to ultrasound-guided
drainage whereas posteriorly located and retroperitoneal collec-
tions may require CT guidance. A direct percutaneous route that
avoids major intra-abdominal structures is desirable however
transhepatic and transgastric routes, for example, may be
required. It is paramount to plan access in order to take the
shortest available route and cross as few intervening structures
as possible e all whilst ensuring a convenient location for the
patient.10 A multi-modality approach may also be considered
where the initial percutaneous puncture into the collection is
performed under ultrasound with further manipulation under
real time fluoroscopy using a variety of guidewires and catheters
in order to gain deeper access.
Deep pelvic collections, which may at first appear difficult if
not impossible to access, may still be amenable to drainage via a
CT guided para-sacral or ultrasound-guided transrectal approach.
Similar techniques are used routinely to aspirate ovarian cysts
using a transvaginal ultrasound probe.
Further imaging post-drain insertion may be indicated in
order to assess residual volume, need for re-siting or upsizing
the drain and to identify any post-drain complications or new
collections.
Figure 7 Axial CT demonstrating intraperitoneal free air anterior to the
liver. The falciform ligament is outlined.
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Small bowel obstruction
Imaging in small bowl obstruction (SBO) aims to confirm or
clarify the diagnosis, propose likely aetiology, comment on de-
gree of obstruction (e.g. partial or complete) and to identify any
complications.
Plain radiography still has an important role in the diagnosis
of SBO, particularly in the emergency department where it can
identify patients who may require further imaging. The config-
uration of dilated bowel points to the likely location of the
obstruction: small bowel is located centrally within the abdomen
and large bowel is arranged peripherally. The mucosal fold
pattern in small bowel, known as the valvulae conniventes, ex-
tends all the way across the lumen whereas the haustra in large
bowel do not. Bowel obstruction should be suspected when the
diameter exceeds 3 cm for small bowel and 5.5 cm for large
bowel. Features of SBO on an erect abdominal radiograph
include air-fluid levels and small pockets of gas trapped between
the valvulae conniventes along the superior wall giving the
‘string of pearls’ sign. Dilated small bowel that is completely fluid
filled appears as a gasless abdomen. The plain radiograph may
also give clues as to the underlying cause of obstruction; for
example, bowel extending below the inguinal line suggests an
inguinal hernia.
Intravenous contrast-enhanced CT of the abdomen and pelvis
in the portal venous phase is routinely obtained in cases of
suspected bowel obstruction. Diluted oral contrast may be
administered in order to help identify subacute or intermittent
obstruction. Identification of fluid filled dilated small bowel loops
with a clear change in calibre or transition point with collapsed
bowel distal to this is the hallmark of diagnosis. Faecal-like
matter may form immediately proximal to the site of obstruction
and can help identify the transition point, this is termed the
‘small bowel faeces sign’.
CT unlike plain radiography can identify the underlying aeti-
ology of the transition such as adhesions, volvulus, hernia or
neoplasm (Figure 8). The most common cause of SBO is adhe-
sions in the setting of previous surgery and while they are not
usually visible on CT, features such as kinking or extraluminal
compression may be apparent.
Obstruction at the hernia orifices is also a frequent cause of
SBO and these areas should be scrutinised on imaging. Internal
hernias are more challenging to identify and may only manifest
as a cluster of bowel loops, mesenteric engorgement or
displacement of the mesenteric vessels11 (Table 2).
Complications of SBO include strangulation when a loop
twists on its mesentery leading to arterial occlusion. Subsequent
ischaemia, necrosis and ultimately perforation occur if this is left
untreated. CT features include circumferential bowel wall
thickening, asymmetric enhancement and pneumatosis.
Large bowel obstruction
Large bowel obstruction is commonly caused by colorectal can-
cer, sigmoid volvulus and diverticulitis.
Plain film radiography will demonstrate peripherally located
dilated loops of bowel. If the ileocaecal valve is competent there
will be no small bowel dilatation e this increases the risk of
perforation due to excessively high intraluminal pressures. It is
possible to make a number of diagnoses on plain radiography.
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 EMERGENCY SURGERY
Figure 8 Coronal CT demonstrating small bowel obstruction second-
ary to incarcerated right inguinal hernia.
Sigmoid volvulus occurs with the twisting of the sigmoid mes-
entery and appears as a large dilated loop of bowel arising from
the pelvis. It usually extends up to the level of T10 in the right
upper quadrant giving the classic ‘coffee bean’ sign. Less com-
mon is the caecal volvulus that extends from the right iliac fossa
to the left upper quadrant. It can be difficult to differentiate the
two due to overlap in the appearances. A key distinguishing
feature is that a sigmoid volvulus will result in dilatation of the
remainder of the large bowel proximal to the transition whereas a
caecal volvulus will not.
Volvulus on CT appears as dilated loops of sigmoid with a bird-
beak appearance of the afferent and efferent segments. The
mesenteric vessels may also be involved giving a whirl-like pattern
to the engorged vessels radiating from the twisted bowel (Figure 9).
Internal hernia types
Left paraduodenal C Most common type
(Fossa of Landzert) C Bowel prolapses through aperture behind
the fourth part of the duodenum
C Encapsulated cluster of small bowel loops
at the duodenojejunal junction between
stomach and pancreas
C May indent posterior wall of stomach and
depress transverse colon
Right paraduodenal C Bowel herniates through defect in first part
(Fossa of Waldeyer) of jejunal mesentery inferior to transverse
segment of duodenum
Foramen of Winslow C Abnormal location of bowel loops in lesser
sac or high subhepatic space
Transmesenteric C Hernias of bowel through congenital or
acquired defect in mesentery or omentum
Table 2
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Figure 9 Axial CT demonstrating whirl-like configuration of the
mesenteric vessels in volvulus.
CT will also delineate the aetiology, level of obstruction and
complications of LBO. Large bowel greater than 5.5 cm and a
caecum greater than 10 cm proximal to a defined transition point
is in keeping with obstruction.
As CT captures the bowel in one moment in time, peristalsing
bowel may mimic a narrowing. Lack of pericolic stranding,
normal wall thickness and comparable luminal diameter distal
and proximal to the narrowing would support normal physio-
logical peristalsis. Grossly dilated large bowel without mechani-
cal obstruction in patients with obstructive symptoms should
raise the possibility of acute colonic pseudo-obstruction or
Ogilvie syndrome. This is usually seen in medical and surgical
patients with underlying conditions and can result in perforation.
Radiological interventions in obstruction
The treatment of bowel obstruction depends on the aetiology and
patient factors. In cases of acute pseudo-obstruction, supportive
management may suffice whereas mechanical obstruction may
require surgery. A sigmoid volvulus can be decompressed with a
flatus tube per rectum or flexible sigmoidoscopy.
Therapeutic oral water-soluble contrast, commonly gastro-
graffin, is used in patients not requiring immediate surgery. The
ionic, hyperosmolar contrast agent is thought to cause fluid shifts
from the extracellular space into the bowel lumen which in-
creases the pressure gradient across the obstruction. Bowel
content is diluted through this effect and allows easier passage
through the narrow lumen. While this does not reduce the need
for surgery, it can reduce hospital stay for patients who do not
require surgery.12
In patients with a short luminal stricture or obstruction, a
combined procedure involving radiologists and endoscopists may
be performed where a self-expanding endoluminal stent is placed.
This may provide symptomatic relief as a palliative procedure or
bridge to definitive surgery. Tumour ingrowth around and into
the stent may necessitate repeat stenting. Similarly, stents can be
placed in other areas such as the duodenum, stomach and
oesophagus in patients with strictures or tumour ingrowth.
Bowel ischaemia
CT has superseded mesenteric catheter angiography for the
detection of bowel ischaemia e the causes of which include
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 EMERGENCY SURGERY
arterial thromboembolism, venous occlusion and non-occlusive
ischaemia. The acquisition of an unenhanced sequence is use-
ful as it can identify vascular calcification and intramural hae-
morrhage. An arterial and portal venous phase CT is commonly
performed with the arterial phase used to assess for mesenteric
vessel patency. The portal venous phase allows assessment of
the mesenteric veins, bowel wall and solid abdominal viscera
(specifically organ infarction).
In mesenteric ischaemia, filling defects in the mesenteric
arterial and venous branches may be visualized; commonly
emboli lodge 3e10 cm from the origin of the superior mesenteric
artery or just beyond the middle colic branch. Bowel wall
thickening greater than 3e5 mm, while not specific, is an indirect
sign of ischaemia that may be secondary to haemorrhage or
oedema. Veno-occlusion usually results in prominent bowel wall
thickening due to venous congestion and subsequent haemor-
rhage. Arterial ischaemia on the other hand may actually result
in a thinner wall due to reduced in flow.13
Absent or diminished enhancement of the bowel wall is a
specific but not sensitive feature of acute ischaemia. This appears
as a halo or target sign. Dilatation of bowel occurs due to inter-
ruption of normal peristalsis and increased secretions. Other
signs of inflammation include stranding of the mesenteric fat and
ascites which if seen in the presence of ischaemia can indicate
transmural wall necrosis.
Pneumatosis cystoides intestinalis appears as focal mural
locules or expansive rims of gas. In the setting of ischaemia, this
is a sign of transmural infarction and is a poor prognostic factor if
associated with portal venous gas (Figure 10). This sign can also
be seen in asymptomatic patients with chronic obstruction pul-
monary disease or those on steroids.
Radiological interventions in ischaemia
In a select group of patients where early ischaemia is identified in
the absence of peritoneal signs, endovascular treatment may be
considered. This includes aspiration embolectomy, mechanical
thrombectomy, catheter-directed lysis and antegrade stenting.
Surgical laparotomy still remains the treatment of choice in
peritonitic patients and will be required in failed endovascular
cases, bowel necrosis or abdominal compartment syndrome.
Figure 10 Axial CT demonstrating rim-like appearance of pneumotosis
intestinalis with air tracking along the mesenteric vessels in bowel
ischaemia.
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Gastrointestinal haemorrhage
CT imaging is the favoured imaging modality in the investigation
of suspected gastrointestinal (GI) bleed where it separates pa-
tients who require catheter embolization to those with alterna-
tive diagnoses that may benefit from other treatment.
A triple phase CT (unenhanced, arterial phase and portal
venous phase) is vital in the assessment of suspected GI bleed.
An unenhanced scan allows characterization of any high-atten-
uation material that may be mistaken for contrast extravasation
on the arterial phase, the identification of vascular calcification
(which may mimic contrast within a vessel) and intraluminal
blood, which appears as hyper-dense fluid. Active haemorrhage
on the arterial phase CT appears as a jetlike linear, swirled or
pooled configuration of high density. CT angiography can detect
bleeds exceeding 0.3e0.5 ml/minute although it is important to
remember that even massive acute GI haemorrhage can be
intermittent and failure to detect active bleeding does not mean
cessation of bleeding.14 High-attenuation material visualized on
the post-contrast scan that was not present on the unenhanced
acquisition ultimately indicates GI haemorrhage.
The portal venous phase is largely used to assess the solid
abdominal viscera and can also identify active bleeding if
intermittent.
Radiological interventions in GI haemorrhage
Catheter angiography is able to detect rates of bleeding of 0.5 ml/
litre and is even more sensitive with selective angiography. It has
the advantage of also allowing immediate treatment. Extravasa-
tion of contrasts signifies a breach in arterial wall integrity
allowing contrast to flow into the bowel lumen, thus outlining
mucosal folds. The identification of pseudo-aneurysms, arterio-
venous fistulas, neovascularity and hyperaemia serve as indirect
signs of GI haemorrhage.
Once a bleeding site is identified, embolization may be per-
formed e the aim of which is to selectively reduce arterial inflow
to allow haemostasis while simultaneously maintaining vascu-
larization to prevent bowel infarct or ischaemia. The optimal
treatment relies on super selective catheterization of the feeding
vessel; this reduces the risk of non-target embolization. A vari-
ety of embolization materials exist including gelatine sponge
and particulate agents such as polyvinyl alcohol (PVA) and
microcoils.
Renal colic and obstructed urinary system
Unenhanced low-dose CT is the modality of choice in the iden-
tification of renal calculi with ultrasound playing a role in pa-
tients where ionizing radiation is of concern.
Diagnosis rests on the identification of a renal or ureteric
calculus. This will appear as a calcific focus on CT. Other signs
that may be present are hydroureter/hydronephrosis, if the cal-
culus is resulting in obstruction, and periureteric/perinephric fat
stranding, which may also be seen in infection (Figure 11). The
presence of fat stranding and a dilated collecting system without
the presence of a calculus may also represent a recently passed
stone.
Delayed excretory phase contrast-enhanced imaging is useful
in delineating the ureter if there is doubt as to whether a calcific
focus lies within the ureter, especially in thin patients where lack
7 Ó 2016 Published by Elsevier Ltd.
 EMERGENCY SURGERY

Figure 12 Axial CT of abdominal aortic aneurysm rupture with retro-

peritoneal haemorrhage displacing the right kidney anteriorly.

imaging protocol of choice with thin slices for multiplanar

reconstruction.
Figure 11 Coronal CT demonstrates left ureteropelvic junction calcu-
Rupture of an AAA results in retroperitoneal haemorrhage
lus with left hydronephrosis. Incidental right non-obstructing renal
calculus.
depicted as high-attenuation fluid in multiple compartments
including the perirenal and pararenal spaces (Figure 12). Intra-
peritoneal haemorrhage can occur if the site of rupture is ante-
of intra-abdominal fat poses a challenge. The urogram also al-
riorly located. On-going haemorrhage manifests as active
lows assessment for potential filling defects caused by neoplasia
contrast extravasation while signs of the rupture site include
or strictures.
discontinuity of the arterial wall itself or disruption of the asso-
Ultrasound is a quick and safe method of assessing the kid-
ciated calcification.
neys for hydronephrosis/pelvicalyceal obstruction or perinephric
abscess formation. Renal stones appear as echogenic foci with Radiological interventions in AAA rupture
posterior acoustic shadowing. Distal stones in the ureterovesical Endovascular aneurysm repair (EVAR) is now preferred over
junction can sometime be identified with a full bladder. Ureteric open surgical repair in patients with multiple risk factors and
jets can be demonstrated with Doppler flow, which if seen ex- suitable anatomy of the aneurysm (Figure 13). It is often a joint
cludes complete obstruction. endeavour between the interventional radiologist and vascular
A plain abdominal radiograph should be obtained if renal surgeon.
calculi are identified on CT in order to aid follow up. CT plays a crucial role in delineating anatomical factors in
guiding repair such as appropriate proximal and distal landing
Radiological interventions in an obstructed urinary
zones, length and angulation of the neck, relation to visceral
system
Percutaneous nephrostomy (PCN) is usually performed under
local anaesthetic using ultrasound with the patient in the prone
position. It is urgently indicated in an infected obstructed system
where the aim of drain insertion is to decompress the pelvicalyceal
system. This also provides access for therapeutic interventions
and diagnostic testing. Cases of obstruction and renal dysfunction
without sepsis is an acute indication but not urgent. Isolated
hydronephrosis is not necessarily an indication for nephrostomy
as its presence does not automatically equal obstruction.
It is common practice to wait until the resolution of sepsis
before antegrade ureteric double-J stents are inserted. Catheter
and guidewire manipulation during the acute phase may pre-
dispose the patient to a septic shower.

Abdominal aortic aneurysm (AAA)

Abdominal aortic aneurysms are true aneurysms that involve
irreversible dilatation of all three layers of the artery greater
than 1.5 times the normal diameter. The risk of rupture is
related to its size with aneurysms measuring between 5 and
5.9 cm having a 3e15% risk of rupture per year.15 Aortic
rupture is a surgical emergency and imaging serves to confirm
the diagnosis and guide treatment. Arterial phase CT is the Figure 13 Three-dimensional surface-shaded reconstruction demon-
strating an endovascular aneurysm repair stent graft.

SURGERY --:- 8 Ó 2016 Published by Elsevier Ltd.

Please cite this article in press as: Patel NK, Hatrick A, Imaging and radiological interventions for the acute abdomen, Surgery (2016), http://
dx.doi.org/10.1016/j.mpsur.2016.09.001
 EMERGENCY SURGERY
vessels and size of endograft required. Taking these factors into
account ensures successful deployment of an appropriate
endograft with extension of the limbs into the iliac arteries via
femoral access sheaths. Inadequate exclusion of the aneurysm
sac predisposes the patient to subsequent endoleaks and pres-
surization of the aneurysm sac.
Conclusion
Imaging plays a vital role in the diagnosis and management of
the acute abdomen and the choice of modality and protocol
should be directed to the clinical question at hand. The advan-
tages and disadvantages of each technique are important to un-
derstand in order to obtain maximum information with as little
risk to the patient. It helps identify patients who are amenable to
radiological guided interventions for both treatment as well as
bridges to definitive surgery. A radiographic and clinical findings. Am J Roentgenol 2006; 186:
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