Imaging Diagnostic for

Acute Abdomen
Hartono YS
Radiology Department Airlangga Medical Faculty/ Dr Soetomo General Hospital
Surabaya
Today’s Topic

 Introduction
 Causes
 Imaging Modalities
 Imaging Findings
 Summary
Introduction

 The 'acute abdomen' is a clinical condition characterized by severe abdominal

pain.

 The differential diagnosis of an acute abdomen includes a wide spectrum of

disorders, ranging from life-threatening diseases to benign self-limiting
conditions.
 Indicated management may vary from emergency surgery to conservative.

 Misdiagnosis may easily result in delayed necessary treatment or unnecessary

surgery.
 On the basis of the results of this clinical evaluation and laboratory
investigations, the clinician will consider imaging examinations to help establish
the correct diagnosis.

 Imaging plays an important role in the treatment management of patients

because clinical evaluation results can be inaccurate.
Causes
Imaging Modalities

 Conventional radiography, ultrasonography (US), and computed tomography

(CT) are frequently used in the diagnostic work-up of patients with acute
abdominal pain.

 Magnetic resonance (MR) imaging are also available, but they are used far less
frequently for initial diagnostic workup.

 Therefore, the diagnostic value of imaging modalities is often expressed in terms

of the change in diagnoses and the change in clinical management.
Conventional Chest and Abdominal
Radiography
 Commonly the initial imaging examination performed.

 Widely available, can be easily performed, and is used to exclude major illness
such as bowel obstruction and perforated viscus.

 Includes supine, LLD and upright conventional abdominal radiography and

upright chest radiography.
 The accuracy in the diagnostic work-up of patients with acute abdominal pain are
not convincing.

 Treatment management changes after review of the radiographs were reported

for only 4% of patients.

 In the majority of patients, further imaging is warranted after conventional

radiography.
 Despite evidence in the literature that conventional radiography has no diagnostic
value in patients suspected of having acute appendicitis.

 Conventional radiography has been reported to have good accuracy in select

cases, such as those of patients suspected of having bowel obstruction, perforated
viscus, urinary tract calculi, or foreign bodies.

 The use of conventional radiography might justifiably be limited to these select

cases only.
US Examination

 Imaging modality commonly used in the diagnostic work-up of patients with

acute abdominal pain.

 Widely available, easily accessible, a real-time dynamic examination that can

reveal the presence or absence of peristalsis & depict blood flow, and possible to
correlate US findings with the point of maximal tenderness.

 Wide availability, lower costs, and absence of radiation exposure are advantages
of US.
 The most common US is the graded-compression procedure
 interposing fat and bowel can be displaced or compressed by means of gradual
compression to show underlying structures.
 if the bowel cannot be compressed, the non compressibility itself is an indication of
inflammation.
 Unique diagnostic information or confirmed one of the differential diagnoses in
65% of patients.
 Correct diagnosis after clinical evaluation increased from 70% to 83% after
evaluation with US.
CT Examination

 Use of CT in the evaluation of acute abdominal pain has increased to a large

extent.

 In the United States, the number of CT examinations performed for this indication
increased 141% between 1996 and 2005.

 Related to the high accuracy of CT in the diagnosis of specific diseases (eg,

appendicitis and diverticulitis) and the rapid patient throughput that can be
achieved with use of multidetector CT scanners.
 The CT technique generally involves scanning of the entire abdomen after
intravenous administration of an iodinated contrast medium.

 The intravenous administration of contrast material facilitates good accuracy—

with a positive predictive value of 95% reported for the diagnosis of appendicitis.

 CT was significantly more sensitive than US (89% vs 70%, P .001).

 In one study, the accuracy of the clinical diagnosis made before CT was performed
improved from 71% to 93% after CT was performed.
 Exposure to ionizing radiation is a disadvantage of CT and the effective radiation
dose for abdominal CT is approximately 10 mSv (conventional radiography is
approximately 0.1–1.0 mSv).

 The use of intravenous contrast medium is a drawback in patients with imminent

renal insufficiency.
Imaging Findings
Normal appendix

• US : as a blind-ending non
peristaltic tubular structure
arising from the base of the
caecum.
• CT : an air-containing non-
distended appendix
• Maximum outer diameter of
6-7 mm, with non inflamed
surrounding fat.
Acute appendicitis
Mesenteric lymphadenitis

• Mesenteric lymphadenitis is a
common mimicker of
appendicitis.
• It is the second most common
cause of right lower quadrant
pain after appendicitis.
• It is defined as a benign self-
limiting inflammation of
right-sided mesenteric lymph
nodes without an identifiable
underlying inflammatory
process, occurring more often
in children than in adults
Acute diverticulitis

• US : A hypoechoic thickened
diverticulum is surrounded
by hyperechoic inflamed fat.
• CT : Fat stranding and focal
thickening of the colonic wall
in an area with diverticula
Diverticulitis

• An inflamed caecal
diverticulum with regional
colonic wall thickening
Acute Cholecystitis

• US : non compressible
('hydropic') GB with a
thickened wall in the region
of maximum tenderness.
• CT : enlarged GB with
edematous thickening of its
wall and some regional fat-
stranding can be found.
Acute cholecystitis
Acute cholecystitis

• A thickened gallbladder wall

and an obstructing gallstone
Empyema GB
Liver abscess
Small Bowel Obstruction

• Distended small-bowel loops

and air-fluid levels
Intussusception

• Obstructive ileus.
• Distended small bowel loops,
but part of the small bowel
and the whole colon is non
distended
Large bowel obstruction

• Apple-core stenosis of the

sigmoid colon caused by
colorectal cancer
• Proximal pre stenotic
dilatation of descending
colon and caecum
Perforated viscus
Perforated viscus

• Diverticulitis of the sigmoid

colon with a contained
perforation and infiltration of
pericolic fat.
Perforated viscus

• Free intraperitoneal air

• Wall thickening at the
duodenal bulb and evidence
of perforation
Perforated viscus
Perforated viscus
Bowel Ischemia

• Portal venous phase CT :

superior mesenteric vein
occlusion
Acute pancreatitis

• Pancreas surrounded by fat

stranding


Ureter stone
Malignant mass of the
kidney
Ectopic pregnancy
Summary

 Imaging plays an important role in the treatment management of patients with

acute abdominal pain because clinical evaluation results can be inaccurate.
 Radiography is rarely indicated for the examination of patients with acute
abdominal pain, with the exception to exclude major illness such as bowel
obstruction and perforated viscus.
 US and CT are imaging modalities commonly used in the diagnostic work-up of
patients with acute abdominal pain.
 CT was significantly more sensitive than US.
 US has advantages include wide availability, lower costs, and absence of radiation
exposure.