Andras Palko - Acute Abdomen

8/18/2019 Andras Palko - Acute Abdomen

http://slidepdf.com/reader/full/andras-palko-acute-abdomen 1/61

Department of Radiology

CT School, Novi Sad, 2012

1

Role of imaging in the evaluation of theacute abdomen

Prof. András Palkó MD, PhD

Department of RadiologyFaculty of General Medicine

University of SzegedHungary





2

Definition

• Sudden onset of severe symptoms requiring emergency

medical or surgical treatment,– typically characterized by intensive abdominal pain

– may be associated with:• muscular defense• paralytic ileus or hyper- (retro-) –peristalsis• nausea, vomiting, meteorism, hiccups•

fever, collapse, shock





3

Potential causes

• perforation• obstruction• ischemia•

bleeding• infection

peritoneal irritation

GI paralysis & defanse musculaire





4

Acute abdomen – top 8

1. Acute appendicitis2. Acute cholecystitis3. Small bowel obstruction (SBO)4. Acute gynecological disease

5. Acute pancreatitis6. Renal colic7. Perforated peptic ulcer8. Acute diverticulitis

account for 90 % of patients referredto hospital





5

Role of imaging

• After stabilizing the patient’s condition rapid diagnosisand therapeutic decision is essential to minimizeprogression and reduce mortality.

•

Clinical presentation, history, and lab test results are toooften non-specific.• Imaging examinations are of utmost importance to

establish diagnosis.





6

What’s wrong? – clinical findings





8

• Cholecystitis– Calculous– Acalculous– Emphysematous

• Hepatitis• Liver abscess• Spontaneous rupture

of a hepatic neoplasm• Right-sided LB diverticulitis• Retrocecal appendicitis





9

• Acute pancreatitis• Duodenal ulcer• Bowel obstruction• Abdominal aortic

aneurysm





10

• Bowel obstruction– SBO

• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous

– LBO• Carcinoma• Volvulus• Diverticulitis

• Perforation• Peptic ulcer• Diverticulitis• Iatrogenic

• Bowel ischemia– Mesenteric artery

• Thromboembolism• Atherosclerosis• Dissection

– Mesenteric vein• Hypercoagulable• Neoplastic• Strangulation,

volvulus• Infectious

• Gastroenterocolitis

• Pseudomembranous colitis

• IBD• Ulcerative colitis• Crohn’s disease





12

• (history, physical examination and lab tests)

• plain X-ray examination– abdomen

• erect or decubitus• supine

– chest• ultrasound

• computed tomography

Diagnostic algorithm





13

What’s wrong? – imaging findings

• Pathological gas accumulation• Localized/diffuse fluid accumulation• Diffuse/segmental gas/fluid levels• Extravasation, leakage• Pathological circulation• Wall thickening (bull’s eye) • Compartment syndrome• Foreign body





14

Pathological gas accumulation

• Pneumoperitoneum– perforation– iatrogenic– per vaginam

•

Pneumoretroperitoneum– perforation– iatrogenic

• Bowel wall– pneumatosis– infarction– necrosis





16






17






18



•







19



•







20



•



Gellett LR et al: Emerg Med J 2002;19:480-481





21


• Biliary system– sphincter Oddi incompetence– postoperative– spontaneous fistula– emphysematous cholecystitis

• Portal vein– mesenteric infarction– air embolus– necrotizing enterocolitis

• Abscess





22




• Abscess





23




• Abscess





24


h l d





25


CT S h l N i S d 2012





26

Pathological gas accumulation –gasless abdomen

• Normal abdomen• Small bowel

obstruction/ischemia•

Ascites• Surgery (e.g. total

colectomy)• Gastroenteritis• Large abdominal mass

Thompson WM: AJR, 191:1093–1099, 2008

CT S h l N i S d 2012





27

Localized/diffuse fluid accumulation

• Ascites– cirrhosis– tumor– hypoalbuminaemia– portal hypertension– lymphatic obstruction

• Inflammation• Perforation• Abscess


CT School No i Sad 2012





28




CT School Novi Sad 2012





29









30









31

Diffuse/segmental gas/fluid levels

• Paralytic ileus

– Diffuse• peritonitis• gastroenteritis• abdominal pain• other (postoperative, drug

effect,electrolyte imbalance,pneumonia,retroperitoneal hemorrhage,etc.)

– Segmental (sentinel loop)• pancreatitis• cholecystitis• appendicitis,• diverticulitis• etc.






32


• Paralytic ileus

– Diffuse• peritonitis• gastroenteritis• abdominal pain• other (postoperative, drug

effect,electrolyte imbalance,pneumonia,retroperitoneal hemorrhage,etc.)

– Segmental (sentinel loop)• pancreatitis• cholecystitis• appendicitis,• diverticulitis• etc.






33


Paulsen SR, RadioGraphics, 26:641, 2006

• Obstruction

– Small bowel• Adhesion• Crohn’s • Neoplasm• Hernia• Radiation• Miscellaneous

– Large bowel• Carcinoma• Volvulus• Diverticulitis


http://radiographics.rsna.org/content/26/3/641/F11.large.jpg





34


• Obstruction






, ,

36


E M Anderson, Imaging 2006;18:198

• Obstruction






Department of Radiology37


www.nypemergency.org

• Obstruction








• Obstruction







Extravasation, leakage

• Perforation (see also pathologic gas/fluid accumulation)

• Bleeding– Endoluminal

(ulcer, tumor, inflammation, iatrogenic, etc)– Extraluminal

(aneurysm, tumor, iatrogenic, etc)– Parenchymal organ

(tumor, iatrogenic, etc)











Yoon W et al: Radiology 239:16-167, 2006

Detectable rate (arteriography): 0.5 – 1.5 mL/min


http://radiology.rsna.org/content/239/1/160/F3.large.jpg






Pathological circulation

• Arterial– thromboembolism (MI, rheumatic

heart disease, atrial fibrillation,etc.)

– arteriosclerosis– dissection– heart failure– others (iatrogenic, idiopathic,

strangulation/volvulus, septicemia,extrinsic mass, etc.)

• Venous– thrombosis– others (extrinsic mass, iatrogenic ,– strangulation/volvulus, etc.)

Kirkpatrick IDC et al: Radiology, 229:91-98, 2003












Shih MCP et al AJR 2007; 188:462-471


http://www.ajronline.org/content/vol188/issue2/images/large/02_05_1168_05a_cmyk.jpeg

http://www.ajronline.org/content/vol188/issue2/images/large/02_05_1168_15a_cmyk.jpeg










McMahon MA et al: Radiographics, 30:445-460, 2010


http://api.ning.com/files/py5E2iOfdI-Or5itqW*YJrmM7zkEPihOmTRkgOIT53viKRsAvOoKhZHybxknwByYduznK1ldufAB9fNxJxkAkeJSCRn3G9MM/RadswikiAortic_dissection_type_B_005.jpg










Okino Y et al: Radiographics, 21:1475-1490, 2001






Wall thickening•

Infarction, ischemia• Intramural hematoma• Inflammation

– epiploic appendagitis– Groove pancreatitis

• Infection– appendicitis– sigmoiditis– typhlitis (neutropenic colitis)– pseudomembranous colitis

(clostridium difficile)– others (TBC, amebiasis, campylobacter,

shigella, etc.)• Neoplasm

Rha SE et al: RadioGraphics, 20:29-42, 2000







Wall thickening

Dibbad R et al: The Internet Journal of Radiology, 12/1, 2010

•










Wall thickening

Noah Gudel, DO; Lisa M. Rock, MD, Medscape 2008

•










•






Wall thickening





Wall thickening•









Foreign body

• Accidental/intentional/iatrogenic• Endoluminal/extraluminal• W./w.o. perforation

Maglinte DDT: Radiology, 236:763-767, 2005






Abdominal compartment syndrome

• Increased intraabdominalpressure

• Various clinical conditions (massivehemorrhage and inflammation, severe gutedema, intestinal obstruction, ascites underpressure)

• Decrease in venous return,perfusion to the intra-abdominalorgans critically reduced

• Imaging (CT):– Round-belly sign - Abdominal

distention with increased (>0.80)sagittal-to-transverse diameter ratio

– Collapse of the vena cava– Bowel wall thickening with

enhancement– Bilateral inguinal herniation





Acute abdomen - algorithm



•

erect or decubitus• supine









•

erect or decubitus• supine



?

Acute abdomen - algorithm

Andras Palko - Acute Abdomen

Documents

Transcript of Andras Palko - Acute Abdomen