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RADIOLOGIC FINDING IN
ACUTE ABDOMEN
Dr. Vonny N. Tubagus, SpRad (K)
BAGIAN RADIOLOGI FK UNSRAT/RSU PROF. RD KANDOU
MANADO
Peninsula Hotel, May 23, 2015
Dr. Vonny N. Tubagus, SpRad (K)
BAGIAN RADIOLOGI FK UNSRAT/RSU PROF. RD KANDOU
MANADO
Peninsula Hotel, May 23, 2015
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Modalitas Radiologi
• X-Ray konventional
• USG
• CT-Scan
• MRI
• Kedokteran Nuklir
• Angiografi(DSA)
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Pem. X-Ray konventional
• Cara pemeriksaan yang menghasilkan gambar tubuh dengan menggunakan sinar – X.
• ----berkembang
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USG(Ultrasonography)
• Pemeriksaan yang menggunakan gelombang suara berfrekuensi tinggi
• Tidak menggunakan sinar-x.
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• US • Imaging modality:- Organ : size & shape (tomographic), movement (fluoroscopic)and relationship with adjacent tissue- Non radiation, fast, simple, non-invasive, painless and safe .- Operator dependent and confused by artefact.
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• CT- Scan ( Computerized Tomography)
• MRI ( Magnetic Resonance Imaging)
--- pem. dengan menggunakan radio
frekuensi dan medan magnet yg
dapat menghasilkan suatu citra/image
- Kedokteran Nuklir
- Angiografi : Pemeriksaan untuk melihat
kelainan p. darah .
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ACUT ABDOMEN
• “Acute abdomen”
- Trauma
- Non trauma
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• Assesing the patient with an acute abdomen need many investigation including laboratory test and imaging studiesplain photo, US, CT and contrast study .
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Etiologi• Hemorrhage• GI perforation• Bowel obstruction• Inflammatory disorder
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Pemeriksaan radiologi pada acut abdomen
• Foto polos Abdomen : erect chest film, supine, and upright (optional:left lateral decubitus)
• USG Abdomen
• CT-Scan Abdomen
• Angiografi/Arteriografi
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FOTO POLOS ABDOMEN• Bermanfaat dalam mendeteksi obstruksi usus,
gas bebas dalam extralumen dan kalsifikasi abdomen.
• Proyeksi rutin : Supine (AP)• Dapat memperlihatkan batas udara/cairan
pada kasus obstruksi, dan gas bebas di bawah diafragma pada kasus perforasi.
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Abdomen posisi tegak• Terlihat :
– Free air– Air-fluid levels
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BARIUM ENEMA =COLON IN LOOP
• Digunakan pada mayoritas pemeriksaan saluran percenaan (usus besar) dengan menggunakan kontras ( spt. Barium)
• Kontras dimasukkan melalui anus yang dikombinasi dengan udara ke dalam usus dan difoto.
• Usus harus dalam keadaan kosong - Penderita dipuasakan - lavament /urus urus.
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Barium Enema
• Indikasi : evaluasi adanya perubahan kebiasaan bab, perdarahan atau mencari lokasi obstruksi usus besar.
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• Pemeriksaan USG– Free peritoneal fluid accumulation on the
Morison’s pouch, the rectovesical pouch, the pouch of Douglas, and the bilateral subphrenic space
• Pemeriksaan CT-Scan– CTgold standars for specific intraabdominal
pathology
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TRAUMA ABDOMEN
• Liver trauma :
- inside , sub capsular, or outside of liver
• - evaluate : another adjacent organ .
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Liver trauma
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• Spleen trauma increasing spleen volume.• U S :
1.- intraperitoneal and subphrenic fluid collection - irregularity of shape rupture ?.
2.Haematome : echo free region and complex echo
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3.Acute haematome : irreguler mass with echo free or echo complex.4.Old haematome: mass echogenic with
reflective area.
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NON-TRAUMA
Gastrointestinal perforation
•Gastrointestinal perforation are serious disorder requiring rapid diagnosis and treatment
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● Radiological appearances:
Foto polos abdomen : - 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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Plain photo
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Pneumoperitoneum
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Rigler’s signFissure for ligamentum teres
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Football sign
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Fluid free/Blood: Echo free in : - Morrison’s pouch.
- left upper quadrant.
- pelvic area ( cul-de-sac )
Transvaginal US
Transrectal US
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ULTRASONOGRAFI (USG)
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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
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• Imaging aims: to confirm the presence of bowel obstruction, define the level obstruction, identify the cause and detect complications such as perforation
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Table 2. Cause of bowel obstruction
Extrinsic Bowel wall IntraluminalAdhesions Neoplasia Intussusception
Hernia Strictures:inflammatory, radiation,chemical
Foreign body
Volvulus Intestinal ischaemia Gallstone ileus
Inflammation/abscess
Malignant infiltration (e.g. peritoenal deposits)
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Small bowel obstruction :
Etiology: - Adhesions due to previous surgery - Strangulated hernias - Volvulus - Gallstone ileus - Intussusception - Neoplastic, etc.
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Small bowel obstrustion• Plain foto abdomen primary investigation of choice
Plain foto abdomen: - Dilated small bowel loops:
- Multiple fluid levels on the erect film
- String of beads sign on the erect film
- Absent or little air in the large bowel
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SBO: valvulae conniventes
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Small-Bowel Obstruction:String of beads sign
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Step ladder
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♥ Ultrasonografi (USG)
- Dilated fluid-filled loops of small-bowel obtruction
- Assessment of the peristaltic activity.
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US: Small bowel obstruction
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• CT-Scan finding :
Small bowel loops measuring>2.5 cm in diameter– Identifiable focal transition zone from
prestenotic dilated bowel to post-stenotic collapsed bowel loops
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CT Scan : 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:
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Large bowel obstruction
Plain foto abd:› Dilated large bowel loops which:
Large: above 5.0 cm diameter Haustra: thick and widely Contain solid faeces
. Caecum maybe dilated
. Small bowel may be dilated
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• 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
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Plain foto : Caecal Volvulus
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coffee bean sign
Plain foto abd :Sigmoid volvulus
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Barium enema
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Ba-enema: Hirschprung
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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
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INFLAMMATORY DISSORDERS
• Acute appendicitis
• Acute pancreatitis
• Acute cholecystitis
• Abdominal absces
• Peritonitis
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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
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Plain foto abd :apendicolith
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• Acute Appendicitis• US :
normal appendix rarely seen
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• Acute appendicitis : non compressible
no peristaltic
appendix 6 mm ( sagital view ).
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• 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
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US : Appendicities
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• CT finding– 90% diagnostic accuracy to detect acute appendicitis– With the good contrastfilling 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
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CT- SCAN
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Pancreatitis Akut US and CT most
precisely define the anatomic extent of the lesions and the detect local complications
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Radiologic finding
• Plain filmsno significant plain film findings in up to two-thirds of patients wih acute pancreatiti
• Plain-film signs may include:– Paralytic ileus in the left upper quadrant– Generalized ileus– Loss of left psoas outline
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• CXR signs that may be seen include:– Left pleura effusion– Atelectasis of left lower lobe– Elevated left hemidiaphragm
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• US finding:– The acutely inflamed pancreasenlarged 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
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CTimaging investigation of choice for acute pancreatitis, 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
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USG
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CT- SCAN
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Acut Cholecystitis Approximately 85%-90% of cases
with acute cholecystitis (AC) develop as a complication of cholelithiasis
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Radiologic Finding
• Plain filmsinsensitive for acute cholecystitis
• Plain films signnonspesific 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
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Gambaran Radiologi
• USinvestigation 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
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• CT scanning contribute little to diagnosis of cholecystitis
• CTinvestigation of complicatios biliary or pericholecystic
abscess
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USG: Cholecystitis Akut
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USG : Cholecystitis Akut
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USG: Cholecystitis Akut
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Peritonitis
• Peritonitisan inflammatory or suppurative reaction of the peritoneum to direct irritation
• Cause:– Inflammatory– Infectious– Ischemic
Exudation,Hematogenous,
Contiguous extension,Iatrogenic manipulation
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Radiologic finding
• Plain abdominal radiograph: cannot provide specific
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• USnonspecific• Abdominal CT
– CT signs • Ascites (free or encapsulated)• Infiltration of the omentum and/or mesentery• Thickening of the parietal peritoneum
• Angiography for ischaemia, hemorrhage
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