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Diverticulitis &
Pneumoperitoneum
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Pneumoperitoneum
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: ?
1 2
3 4
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Anatomic consideration
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Scanning Method
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:
?1.
2. X-ray
3. X-ray
4.
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Intraperitoneal free air
Air
Echogenic areas +
Posterior reverberation (ring-down)artifacts
Shifting phenomenon
Location
Epigastric region (Supine)
Left lateral decubitus position
Others: echogenic fluid
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Pneumoperitoneum
Echogenic line
Ring-down artifacts
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Intraperitoneal free air
Moriwaki, Y. et al. Arch Surg 2009;144:137-141.
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Effect of position change
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Effect of respiration
L: lung;P: neumo eritoneum
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Scissors Maneuver
J Clin Ultrasound 2004; 32:381-385Okkes Ibrahim Karahan, JOURNAL OF CLINICAL ULTRASOUND 2004
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EPSSEnhancement of the peritoneal stripe sign
Ashwin Asrani
Emerg Radiol 2007
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Air but not IPFA
Air in Lung
Air in GI tract
Subcutaneous emphysema Chilaiditi syndrome
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Sensitivity Specificity PPV NPV accuracy
US 92 53 95 39 88
X-ray 78 53 94 20 76
BJS 2002; 89:351-354BJS 2002
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IPFA by US in Trauma and acute abdomen
Moriwaki, Y. et al. Arch Surg 2009;144:137-141.
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Case 1
18M, Severe epigastralgia
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Case 1
18M, Severe epigastralgia
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_18m_16452446_Easy/PPU_18m_16452446.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 2
37M with severe epigastralgia
CC: sudden onset of
severe epigastric pain
followed nausea and
vomiting PE: painful
expression; epigastric
muscle guarding
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_37M_14320707/1.mpg8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 3
40M, epigastric pain for one day
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_40M_15744015_%E5%9B%9B%E8%99%95%E9%83%BD%E6%9C%89Air/PPU_40M_15744015.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 4
46F, epigstric pain
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Case 4
46F, epigstric pain
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_46F_15867957_Easy/PPU_48F_15867957.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 5
55M, Epigastric pain & guarding
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Case 5
55M, Epigastric pain & guarding
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_55M_13397476_%E6%9E%97%E5%95%9F%E6%BA%90_%E8%B6%85%E9%9B%A3/PPU_1.wmvhttp://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_55M_13397476_%E6%9E%97%E5%95%9F%E6%BA%90_%E8%B6%85%E9%9B%A38/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 6
56M, severe epigastralgia
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_56M_11329022_Tract/PPU_56M_11329022.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 7
56M,diffuse abdominal pain
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_56M_13720846/PPU.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 8
60M with epigastralgia
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_60M_04358947_Easy/PPU_60M_04358947.wmvhttp://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_60M_04358947_Easy/PPU_60M_04358947.wmvhttp://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_60M_04358947_Easy/PPU_60M_04358947.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 8
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Case 9
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_78M_03536129_Curtan%20sign/PPU_78M_03536129_1000904%E8%80%83%E9%A1%8C.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 10
81F with epigastralgia
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_81F_04668433_initial%20failed%20to%20find%20out8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 10
Worsening pain next morning
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/PPU/PPU_81F_04668433_initial%20failed%20to%20find%20out/PPU_81F_04668433.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Diverticulitis
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:1.
2. 6
3. 5mm
4.
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: curvelinear probe 3.5-5 MHz
: (or)
: NPO
:
: 2-4mm Stomach: >7mm abnormal
Bowel: >4mm abnormal
:
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:
?1. 2.
3.
4.
5.
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Normal anatomy of GI tract
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* * * *
*
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Graded compression technique
:
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:
?1.
2.
3.
4. (LN, fat, ascites)
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GI tract lesions on sonography
1. (>4mm)
2.
3.
4.
5.
6. (LN, fat, ascites)
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Alvarado Score
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Appendicitis
Eur Radiol. 2002;12:1748-61
Diameter > 6mm (Cross section)
Non-compressiblity of appendix
Localized pain during compressionwith the transducer
Alteration of the periappendiceal fat
(echogenic & non-compressible fat)
Obstruction of the lumen by anappendicolith
Hypervascularizaion in colorDoppler of appendix and
surrounding fat
http://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdf8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Landmark of Appendix
RLQ
Iliac crest
Psoas muscle
Iliac vessels Cecum & A-colon
http://localhost/var/www/apps/conversion/current/tmp/scratch_2/Appendicitis/Landmark_Appendicitis_18M_15721675_%E9%A1%8F%E7%91%9E%E6%AF%85.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Colon
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/GI%20tract/%E6%93%8D%E4%BD%9C%E6%95%99%E5%AD%B8_Colon/Colon_demo.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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?1. Corona sign
2. Target sign
3. Curtain sign
4. Dome sign
5. Veiled Kidney sign
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Dome sign:
acute colonic diverticulitis
J Clin Ultrasound. 2000;28:340-6.
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Copyright Radiological Society of North America, 2003
O'Malley, M. E. et al. Radiographics 2003;23:59-72
Right-sided diverticulitis in a 32-year-old woman
with right lower quadrant pain and fever
C 1
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Case 1
21M with RLQ pain
C 2
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Cecal%20diverticulitis_21M_12433080/Cecal%20diverticulitis_21M_12433080.mpg8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 2
48M with right abdominal pain
Case 3
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis%20rupture_48M_05986568http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis%20rupture_48M_05986568/Diverticulitis%20rupture_48M_05986568.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 318M with RLQ pain
C 4
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_18M_16503886http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_18M_16503886/Diverticulitis_19M_16503886.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 4
25F with LLQ pain
C 5
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_25F_17058143http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_25F_17058143/Diverticulitis_25F_17058143.mpg8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 5
26F with RUQ pain
C 6
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_26F_01407769http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_26F_01407769/Diverticulitis_26F_01407769.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 6
26F with RUQ pain
C 7
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_26F_16165727http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_26F_16165727/Diverticulitis_26F_16165727.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 7
27M with RLQ pain
C 8
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_27M_09423356http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_27M_09423356/Diverticulitis_27M_09423356.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 8
31F with RLQ pain
Case 9
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_31F_15272754/Diverticulitis_31F_15272754.wmvhttp://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_31F_152727548/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 9
55F, fever and left flank pain
Case 10
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_55F_02077935_Dhttp://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_55F_02077935_D/Diverticulitis_55F_02077935.wmv8/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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Case 10
32M with RLQ pain
http://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_Terminal%20ileum_%2032M_16478615/Terminal%20ileum%20diverticulitis_32M_16478615.wmvhttp://localhost/var/www/apps/conversion/SKH_EUS%20cases/Diverticulitis/Diverticulitis_Terminal%20ileum_%2032M_164786158/3/2019 1001108_Diverticulitis & Pneumoperitoneum@
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GI tract lesions on sonography
1. (>4mm)
2.
3.
4.
5.
6. (LN, fat, ascites)
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Take-Home Points
1. 2.
3.
4.
NPO
5. History & PEEUS
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