Acute Abdomen

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The ACUTE ABDOMEN:

The ACUTE ABDOMEN The role of the Plain Film Abdominal Series MI Zucker, MD

A dr Z Lecture:

A dr Z Lecture

The Abdominal Series:

The Abdominal Series For all acute abdominal complaints where plain film imaging is indicated, get a COMPLETE abdominal series Exceptions: Suspected renal calculus or foreign body, where a single view is OK CT and ultrasound are often performed after plain films

Abdominal Series Indications::

Abdominal Series Indications: Highest yield: Presentations suggestive of free air or obstruction Not very good for masses, ascites, organomegaly, biliary tract disease, GI bleeding and vague abdominal complaints Yield is higher in the elderly

The Abdominal Series:

The Abdominal Series Erect chest, AP supine and erect abdomen Or, if patient unable to sit/stand: supine chest, supine and left lateral decubitus abdomen For calculus or foreign body: AP supine abdomen

The Erect Chest:

The Erect Chest Best for free air To evaluate for intrathoracic abnormalities presenting with abdominal complaints, especially pneumonia (more common in kids)

Supine Abdomen:

Supine Abdomen Best for abdominal detail: Organs, bones and joints, calcifications, fat and gas pattern

Erect Abdomen:

Erect Abdomen For air-fluid levels and little else

Left Lateral Decubitus Abdomen:

Left Lateral Decubitus Abdomen Substitute for erect chest (free air) and erect abdomen (air-fluid levels) in a patient unable to sit or stand

Indications for a single erect abdomen film ONLY:

Indications for a single erect abdomen film ONLY NONE None None None

The Check List:

The Check List Bones and joints Calcifications Organs Fat Gas: In bowel and outside of bowel

A memory aid:

A memory aid “First organs, bones, and stones, Then masses, fat, and gas. Don’t forget the corner zones, And you’ll always cover your…subject”

The Normal Abdominal Series:

The Normal Abdominal Series Chest Supine abdomen Erect abdomen Left lateral decubitus abdomen

Chest:

Chest

Supine Abdomen:

Supine Abdomen

Erect Abdomen:

Erect Abdomen

Left Lateral Decubitus Abdomen:

Left Lateral Decubitus Abdomen

Don’t forget to look for pneumonia:

Don’t forget to look for pneumonia

GAS:

GAS In the gut, and elsewhere

PNEUMOPERITONEUM:

PNEUMOPERITONEUM FREE AIR: Perforated Gut

Free Air:

Free Air Best views: Erect chest and left lateral decubitus abdomen Erect abdomen is less sensitive Supine abdomen is insensitive

How Sensitive?:

How Sensitive? Plain films are 85% sensitive for free air Theoretical threshold is 2 cc CT is much more sensitive and is the “Gold Standard”

Free Air: Erect Chest:

Free Air: Erect Chest Air under the diaphragm Usually on the right Occasionally only seen on the left

Free Air: Erect Chest:

Free Air: Erect Chest

Free Air: Erect Chest:

Free Air: Erect Chest

Free Air: Erect Chest:

Free Air: Erect Chest

Free Air: Left Lateral Decubitus:

Free Air: Left Lateral Decubitus Right side up, left side down Patient who can’t sit or stand Air under right abdominal wall

Free Air: Left Lateral Decubitus:

Free Air: Left Lateral Decubitus

Free Air: Supine Abdomen:

Free Air: Supine Abdomen Double bowel wall sign Falciform ligament sign

Double Wall sign:

Double Wall sign

Falciform Ligament sign:

Falciform Ligament sign

Pneumoretroperitoneum:

Pneumoretroperitoneum From perforation of posterior extraperitoneal portions of duodenum or colon Extension from or through the mediastinum

Pneumoretroperitoneum :

Pneumoretroperitoneum

Air in Biliary System:

Air in Biliary System Bile ducts Gall bladder

Air in Biliary System:

Air in Biliary System Usually secondary to surgery on bile ducts Can be due to biliary-bowel fistula from infection or neoplasm Rarely, can be due to infection

Air in Bile Ducts:

Air in Bile Ducts

Air in Gall Bladder:

Air in Gall Bladder

Portal Venous Air:

Portal Venous Air A sign of dead or dying bowel

Portal Venous Air:

Portal Venous Air

The GUT:

The GUT Gas and Fluid Too Much and Too Little

The Gas Pattern:

The Gas Pattern Can be specific for obstruction Often, nonspecific: General ileus, focal ileus, ischemia, or obstruction A paucity of gas may be due to vomiting or fluid-filled bowel

OBSTRUCTION:

OBSTRUCTION Small bowel Colon

OBSTRUCTION:

OBSTRUCTION Small bowel obstruction much more common than colon: 70:30

Small Bowel Obstruction: Causes:

Small Bowel Obstruction: Causes Adhesions 80% Hernia 15% Tumors, intussusception, midgut volvulus, etc.

Small Bowel Obstruction: Findings:

Small Bowel Obstruction: Findings Step-ladder dilated bowel loops on supine view Step-ladder air-fluid levels on erect/decubitus views Stretch sign on supine view String-of-pearls sign on erect/decubitus views

How Big is Big? :

How Big is Big? In an adult, any visible small bowel is abnormal, but small amounts often not significant. Kids normally have small amounts. Jejunum over 3 cm and ileum over 2 cm diameter is very abnormal, but not specific for obstruction

Air, Fluid or Both?:

Air, Fluid or Both? Small bowel can be distended by either air or fluid or both Fluid-filled bowel may be more significant than air-filled bowel, but often the significance is the same

Air Filled Small Bowel:

Air Filled Small Bowel

Fluid Filled Small Bowel:

Fluid Filled Small Bowel

Air-Fluid Levels:

Air-Fluid Levels Always abnormal in small bowel, but not specific; often normal in colon The height of the fluid levels, same or different, is NOT helpful in distinguishing ileus from obstruction

Small Bowel Air-Fluid Levels:

Small Bowel Air-Fluid Levels

What is Dilated?:

What is Dilated? If small bowel and colon dilated equally, probably not small bowel obstruction: nonspecific ILEUS If small bowel significantly more dilated than colon, suggests SBO Some gas in colon does NOT exclude SBO

Ileus:

Ileus

Classic Small Bowel Obstruction, Supine:

Classic Small Bowel Obstruction, Supine

Classic Small Bowel Obstruction, Erect:

Classic Small Bowel Obstruction, Erect

Stretch Sign: Supine:

Stretch Sign: Supine

String-of-Pearls Sign: Erect:

String-of-Pearls Sign: Erect

SBO: Hernia:

SBO: Hernia

COLON Obstruction Causes:

COLON Obstruction Causes Carcinoma of the colon 80% Volvulus 5% Diverticulitis 5% Fecal impaction 5% Everything else 5%

Colon Obstruction: Carcinoma:

Colon Obstruction: Carcinoma

Colon Obstruction: Volvulus:

Colon Obstruction: Volvulus 5% of total 80% sigmoid 20% cecum

Volulus: Sigmoid:

Volulus: Sigmoid

Volvulus: Cecum:

Volvulus: Cecum

Colon Obstruction: Measurements:

Colon Obstruction: Measurements The cecum is the most distensible part of the colon A cecum of 9 cm diameter is cause for concern A cecum of 11 cm is impending perforation

Distended Cecum:

Distended Cecum

Other Emergency Conditions of the Gut:

Other Emergency Conditions of the Gut Toxic megacolon: Crohn, UC; 5cm transverse colon is impending perforation Enterocolitis: C. diff. and other microbes Ischemia

Toxic Megacolon:

Toxic Megacolon

A word on Thumbprinting:

A word on Thumbprinting It means thickened bowel wall It can occur acutely in C. diff. or ischemia or hemorrhage Chronically, it can be seen in inflammatory bowel disease and neoplasm and a few other less common diseases

C. diff. Enterocolitis:

C. diff. Enterocolitis

Ischemic Bowel Disease:

Ischemic Bowel Disease Arterial emboli: A. fib., MI Arterial thrombi: ASCVD Venous thrombi: Hypercoag., neoplasm Non-occulsive mesenteric ischemia: Low flow states

Ischemia: Findings:

Ischemia: Findings Normal gas pattern Non-specific ileus Thumbprinting Gas in bowel wall Gas in portal vein system Free air

Ischemia: Thumbprinting:

Ischemia: Thumbprinting

Ischemia: CT:

Ischemia: CT

ACUTE APPENDICITIS:

ACUTE APPENDICITIS

Acute Appendicitis: Findings:

Acute Appendicitis: Findings Normal Focal ileus Appendicolith Mass Free air is very rare

Focal Ileus:

Focal Ileus

Appendicolith:

Appendicolith

Acute Appendicitis: CT:

Acute Appendicitis: CT

Acute Appendicitis: CT:

Acute Appendicitis: CT

Gall Bladder Disease:

Gall Bladder Disease

Cholelithiasis:

Cholelithiasis

Cholelithiasis: Ultrasound:

Cholelithiasis: Ultrasound

PANCREATITIS:

PANCREATITIS Acute

PANCREATITIS: Findings:

PANCREATITIS: Findings Normal General nonspecific ileus Focal ileus: Sentinel loop, colon cut-off sign Pancreatic calculi are found in CHRONIC pancreatitis, not acute

Focal Ileus:

Focal Ileus

Chronic Pancreatitis:

Chronic Pancreatitis

Abdominal Aortic Aneurysm:

Abdominal Aortic Aneurysm

AAA:

AAA Plain films are not sensitive, but can be diagnostic Calcified walls of aorta can allow measurement of lumen AAA if over 3 cm AP diameter Ultrasound and CT are much more sensitive

AAA:

AAA

AAA: CT:

AAA: CT

A few more…:

A few more… The odd and the interesting

Echinococcus cyst:

Echinococcus cyst

Ascariasis:

Ascariasis

Ascariasis:

Ascariasis

Foreign Body: Battery:

Foreign Body: Battery

Foreign Body: Battery:

Foreign Body: Battery

Tongue Ornament Misadventure:

Tongue Ornament Misadventure

Body Packer or Mule:

Body Packer or Mule

Customer of Body Packer:

Customer of Body Packer

???:

???

GOODBYE:

GOODBYE Copyright 2004 MI Zucker, MD

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