A site specific A site specific approach to approach to radiologic radiologic diagnosisdiagnosis

Dr. Ahmed Refaey Dr. Ahmed Refaey

Abdominal pain

Locations of abdominal painLocations of abdominal pain

• Right upper quadrant RUQRight upper quadrant RUQ

• Left upper quadrant LUQLeft upper quadrant LUQ

• Right Lower quadrant RLQRight Lower quadrant RLQ

• Left lower quadrant LLQLeft lower quadrant LLQ

• MidepigastricMidepigastric

Acute RUQ painAcute RUQ pain

• Acute cholecystitisAcute cholecystitis – – most commonmost common

• DDDD

- PUD- PUD

- acute hepatitis- acute hepatitis

- liver abscess- liver abscess

- RLL pneumonia- RLL pneumonia

RUQ pain imaging RUQ pain imaging evaluationevaluation• UltrasoundUltrasound

• Acute Acute cholecystitischolecystitis – – most commonmost common

• DDDD

- PUD- PUD

- acute hepatitis- acute hepatitis

- liver abscess- liver abscess

- RLL pneumonia- RLL pneumonia

US in acute cholecystitisUS in acute cholecystitis

• Gall stones with …..Gall stones with …..

……. ( . ( sonographic Murphy’s sign )sonographic Murphy’s sign )

• distended gall bladderdistended gall bladder

• Pericholecystic fluid collectionPericholecystic fluid collection

• Obstructing stone in GB neck or in Obstructing stone in GB neck or in cystic ductcystic duct

• gall bladder wall thickening (> 3 mm )gall bladder wall thickening (> 3 mm )

LUQ painLUQ pain

LUQ painLUQ pain

• Peptic ulcer diseasePeptic ulcer disease

• Splenic infarctSplenic infarct

• LLL pneumoniaLLL pneumonia

Diagnostic testsDiagnostic tests

• Plain X-ray chest --Plain X-ray chest -- pneumoniapneumonia

• US -US - splenic infarctsplenic infarct

• UGI -UGI - peptic ulcer peptic ulcer diseasedisease

RLQ painRLQ pain

RLQ painRLQ pain

• Acute appendicitisAcute appendicitis

• Mesenteric adenitisMesenteric adenitis

• DiverticulitisDiverticulitis

• Urinary tract calculiUrinary tract calculi

• Gynacologic diseaseGynacologic disease

Diagnostic imagingDiagnostic imaging

• USUS

• CTCT

• Exceptions for CTExceptions for CT

* children* children

* pregnant women* pregnant women

• Acute appendicitisAcute appendicitis

• Mesenteric adenitisMesenteric adenitis

• DiverticulitisDiverticulitis

• Urinary tract calculiUrinary tract calculi

• Gynacologic diseaseGynacologic disease

CT findings in acute CT findings in acute appendicitisappendicitis

• Dilated appendix ( > 6 mm )Dilated appendix ( > 6 mm )

• Non filling of the appendix with contrastNon filling of the appendix with contrast

• Peri-appendiceal inflammatory changesPeri-appendiceal inflammatory changes

• Increased enhancement of the wallIncreased enhancement of the wall

• AppendicolithAppendicolith

• Accuracy of CT is 94-98 %Accuracy of CT is 94-98 %

US findings in acute US findings in acute appendicitisappendicitis

• Non-compressibleNon-compressible

• Dilated appendix ( > 6 mm )Dilated appendix ( > 6 mm )

• Hyperemic thick wallHyperemic thick wall

• AppendicolithAppendicolith

• Surrounded by omentumSurrounded by omentum

• Peri-appendiceal fluid collectionPeri-appendiceal fluid collection

Mesenteric adenitisMesenteric adenitis

• Clinical presentation similar to Clinical presentation similar to appendicitisappendicitis

• inflammatory / infectious processinflammatory / infectious process

• Children > adultsChildren > adults

• Most common alternative condition Most common alternative condition identified at surgery with removal of normal identified at surgery with removal of normal appendix appendix

Mesenteric adenitis vs Mesenteric adenitis vs appendicitisappendicitis

• Both may have lymphadenopathy Both may have lymphadenopathy and ileal wall thickening.and ileal wall thickening.

• Appendix is normal in mesenteric Appendix is normal in mesenteric adenitis.adenitis.

Rt side diverticulitisRt side diverticulitis

Uretric stoneUretric stone

LLQ painLLQ pain

LLQ painLLQ pain

• DivericulitisDivericulitis

• Epiploic appendagitisEpiploic appendagitis

• Perforated colon cancerPerforated colon cancer

• Urinary tract calculiUrinary tract calculi

• Gynacologic diseaseGynacologic disease

Diagnostic imagingDiagnostic imaging

• CT: CT: best overall examinationbest overall examination

• US US : better for females : better for females

CT in diverticulitisCT in diverticulitis

• DiverticulosisDiverticulosis

• Wall thickeningWall thickening

• Inflammatory changes in pericolonic fatInflammatory changes in pericolonic fat

• Extraluminal air or abscessExtraluminal air or abscess

• Soft tissue inflammatory mass Soft tissue inflammatory mass ( phlegmon)( phlegmon)

• Evidence of colovesical fistula Evidence of colovesical fistula

Epiploic appendagitisEpiploic appendagitis

• Epiploic appendages Epiploic appendages

* small fatty * small fatty protrusions protrusions

* 2-5 cm long* 2-5 cm long

* serosal surface of * serosal surface of coloncolon

Epiploic appendagitisEpiploic appendagitis

• Torsion of epiploic appendagesTorsion of epiploic appendages

• Clinical presentation similar to Clinical presentation similar to diverticulitisdiverticulitis

* localized abdominal pain, fever * localized abdominal pain, fever and elevated WBCsand elevated WBCs

* typically no nausea and vomiting* typically no nausea and vomiting

CT in epiploic appendagitisCT in epiploic appendagitis

• Low density mass ( fat ).Low density mass ( fat ).

• Surrounding hyperdense rimSurrounding hyperdense rim

• May have central dotMay have central dot

( thrombosed vessel)( thrombosed vessel)

Left uretric stoneLeft uretric stone

Qynacologic causes of Qynacologic causes of LQ/pelvic painLQ/pelvic pain

• PIDPID

• Ruptured ovarian cystRuptured ovarian cyst

• Hemorrhagic ovarian cystHemorrhagic ovarian cyst

• Adenexal torsionAdenexal torsion

• Ectopic pregnancyEctopic pregnancy

Diagnostic imagingDiagnostic imaging

• US is the primary imaging modalityUS is the primary imaging modality

Midepigastric painMidepigastric pain

Midepigastric painMidepigastric pain

• PUDPUD

• Acute pancreatitisAcute pancreatitis

• Aortic dissection Aortic dissection

• Aortic aneurysm ruptureAortic aneurysm rupture

Diagnostic imagingDiagnostic imaging

• CTCT the best for all except PUD the best for all except PUD

PUDAcute pancreatitisAortic dissection Aortic aneurysm rupture

Acute pancreatitisAcute pancreatitis diagnostic imagingdiagnostic imaging

•CTCT is the modality of choice is the modality of choice

• USUS may be useful screening tool may be useful screening tool

CT in acute pancreatitisCT in acute pancreatitis

• Focal or diffuse enlargementFocal or diffuse enlargement

• Peripancreatic inflammationPeripancreatic inflammation

• Areas of necrosisAreas of necrosis

• Peripancreatic collectionPeripancreatic collection

Abdominal aortic aneurysmAbdominal aortic aneurysm

• Without rupture, may present with Without rupture, may present with pulsatile abdominal mass without pulsatile abdominal mass without painpain

• With rupture, presents with With rupture, presents with midabdominal and back painmidabdominal and back pain

CT diagnosis of AAA ruptureCT diagnosis of AAA rupture

• Retroperitoneal hematomaRetroperitoneal hematoma

• Contrast extravasationContrast extravasation

Abdominal aortic dissectionAbdominal aortic dissection

•CTCT is the modality of choice is the modality of choice

Abdominal aortic dissectionAbdominal aortic dissection CT diagnosisCT diagnosis

• Contrast in 2 channelsContrast in 2 channels

• Intervening intimal flapIntervening intimal flap

SummarySummary

• RUQ pain RUQ pain acute cholecystitis acute cholecystitis USUS

• LUQ pain LUQ pain splenic/gastric splenic/gastric UGI/USUGI/US

• RLQ pain RLQ pain A.appendicitis A.appendicitis CT/USCT/US

• LLQ pain LLQ pain diverticulitis diverticulitis CTCT

• Midepigastric Midepigastric pancreas/aortapancreas/aorta CTCT

• Young femaleYoung female pelvic pain pelvic pain USUS

• Children Children use use USUS whenever possible whenever possible