Case 1 A 69 year old female presents to the ED with a 3 day
history of worsening abdominal pain and distension. Exam revealed
distension, tympani, and volunteering guarding, but no rebound pain
or signs of peritonitis. An X-ray was ordered A 69 year old female
presents to the ED with a 3 day history of worsening abdominal pain
and distension. Exam revealed distension, tympani, and volunteering
guarding, but no rebound pain or signs of peritonitis. An X-ray was
ordered
Slide 3
Case 1 Lateral Chest X-ray The spleen (*) can be seen outlined
by the lucency created by the pocket of air Frontal Chest X-ray
Extensive air can be seen under the diaphragm. The arrow points to
gallbladder that is also surrounded by air Pneumoperitoneum-
Presence of air in the peritoneum cavity. It is most often caused
by perforation of an abdominal viscus (i.e. a perforated
ulcer).
Slide 4
Case 1 Unlike in the previous films pneumoperitoneum is usually
more subtle and can be easily overlooked. To the right you can see
a plain radiograph of the right upper quadrant that shows a small
streak of air under the diaphragm (white arrow). Unlike in the
previous films pneumoperitoneum is usually more subtle and can be
easily overlooked. To the right you can see a plain radiograph of
the right upper quadrant that shows a small streak of air under the
diaphragm (white arrow).
Slide 5
Case 1 CT scans are a great tool for visualizing pneumo-
peritoneum. When the patient is supine, anteriorly placed gas can
be differentiated from gas in the bowels. CT can also detect
extravasation of inflammatory fluid into the abdomen sometimes
making localization of the perforation possible. CT scans are a
great tool for visualizing pneumo- peritoneum. When the patient is
supine, anteriorly placed gas can be differentiated from gas in the
bowels. CT can also detect extravasation of inflammatory fluid into
the abdomen sometimes making localization of the perforation
possible.
Slide 6
Case 1 In Pneumoperitoneum sometimes the Rigler Sign can be
observed. It basically is when lucency from gas can be observed on
both sides of the intestine. Green Arrows Air at the intra-luminal
side White Arrows Air at the extra-luminal side Green Arrows Air at
the intra-luminal side White Arrows Air at the extra-luminal side
White arrows Points to the intestinal wall that is surround on both
sides by air
Slide 7
Case 1 The Football sign is seen in the setting of massive
pneumo- peritoneum. It is where the abdomen is outlined by gas from
a perforated viscus. In the image to the right the falciform
ligament can be seen overlying the vertebra (Long straight arrows).
This is often included as a feature of the football sign. At left-
the falciform ligament can be seen, but it is to the side of the
spine (orange arrow)
Slide 8
Case 2 The patient is a 58 year old male who presents with
bilous vomiting and poorly localized abdominal pain that has been
progressing over last 24 hours. 4 months ago the patient had a
laparotomy for appendicitis. Exam: Abdominal distension, and
hyperactive bowel sounds Plain abdominal X-ray was ordered. (notice
the multiple distended loops of small bowel) The patient is a 58
year old male who presents with bilous vomiting and poorly
localized abdominal pain that has been progressing over last 24
hours. 4 months ago the patient had a laparotomy for appendicitis.
Exam: Abdominal distension, and hyperactive bowel sounds Plain
abdominal X-ray was ordered. (notice the multiple distended loops
of small bowel)
Slide 9
Case 2 Small bowel obstruction (SBO) is seen most commonly in
patients who develop adhesions after previous surgeries. In
pediatric patients think of intussusception, Meckels diverticulum,
or an incarcerated hernia. On X-ray look for dilated loops of bowel
(white arrows) and air fluid levels (orange arrows)
Slide 10
Case 2 CT is a useful test in guiding therapy. It can help
answer: - Is there an obstruction? - Where is the transition point
(obstruction)? -Cause of the obstruction? -Associated
complications? The above CT shows dilated loops of small bowel
(white arrows). Notice that the colon is collapsed (red arrow).
This is consistent with a mechanical small bowel obstruction.
Slide 11
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Slide 14
Case 3 65 year old female presents with gradually worsening
abdominal pain, constipation, and today had an episode of foul
smelling vomit. On exam he had a distended abdomen, tenderness with
palpation, and quiet bowel sounds. Abdominal X-rays were ordered
(again, notice the dilated loops of bowel)
Slide 15
Large bowel Obstruction (LBO) Like SBO proximal bowel is often
dilated (white arrow) with air fluid levels (orange arrows). In an
adult the most common causes are: Diverticulitis, colon cancer, and
a volvulus. Large bowel Obstruction (LBO) Like SBO proximal bowel
is often dilated (white arrow) with air fluid levels (orange
arrows). In an adult the most common causes are: Diverticulitis,
colon cancer, and a volvulus. Case 3
Slide 16
Large bowel Obstruction: - Like in SBO gases and feces tend to
accumulate proximal to the obstruction. - In longstanding LBO,
muscular exhaustion can result in the effacement of haustra. - The
Cecum (*) generally dilates more than any other section of large
bowel. -Dilation > 10cm indicates possible perforation Large
bowel Obstruction: - Like in SBO gases and feces tend to accumulate
proximal to the obstruction. - In longstanding LBO, muscular
exhaustion can result in the effacement of haustra. - The Cecum (*)
generally dilates more than any other section of large bowel.
-Dilation > 10cm indicates possible perforation Case 3 *
Slide 17
Large bowel Obstruction The Coffee Bean Sign Name given to the
radiologic appearance of a sigmoid volulus.
Slide 18
This CT shows dilated loops of both small bowel (white arrow)
and large bowel (red arrow) Case 3 Large Bowel Obstruction
Slide 19
Case 4 A 22 year old male that presents with intermittent
abdominal pain. The physical reveals RLQ abdominal pain The CT to
the right was ordered.
Slide 20
Case 4 CT Abdomen reveals a dilated appendix with a thickened
wall (white arrow) CT abdomen of another patient. The hyperdensity
is an appendicolith (white arrow). Notice the fat stranding
surrounding the appendix. Acute Appendicitis
Slide 21
Case 4 Acute Appendicitis A psoas abscess is a complication of
acute appendicitis (*). Notice the areas of inflammation over the
psoas muscles (p). *
Slide 22
Case 4 Acute Appendicitis Ultrasound is a great tool in
detecting acute appendicitis in children and pregnant women. It is
an operator dependent exam. These two US scans show the same
inflamed appendix (long arrow). Notice the hyper-echoic
peri-appendiceal tissue surrounding the gallbladder, this is
inflamation.
Slide 23
Case 4 Acute Appendicitis Notice the hyper- echoic mass in the
center of the inflamed appendix. This appendicolith (*), has
echogenic shadowing. *
Slide 24
Case 5 A 48 year old male presented to his primary care
provider with a low grade intermittent fever and occasional
episodes of bloody diarrhea. Physical exam was negative, except for
heme positive stool. The patient was evaluated with a barium enema
exam. Notice the loss of haustral folds in the descending colon
(white arrows)
Slide 25
Case 5 This is another radiograph from the same patient. Notice
how featureless the sigmoid colon is. This is a classic
representation of lead pipe bowel seen in chronic ulcerative
colitis. This typically only effects the left side of the colon in
UC. Inflammatory bowel disease- Ulcerative Colitis
Slide 26
Case 5 Pseudo polyps- are where the islands of hyperplastic
mucosa protrude from a background of ulceration. This give the
appearance of a polyp. Inflammatory bowel disease- Ulcerative
Colitis
Slide 27
Case 5 This is a non-contrast CT in a patient with active
Crohns Disease. Notice the prominence of the mesenteric vasculature
in this acute inflammatory process. This is called the Comb Sign.
(Orange Arrows) Inflammatory bowel disease- Crohns Disease
Slide 28
Case 5 In longstanding Crohns Fistulas can sometimes develop.
An Ileo-ileo fistula can be seen in the coronal CT to the right
(Arrow Heads) Inflammatory bowel disease- Crohns Disease
Slide 29
Case 5 In the above CT, active inflammation due to crohns
disease can be seen. This manifests as thickened bowel walls,
mesenteric fat stranding, and mesenteric adenopathy. Inflammatory
bowel disease- Crohns Disease
Slide 30
Case 5 Crohns vs Ulcerative Colitis CharacteristicCrohns
DiseaseUlcerative Colitis Site of OriginDistal Ileum, proximal
colonRectum Thickness of Pathology TransmuralMucosa and submucosa
only ProgressionIrregular (skip lesions)Proximal, continuous from
the rectum, no skipped areas LocationFrom mouth to anusInvolves
colon and rectum, rarely extends to ileum Change in Bowel Habit
Obstruction, adb. PainBloody Diarrhea Classic LesionsFistula,
abscesses, cobble- stoning, string sign, comb sign Pseudopolyps,
lead pipe colon, toxic mega-colon Colon Cancer RiskSlightly
increasedMarkedly increased Surgery Cures Bowel disease No (can
worsen it)Yes (proctocolectomy with ileoanal anastomosis)
Slide 31
Case 6 A 60 year old man presents with abdominal and back pain
that radiates down his right leg. Physical exam: Pulsitile mass
R>>L The following abdominal X-ray was taken.
Slide 32
Case 6 Abdominal Aortic Aneurysm (AAA) The bulging infra renal
aneurysm is in red.
Slide 33
Case 6 This is the CT from the same patient seen in the
previous slide. Abdominal Aortic Aneurysm (AAA)
Slide 34
Ultrasound can be a good screening to for AAA. Its sensitivity
is competitive to both MRI and CT. Case 6
Slide 35
Abdominal Aortic Aneurysm (AAA) Aortography can be used to
assess the aneurysm. One drawback to this technique is that it
tends to underestimate the aneurysm size. Due to it only show the
patent vessel lumen.
Slide 36
Case 6 Abdominal Aortic Aneurysm (AAA) Endovascular grafts can
be used to repair the AAA and prevent eventual rupture.
Slide 37
Case 6 Abdominal Aortic Aneurysm (AAA) In this aortogram the
implanted graft can be seen in the lumen of the aorta.
Slide 38
Case 7 A 68 year old man presents with abdominal pain. PMH:
Hepatitis B. Physical exam: Markedly enlarged Spleen The following
CT was performed. Notice the nodular appearance of the liver and
enlarged spleen (*). *
Slide 39
Case 7 This patient is suffering from Cirrhosis. This image is
of the same patient just on the coronal plane. Cirrhosis.
Slide 40
Case 7 This image is also of the same patient. This slice is
from the superficial abdominal wall. Notice the multiple enlarge
peri- umbilical vessels, this is know as caput medusa (white
arrows). Cirrhosis.
Slide 41
Case 8 A 79 year old male with PMH of prostate cancer, who
present with abdominal pain. The following CT was performed.
Slide 42
Case 8 This patient prostate cancer had spread to his liver.
The high vascularity of the liver makes it a common location for
cancer to metastasize to. Metastatic liver disease
Slide 43
Case 8 Metastatic liver disease Metastatic Colon Cancer
Slide 44
Case 8 Metastatic liver disease Metastatic Colon Cancer With
central calcifications
Slide 45
Case 8 Metastatic liver disease MRI of metastatic uterine leio-
myosarcoma Notice the ring enhancing lesion
Slide 46
Case 8 Metastatic liver disease ABC The above three images is
from a 58 year old female with a large met from breast cancer. (A)
CT showing the large metastisis in the left lobe of the liver. (red
circle) (B) Shows the radio frequency ablation probe and its
position at the tumor site. (C) Follow up CT showing tumor necrosis
and shrinkage.
Slide 47
Case 9 An 26 year old female patient in the ER after Ped vs
Car. The patients vitals are stable. The following CT scan was
performed. Notice the irregular appearance of the spleen (*).
*
Slide 48
Case 9 The patient is suffering from a splenic laceration.
Slide 49
Splenic laceration Case 9 Interventional radiologist have a
variety of option to reduce bleeding in splenic lacerations. The
end result is the same, clotting off the artery to prevent distal
bleeding. (A) Splenic arteriogram, revealing multiple aneurisms in
the upper pole (arrows). (B) Arteriogram after ablation of upper
pole. Notice that the lower poles vasculature is still intact
(arrows) AB
Slide 50
Case 10 A 38 year old patient present with left flank paint and
cloudy urine that sometimes has a red tinge. Physical Exam: WNL The
following X-Ray was taken.
Slide 51
Case 10 The patient has a large calculus in the right kidney
pelvis. (red circle) The patient also has a smaller stone at the
ureterovesicular junction. (white arrow) Obstructive ureteral
calculus
Slide 52
Case 10 The same patient had the following CT. (A) Notice the
large calculus in the R. renal pelvis. Also, Notice the significant
hydronephrosis in the L. Renal pelvis. (B) Notice the stone in the
L. distal ureter, no doubt causing the proximal hydronephrosis.
Obstructive ureteral calculus AB