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

Modalitas Radiologi

• X-Ray konventional

• USG

• CT-Scan

• MRI

• Kedokteran Nuklir

• Angiografi(DSA)

Pem. X-Ray konventional

• Cara pemeriksaan yang menghasilkan gambar tubuh dengan menggunakan sinar – X.

• ----berkembang

USG(Ultrasonography)

• Pemeriksaan yang menggunakan gelombang suara berfrekuensi tinggi

• Tidak menggunakan sinar-x.

• 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.

• 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 .

ACUT ABDOMEN

• “Acute abdomen”

- Trauma

- Non trauma

• Assesing the patient with an acute abdomen need many investigation including laboratory test and imaging studiesplain photo, US, CT and contrast study .

Etiologi• Hemorrhage• GI perforation• Bowel obstruction• Inflammatory disorder

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

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.

Abdomen posisi tegak• Terlihat :

– Free air– Air-fluid levels

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.

Barium Enema

• Indikasi : evaluasi adanya perubahan kebiasaan bab, perdarahan atau mencari lokasi obstruksi usus besar.

• 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

TRAUMA ABDOMEN

• Liver trauma :

- inside , sub capsular, or outside of liver

• - evaluate : another adjacent organ .

Liver trauma

• 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

3.Acute haematome : irreguler mass with echo free or echo complex.4.Old haematome: mass echogenic with

reflective area.

NON-TRAUMA

Gastrointestinal perforation

•Gastrointestinal perforation are serious disorder requiring rapid diagnosis and treatment

● 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

Pneumoperitoneum

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Rigler’s signFissure for ligamentum teres

Football sign

Fluid free/Blood: Echo free in : - Morrison’s pouch.

- left upper quadrant.

- pelvic area ( cul-de-sac )

Transvaginal US

Transrectal US

ULTRASONOGRAFI (USG)

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

• Imaging aims: to confirm the presence of bowel obstruction, define the level obstruction, identify the cause and detect complications such as perforation

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)

Small bowel obstruction :

Etiology: - Adhesions due to previous surgery - Strangulated hernias - Volvulus - Gallstone ileus - Intussusception - Neoplastic, etc.

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

SBO: valvulae conniventes

Small-Bowel Obstruction:String of beads sign

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Step ladder

♥ Ultrasonografi (USG)

- Dilated fluid-filled loops of small-bowel obtruction

- Assessment of the peristaltic activity.

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US: Small bowel obstruction

• 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

CT Scan : SBO

Fluid-filled loops Bowel calibre change

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

• 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

Plain foto : Caecal Volvulus

coffee bean sign

Plain foto abd :Sigmoid volvulus

Barium enema

Ba-enema: Hirschprung

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

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

Plain foto abd :apendicolith

• Acute Appendicitis• US :

normal appendix rarely seen

• Acute appendicitis : non compressible

no peristaltic

appendix 6 mm ( sagital view ).

• 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

US : Appendicities

• 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

CT- SCAN

Pancreatitis Akut US and CT most

precisely define the anatomic extent of the lesions and the detect local complications

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

• CXR signs that may be seen include:– Left pleura effusion– Atelectasis of left lower lobe– Elevated left hemidiaphragm

• 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

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

USG

CT- SCAN

Acut Cholecystitis Approximately 85%-90% of cases

with acute cholecystitis (AC) develop as a complication of cholelithiasis

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

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

• CT scanning contribute little to diagnosis of cholecystitis

• CTinvestigation of complicatios biliary or pericholecystic

abscess

USG: Cholecystitis Akut

USG : Cholecystitis Akut

USG: Cholecystitis Akut

Peritonitis

• Peritonitisan inflammatory or suppurative reaction of the peritoneum to direct irritation

• Cause:– Inflammatory– Infectious– Ischemic

Exudation,Hematogenous,

Contiguous extension,Iatrogenic manipulation

Radiologic finding

• Plain abdominal radiograph: cannot provide specific

• 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

THANK YOU