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Imaging in acute abdominal pain
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IMAGING PATIENTS WITHIMAGING PATIENTS WITH
ACUTE ABDOMINAL PAIN ACUTE ABDOMINAL PAIN
OverviewOverviewImaging modalitiesIndications Systematic approach to
abdominal x-rayClinical scenario
Imaging ModalitiesImaging Modalities
1. Plain Abdominal Radiograph2. Ultrasound FAST Formal US3.CT
AXR - IndicationsAXR - IndicationsSuspected bowel obstruction Suspected perforationSuspected foreign bodyModerate to severe
undifferentiated abdominal painRenal tract calculi follow-up(Exclude pregnancy)0.1-1 mSv
Abdominal Ultrasound - Abdominal Ultrasound - IndicationsIndicationsTrauma survey and follow up
(FAST)Suspected acute cholocystitisSuspected acute pyelonephritis –
single kidney, transplant, immunocompromised, abnormal renal function, DM, cong anomalies, recurrent/failed to respond to AB, equivocal
RIF pain – young femalesAscites localization
Abdominal CT - IndicationsAbdominal CT - IndicationsAppendicitisColitis (Inflammatory, infective,
ischaemic), DiverticulitisPerforation – Normal erect CXR
strong clinical suspicionStrong suspicion of bowel
obstruction on AXR – further investigation (If not for urgent surgery), uncertainty about the site of obstruction
Urolithiasis AAA/rupture
CT vs USCT vs USRadiation dose (10mSv for
abdominal CT)Patient’s age <25yrs Estimated risk of induced cancer 1
in 900 Estimated risk of induced fatal
cancer 1 in 1800
Body habitus
CTCTHigh sensitivityHigh specificityAvailabilityNot real time, but dynamic study
(artery,vein, delayed phases)Lack of operator dependence
USUSInexpensivePortableSafeDynamic and real time survey
Operator dependence
AXRAXROften anatomical structures are not
demonstratedAbnormalities can be obscured by
anatomical structuresStomach – seen when it contains
air, LUQSmall bowel – generally central,
valvulae conniventesLarge bowel – peripheral, haustra,
retroperitoneal colon is relatively constant in position
AXR AXR Soft tissue – assessment is
limited liver, spleen, psoas, kidney,
bladder, lung basesBones – landmarks ureters, VUJAdded densities – artifacts or
calcified soft tissue
AXRAXR
Abdominal painAbdominal painPlain AXR 1.Strong suspicion of small bowel
obstruction2.Strong suspicion of large bowel
obstruction3.Uncertainty about the site of
obstruction69% sensitivity and 57% specificity
for bowel obstruction
Strong suspicion of paralytic ileus or psedo-obstruction – no imaging
Strong suspicion of small Strong suspicion of small bowel obstruction - AXRbowel obstruction - AXRNo further imaging - needs urgent surgery - known adhesive obstruction and
to be managed conservativelyFurther Imaging - acute high grade symptoms
CT- 94% sensitivity 96% specificitySensitivity low (64%) for low grade
SBO
Suspected large bowel Suspected large bowel obstructionobstructionSigns of volvulus – contrast enema CTSuspected complicated diverticulitis –
CT Likely obstructing lesion – CT (mural
changes and transcolonic abnormalities) Contrast
enema
Colon 5.5 cm, cecum 10cmCT 96% sensitivity, 93% specificity
Sentinel loop in pancSentinel loop in panc
Paralytic ileusParalytic ileus
Coffee bean in sigmoid volvCoffee bean in sigmoid volv
Caecal volvCaecal volv
PerforationPerforationPeptic ulcerDiverticulitisMalignancy
CXR – insensitive for air pockets <1mm
less sensitive for 1-13mmCT – 86% can detect the site of
perforation
Bowel ischemiaBowel ischemiaAccuracy of CT is comparable to
angiographySensitivity 93% and 96%
respectivelySpecificity 79% and 99%
respectively
Arterial and PV phases – ischemia could be arterial or venous
Bowel ischaemiaBowel ischaemia
Cases
Suspected acute Suspected acute cholecystitischolecystitisUS (88% sensitivity 80%
specificity)Acute abdominal pain - CT has
demonstrated accuracy comparable to that of US in diagnosing acute cholecystitis
Cholestatic jaundiceCholestatic jaundiceUS – to assess duct dilatation Yes – cause identified – treat cause not identified suspect stone -
MRCP/CTIVC/EUS suspect malignancy
– CT No – consider hepatocellular
Acute LIF painAcute LIF painFemale of reproductive age – US
to exclude gynaecological pathology
Suspected acute diverticulitis – CT
Suspected renal colic 1st/recurrent presentation, age
(>/<50y), pregnantOther - CT
Acute RIF painAcute RIF painHigh likelihood of appendicitis –
young patient (US to exclude gynae pathology)
Atypical for appendicitis young or thin patients – US others – CT
Graded compression – to identify non compressible bowel
DiverticulitisDiverticulitis
Ovarian torsionOvarian torsion
Acute PancreatitisAcute PancreatitisClinical and biochemicalUS – gall stonesCT- diagnosis uncertain assessment of severe cases failure to improve or sudden
clinical deterioration clinically suggestive of
developing complications follow up
Scrotal painScrotal pain
USTraumaEpididymo-orchitis?? Torsion
EpidydimitisEpidydimitis
TorsionTorsion
TraumaTrauma
1. FAST – Focussed Assessment with Sonography for Trauma
2. CT
Small bowel obstructionSmall bowel obstruction
Small bowel obstructionSmall bowel obstruction
PneumoperitoneumPneumoperitoneum
PneumoperitoneumPneumoperitoneum
ColitisColitis
AppendicitisAppendicitis
THANK YOUTHANK YOU