IMAGING OF ACUTE ABDOMEN

Objectives

To know the imaging modalities used in the assessment of the acute

abdomen

To understand the choice of imaging methods in different conditions causing

acute abdomen and limitations of each modality

To identify the imaging appearances of common conditions causing acute

abdomen

Acute abdomen
A clinical condition characterized by sudden onset of severe abdominal pain
developing over a period of hours requiring early surgical or medical treatment.

Causes of acute abdomen (except trauma)

Role of Imaging

Aid rapid & accurate diagnosis.

Aid in therapy using interventional radiological techniques.

Imaging Methods in acute abdomen

Plain Film Radiography

Contrast Studies
Ultra Sound
Computerized Tomography
Nuclear Medicine
Magnetic resonance imaging

Choice of Imaging depends on the clinical diagnosis and the imaging facilities
available in the institution.
Plain Film Radiography in acute abdomen

Remains the current first line radiological test in suspected bowel obstruction
and detection of free air.
Detects calcifications related to acute abdomen.
Detects soft tissue masses and gas.

Ultrasonography

No ionizing radiation ( Important in younger patients and pregnant women)

The spatial resolution of a high-frequency US image is higher than that of a
CT image if the target organ can be approached closely.
The dynamic, real-time qualities -can observe fetal movements, peristalsis
etc.
Directly visualize blood flow and pulsations.

CT

Multi-slice CT is increasingly replacing ultrasonography for the evaluation of

patients with acute abdominal pain.

MRI

Useful to evaluate acute abdomen in pregnancy

Isotope studies

Useful in GI bleeding

Plain Radiography

Standard Radiographs
Supine AP abdomen
Erect PA Chest
Additional Radiographs
Erect- AP abdomen
Left lateral decubitus abdomen

Normal supine AP Abdomen/Erect AP abdomen

Plain Radiograph helps to detect

Three
1.
2.
3.

Bowel obstruction
Pneumoperitoneum
Pneumonia mimicking abdominal pain
Emphysematous pyelonephritis or cholecystitis
Cardinal Radiological signs of a bowel obstruction are,
Absence of distal gas.
Differential distension
Long / differential air fluid levels

Small bowel obstruction

Supine AP abdomen

Erect AP abdomen

Large bowel obstruction

Distended colon proximal to obstruction (peripheral location)

Small bowel also distended if ileo-caecal valve is incompetent

Sigmoid Volvulus

Paralytic ileus

Supine AP abdomen - Distension of small bowel and colon

Erect AP abdomen- Fluid levels may be seen in colon but not in small bowel

Pneumoperitoneum- Supine AP abdomen

Riglers sign
Falciform ligament outlined by air

Perforation of GIT -Pneumoperitoneum

Erect PA chest
Free air seen under the diaphragm

Pneumoperitoneum- Left lateral decubitus

Free air seen between liver and lateral abdominal wall

Ischaemic colitis

Pneumobilia

Calcifications related acute abdomen

Aortic and arterial

Urinary tract calculi (85% calcify)

Gallstones(10-15% calcify)
Pancreatic secondary to chronic pancreatitis
appendicoliths

GB calculi

Appendicolith

Pancreatic calcification

Ureteric calculi

Gallstone ileus

Contrast studies

Barium or water soluble GI contrast study

Small bowel

Identify its cause and location

Adhesions account for 60-80% of all cases

obstruction

The 'Small Bowel Feces Sign' (SBFS) is a very useful sign as it is seen at
the zone of transition thus facilitating identification of the cause of the
obstruction.

Choice of imaging modalities in different common

conditions and its appearances

US / contrast studies / CT / Isotope / MRI

1. Acute appendicitis

Most common abdominal surgical emergency.

US confirms appendicitis by visualizing the inflamed appendix (successful in
90 %) or to exclude appendicitis, either by visualization of the normal
appendix (successful in 50%) or by demonstrating an alternative condition
(possible in 20 %).
If US result is equivocal /if most of the above patients in the latter group are
obese, - >CT.
An inflamed appendix has a diameter >6 mm, and is usually surrounded by
inflamed fat. The presence of a faecolith or hypervascularity on power
Doppler strongly supports inflammation.

Appendicitis with appendicolith - MRI

2. Cholecystitis
Signs

of cholecystitis
Gall bladder wall thickening
Hydropic gall bladder
Positive Murphy sign

Imaging Modalities-US, CT, MRI

3.

Pancreatiti
s

Imaging Modalities-US, CT, MRI

4. Intussusception

Imaging Modalities-US, CT, MRI

5. Diverticulitis

6. Ureteric calculi

7. Ruptured aneurysm

Sonography is a quick and convenient modality, but it is much less sensitive and
specific for the diagnosis of aneurysmal rupture than CT.
The absence of sonographic evidence of rupture does not rule out this entity if
clinical suspicion is high.

Acute GI Bleeding
Minimum of 0.5ml/min is detected
Optimum sensitivity with 1ml/min

8. Salphingitis

9. Ectopic pregnancy

Interventional radiological techniques used in acute abdomen

1. Selective angiographic infusion of vasoconstrictive agents
2. Embolic occlusion of bleeding vessels
Embolisation