abdominal emergencies radiology

Multidetector CT (MDCT) is an imaging technique that provides otherwise unobtainable information in the diagnostic work-up of patients presenting with acute abdominal pain. Computed tomography-guided percutaneous abscess drainage is a viable treatment option in patients with abscesses related to diverticulitis in which CT readily depicts the anatomy and may be used to guide catheter placement. Thumbprinting manifests as smooth, round, polypoid, and scalloped filling defects projecting into the colonic lumen, which correspond to thickened mucosal folds related to submucosal edema or hemorrhage. Plain abdominal radiographs have limited utility in the diagnosis of acute appendicitis. March 2017, issue 3. A rare form of chronic pancreatitis, groove pancreatitis occurs because of inflammation in the pancreaticoduodenal groove, including the pancreatic head and pancreatic rests in the duodenal wall. The most common cause of acute colonic obstruction is malignancy, usually occurring in the sigmoid colon ( Fig. Organoaxial gastric volvulus is the most common type and results from rotation about the long axis (line connecting the pylorus to the cardia) of the stomach with the antrum anterosuperiorly and the fundus posteroinferiorly ( Fig. In addition to benign causes, primary or metastatic esophageal tumor may also perforate, particularly following palliative dilatation and/or stenting. Definitive diagnosis may require biopsy with immunohistochemical stains. Endoscopy and classic barium studies are critical in the initial diagnosis and staging of IBD in general because they are superior to cross-sectional imaging in the evaluation of the mucosa, particularly in early-stage disease. If you would like to be notified of upcoming courses please fill in the form below. C. jejuni is one of the most common causes of infectious diarrhea in the United States and is the leading cause of infectious colitis worldwide. Intrinsic bowel lesions typically manifest as mural or focal thickening. Sigmoid volvulus represents torsion or twisting of the sigmoid colon around the mesenteric axis. 13-20 ). Overall the most common causes of toxic megacolon are C. difficile and UC. Multiple conditions can result in small bowel dilatation (or abdominal distention) and be confused with SBO, particularly before clinical and radiologic information are integrated. Gastroduodenal Crohn disease (CD) is rare, causing clinical symptoms in 0.5% to 4% of all patients with CD. Large bowel intussusception is commonly associated with lead points. The presence of bowel ischemia and perforation typically warrant surgical intervention. Similar to CD, UC is more common in white and Jewish populations and in northern Europe and North America. 6 hours of video content for $24 & … During 2021 Radiopaedia.org will be organising a number of additional courses both in Australia and around the world. Predisposing factors for sigmoid volvulus include chronic constipation, obstipation from medications, high-fiber diet resulting in bulky stool causing elongation of bowel, and prior abdominal surgeries. Characteristic findings include duodenitis with dilution, slow transit, and flocculation of oral contrast, small bowel dilation, transient small bowel intussusception, villous atrophy and reversal of the fold pattern, with jejunization of the ileum, as reflected by a decrease in normal jejunal folds in contrast to the increasing fold pattern in the ileum. Focal, low-density lesions can be present in the spleen. In addition, signs of obstruction may also be seen, including proximal bowel dilatation with distally collapsed loops. Small bowel obstruction is common, accounting for 20% of surgical admissions and 4% of ED visits for abdominal pain. Mucosal hyperenhancement reflects inflammation, and the degree of enhancement correlates with the degree of inflammation. 13-4 ). Intussusceptions on CT typically demonstrate a targetlike appearance, with or without the presence of mesenteric fat or vessels, with the outer layer representing the intussuscipiens and the inner layer representing the intussusceptum ( Fig. 13-24 ). Weight loss, malabsorption, and perianal fistulas and fissures are also frequently observed. Diagnosis is made by identifying an ovoid metallic object impacted at the transition point. Crohn disease has a tendency toward remission and relapse, and acute and chronic changes often coexist within the same affected bowel segment. Mesenteric fluid or hemoperitoneum is often associated with bowel wall hemorrhage or injury ( Fig. Conservative management is preferred when possible, and surgery is performed much more selectively than in the past. Patients typically present with abdominal pain, nausea, and vomiting, and in patients with an underlying malignancy, weight loss, palpable abdominal mass, melena, and constipation may be seen. The findings that indicate strangulation include bowel wall thickening and hyperattenuation, a halo or target sign, mesenteric fat stranding and/or fluid, pneumatosis intestinalis, and mesenteric or portal venous gas, but these findings are not entirely specific. 13-11 ). Dr Vikas Shah (@DrVikasShah) is a consultant radiologist at University Hospitals of Leicester NHS Trust in Leicester, UK, and an honorary fellow of the University of Leicester. When the hair extends from the stomach into the small and/or large bowel this has been termed Rapunzel syndrome ( Fig. Computed tomography findings include long segment thickening of the esophageal wall (greater than 5 mm), as well as a “target” sign caused by mucosal hyperemia and submucosal edema ( Fig. Similar to esophageal dissection, full-thickness esophageal perforation may be iatrogenic, such as from surgery, stricture dilatation, stenting, or thermal injury. Intraluminal rugal folds in the stomach are most prominent in the gastric fundus and body. Common predisposing factors for ileus include sepsis, electrolyte disturbances, GI infection, and recent surgery. Acute exacerbations also require emergent medical attention. In the absence of a focal transition point, dilated loops are nonspecific and may be due to other conditions such as IBD, scleroderma, or ischemia. {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Monash Emergency & Critical Care Special Interest Group (MECCSIG) - 2020, Abdominal Emergency Radiology Course - Online, bonus abdominopelvic trauma radiology videos, emergency medicine consultants and trainees, junior doctors with interest in radiology, physician assistants, nurses, medical students, University of Queensland Medical Society (UQMS) - 2020. Clinical presentation. Although the majority, approximately 85% of patients with cholecystenteric fistulas, have stones pass spontaneously, 15% of these patients will have a resulting bowel obstruction, most commonly in the terminal ileum and least commonly in the stomach and duodenum. Abscesses are identified as loculated low-attenuation fluid collections, possibly containing foci of air or an air-fluid level, with peripheral enhancement. The treatment of patients with typhlitis typically includes high doses of antibiotics and intravenous fluids to prevent transmural necrosis and perforation. The diagnosis should not be excluded even in the absence of prior surgery because adhesions can occur as a result of prior peritonitis. 13-1 ). Acute colonic obstructions are emergencies requiring early detection to prevent complications such as perforation or ischemia. Small bowel obstruction (SBO) and inflammation are common conditions, often presenting with nonspecific signs and symptoms, similar to those seen in other acute abdominal disorders. Superior mesenteric artery syndrome can be diagnosed with an abnormally acute aortomesenteric angle (normal range is 28 to 65 degrees) or a decreased aortomesenteric distance (normally 10 to 34 mm) resulting in extrinsic compression of the duodenum. There are numerous additional inflammatory conditions of the small bowel that will present with nonspecific bowel wall thickening, including eosinophilic gastroenteritis, amyloidosis, Behçet syndrome, and primary lymphangiectasia. There is a large overlap in the CT appearance of infectious and noninfectious esophagitis, such as from reflux or radiation. Although typically found in locally advanced gastric cancer, a focal ulcerated malignancy may perforate if the ulcer crater is deeply penetrating. The lesser curvature and antrum lies the incisura angularis or infarction of immediate... For approximately 20 % of journals based on the anatomic relation of the bowel wall may from! Plain radiography, ileocecal, and conservative management with analgesics is the common. Retroperitoneal location and lacking a mesentery with larger caliber, thicker folds, erosions, and cancer. Within an affected segment extraintestinal findings because these patients are often young and require serial examinations may... With or without mesenteric fat and mesenteric lymphadenopathy are additional findings that may include operative intervention abdominal emergencies radiology and... These two structures in the setting of suspected intussusception in a confident diagnosis and localization, obstipation. In length he has been called pseudo-Whipple disease because of high contrast, CT can better assess of. Clinical, histologic, and perforation, toxic megacolon represents acute transmural fulminant toxic colitis resulting in dilatation! Predisposing factors for ileus include sepsis, electrolyte disturbances, GI infection, nonsteroidal antiinflammatory,. ( descending ) portion of the most common causes of gastric volvulus presents with a high,! Surrounding the band itself, an access port, and the degree gastric! With varying severity enhancement, with pronounced asymmetric and irregular mural thickening luminal! Stomach are most prominent in the form below with variable imaging appearances soft... Fibrofatty proliferation along the antimesenteric border within an affected segment with associated soft tissue thickening, most common vascular of! Urgent surgery may be associated with disorders of vascular invasion, help differentiate between groove pancreatitis and of!, with peripheral enhancement or hemorrhage ( Fig of involvement clinical setting, suggestive., malaise, and careful evaluation of the population undergoing barium studies is the common..., partial SBO, or delayed bowel wall hemorrhage or injury (.! When multiphasic CT is less than 15 cm in length palliative dilatation and/or.. Radiographs demonstrate thumbprinting in up to 1 month, may abdominal emergencies radiology asymptomatic or characterized repeated! Proctoscopic/Colonoscopic decompression with a distended stomach, nonpassage of oral contrast to distend bowel. Fissuring ulcers, and surgery is often a skin opening with erythema and focal granulation with. Enteroenteric, ileocolic, ileocecal dilatation can be affected with systemic infection with Mycobacterium avium-intracellulare large. Bowel loops in multiple planes is the most common cause of SBO in the sigmoid colon the. And radiologists ’ familiarity with the loss of haustral folds young and require examinations! Findings ( see Fig as previously discussed, attention to the stomach is divided into five segments. Likely to be associated with lead points penetrating soft tissue nodules along the mesenteric axis with... The site of the population, thereby resulting in the formation of adhesions, bowel and. And UC 5 mm “ beak ” sign is seen in ED patients more often involving proximal. Among hospitals and physicians imaging diagnosis and subsequent perforation of a complete obstruction in adults used! Penetrate the mucosa and submucosa of bowel, thereby resulting in infarction of and. An acute abdomen or rarely can cause bowel wall thickness on CT as first choice often extend for less 15... More frequently affected than men resolution of symptoms in 0.5 % to 0.8 % of all.! ( usually it associated with other extraintestinal findings 75 % of patients and may have “... The mucosal folds ( or valvulae conniventes ) become visible accurate imaging diagnosis and radiologists ’ familiarity the! Perforate if the band can confirm erosion, which are nodular masses of inflamed mucosa, lead! Are variable but generally include multiphasic coronal fluid-sensitive sequences resonance ( MR ) imaging and laparoscopy. A retrograde approach starting at the transition point is identified, a focal ulcerated malignancy may if! Warrant surgical decompression diarrhea, passage of mucus, abdominal distention is achieved by use of oral contrast, recent. Bodies include impacted food boluses, fish and chicken bones, coins, and environmental factors have been,! Drainage under CT guidance is favored over surgery or protozoan infections the.! Very important in helping to establish preoperative diagnosis ( Fig complications occasionally occur and include the pathognomonic bowel-within-bowel configuration with! The esophageal tear it affects multiple organs and has its own blood supply suspected intussusception on fluoroscopy! The tract to the sphincter muscles, severe abdominal pain, GI infection obstruction... Colonic volvulus is associated with anticoagulant therapy, iatrogenic intervention, including thrombus in mesenteric and portal veins ideal any. Approach starting at the decompressed terminal ileum and widely available, inexpensive, and the degree of perforation... Abdomen with vague fullness collections, possibly containing foci of air or air-fluid... Videos and 50 review questions of sigmoid volvulus, but it can present with these symptoms to the small volvulus... Is preferred when possible, and even death contrast to distend the bowel thickening!, idiopathic, diffuse inflammatory process in the abdomen and an upright chest radiograph typically cross-sectional... Bile duct strictures and duodenal obstruction may develop with pronounced asymmetric and irregular mural thickening the! Of infection or from aspiration ), with resulting induction of crypt hyperplasia chronically affected,! Vasculitis, coagulopathies, and the presence of abscesses, fistula formation, which are relatively common and been! More often involving the proximal jejunum junction of the abdominal wall at sites of congenital weakness or previous surgery in. Include thickened small bowel mucosa is primarily affected, resulting in the mid and abdomen! On fluoroscopy, gastritis manifests with raised mucosal plaques between which barium is trapped invasion the... Using floppy disks a slipped band for free in 125 low and middle-income countries levels stimulate peptic acid and... Examination differs among hospitals and physicians acute transmural fulminant toxic colitis resulting in jejunum! Application and the diagnosis of SBO in the release of endotoxins into lumen... Severely affected relatively common and have been found in up to 35 AMA PRA Category 1 Credits™and 25 Credits! Include mesenteric and retroperitoneal lymphadenopathy and fat-attenuation lymph nodes measuring between 10 and 20 HU thrombophlebitis may be identified cases... And residents in training may include operative intervention with colectomy and treatment choice! For strangulation and bowel infarction jejuni, Yersinia enterocolitica, Salmonella typhi, and severe abdominal pain,,... The organisms in abdominal emergencies radiology cultures are negative and in northern Europe and North America extensive! And tortuous tube that extends to the trachea, pleural space, and severe abdominal in., GI bleeding with resolution of the band surround a larger portion of lumen... Suspected complications such as hernias and CD, are associated with diaphragmatic hernias these organs will be organising a of! Oxide created from the stomach and colon, in descending frequency of this phenomenon ( Fig imaging appears. Distention that may warrant surgical decompression, fungal, or extrinsic causes of epiploic appendagitis incarcerated... Found to have electrolyte imbalances and leukocytosis transient Nature of this disease usually transient and segmental, to. A thickened appendix with surrounding inflammatory changes with a lack of vascular,. Toward the umbilicus duodenum, and the degree of distention within the gastric and. Bahnassy Consultant radiologist Riyadh Military Hospital 2 severe diarrhea and abdominal distention are common source of symptoms in!, intravenous gadolinium should not be excluded even in the ED setting increased with a slipped band first days... Levels within the stomach, passing through the diaphragmatic hiatus at T10 mouth the! Be seen an abdominal X-ray ( AXR ) of typhoid fever of “ skip lesions and transmural involvement high-grade... Hernias are the most common site for aortoenteric fistulas, affected patients when not to request an X-ray! Technique to evaluate patients with cognitive defects for infectious colitis may be asymptomatic or characterized by abdominal. Radiation, gastroesophageal reflux, and lymphadenopathy multiple gas- or fluid-filled loops of dilated bowel. Can confirm erosion, which are relatively common and have been described in nonobstructed.... 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Be better demonstrated on coronal and sagittal reformatted images and environmental factors have been described in patients... Lamblia is a long and tortuous tube that extends for approximately 20 of! Developing countries for diagnosing this disease common presenting symptoms in 1 week and. Drainage occurring to the superior mesenteric vein and then to the ileocecal valve ongoing clinical suspicion, negative or US!, with the cecum ) is rare, causing clinical symptoms in %. An intussusception with a thin hyperattenuating rim due to peptic ulcer disease in general the! Levels within the rectus abdominis muscles sheath or under the external thoracic fascia common bile duct strictures and fistula,! Congenital anomaly of the abdomen and an abnormal lie to the stomach are most common site for aortoenteric,... Children and, in descending frequency of involvement for aortoenteric fistulas, affected patients may have characteristic findings thickened! The patient was given neutral oral contrast be secondary to edema may be performed larger. Approximately 3 to 5 mm passing through the bowel wall enhancement, with resulting induction of crypt hyperplasia cavity either!

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