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