Perspective

Sonography
Considerations
Julien B. C. M. Puylaert1, Friso M. van der Zant1, Arie M. Rijke2

and the Acute

Abdomen:

Practical

O
. .

ver the past 10 years, has gained acceptance

ing

sonography for examinabdominal noninvasive,

of

27%;

and

concomitant

serious

therapeutic

required

as well

as patients
surgery

with a remote
(Figs. 1 and of 2).

possi-

patients

with

acute

delay in 14% of patients who needed [1]. Another prospective study dividing into three
clinical

surgery patients and low

bility ofrequiring
Not abdomen tice
formed makes surprisingly,

sonography

the acute pracperpain

pain.
rapid,

Sonography
inexpensive,

is dynamic,

categories
suspicion)

(high,
showed

equivocal,
that even

has markedly institutions.

on indication

affected
of acute abdominal

routine
abdominal sonographic

however, limited cannot

more

and readily accessible; it has some serious drawbacks. Use is the ultrasound
techniques,

in the high-

in many
up 25%

Sonography

in obese patients; penetrate

than other bone radiologic

beam
is oper-

suspicion have an patients

inflamed

group, 35% appendicitis, appendix aortic

more than [2].

of the patients whereas 5% group In 30 patients

did not of the had with an a

of all

or gas; and sonography, requires several

on

in the low-suspicion aneurysm,

6 hr because

examinations wide, acute most frequent to the hospital

at our abdominal reason

when

institution, pain has

they

and nationbecome the to go in

ator-dependent

and

skill,

dedication,
aspects acute

ruptured
delayed

and experience. In this perspective,

of using sonography pain are abdominal

treatment was of misdiagnosis diagnoand that studies as of in cases

for radiologists are on call.

practical
with

[3]. These

figures for

show abdomen

that the clinical is unreliable

imaging

patients

sis of an acute the threshold a helpful clinical

include

the choice

highlighted. These aspects between sonography and CT of

radiologic concept
tool used

Sonography Several easily

gram. They

or CT as Initial acute abdominal a ruptured

an

Technique?
are

should be low. The

diagnostic

of sonography only

conditions

more

as an initial examining technique, the timing the sonographic examination, sonographically guided graphic
findings puncture,

detected

on a CT scan

than
aortic

on a sonoaneurysm, rupture, a an and usually

doubt

is and should of sonography

be

rejected.

include dissection,
aneurysm,

the the

value
and,

of indirect
finally,

sonocommu-

The impact

on clinical abdomen
with

manis
sus-

an aortic
mycotic

an esophageal

findings,
on

significance

of normal

a sonogram,

agement of patients with an acute impressive. In a study of patients pected appendicitis, nificantly in 26% sonographic

incarcerated hepatic
provide have abscess,

internal

acute pancreatitis, hernia, and perirenal CT scans

patients

nication

with the clinician.

findings

sig-

abscesses.

In addition,

changed the therapeutic management of patients [4]. In three independent using sonography, 13%,
delay.

better results in obese retrocecal appendicitis,

deeply located sigmoid

who appendiceal

Indications Traditionally,
negative ill-advised surgical

studies surgeons delay.

the

negative and
7%,

laparotomy respectively, in unnecesvirtually

have

accepted

a high serious
A

rates
sary

were
surgical

13%,

closed-loop
perforation

bowel

obstruction,

diverticulitis, gastrointestinal and emphyin experito condia reason-

laparotomy surgical
delay inside

rate to avoid Nonetheless,

hospital

the risks of
is common.

[4-61 with a concomitant

In our

reduction
institution,

to the retropetitoneum,

sematous enced reliably tions

cholecystitis. hands, the sonograrn most diagnose

However, acute abdominal

all patients pain

patients

with referred for

acute for

or subacute a sonogram, surgery seems

abdominal including definitely

can still be used

prospective appendicitis

study showed

of patients a negative

with

a suspected rate

are

laparotomy

whom

in most

patients

[4]. Therefore,

Received June 1, 1995; accepted after revision July 23,

1

1996.

Department of Radiology, Westeinde Hospital. Ujnbaan 32, 2512 VA The Hague, the Netherlands.
of Radiology. Health Sciences Center, University of Virginia. Lee St, Charlottesville,

Address VA 22908.

correspondence

to J. B. C. M. Puylaert

2Department

AJR 1997;168:179-186

0361-803X/97/1681-179

American Roentgen Ray Society

AJR:168, January

1997

179

Puylaert

et al. man with acute appendicitis had 2-day history of constipation and uncomfortable sensation in lower abdomen. No local or rebound tenderness and no fever were present Erythrocyte sedimentation rate was 32 mm! hr with normal leukocyte count Proposed management was conservative. A and B, Sonography showed inflamed appendix in longitudinal (A) and transverse (B) plane. Appendix was subsequently removed. Fig. 1-68-year-old

able course

of action

is to begin

with

the least

ticular radiologist possible

patient. should

During

the

examination,
consider

the

nation structure palpable

most

is helpful

when

identifying

what

organ

or
the

expensive and least invasive technique and proceed to a CT scan only in cases of an inconclusive sonogram. Examination Technique

continuously

all on

corresponds
region may conditions

to the most painful

if in women pelvis, is deep in the

area or
vaginal gynesig-

differential sonographic
with may

diagnoses findings.
the raise

depending This symptomrequires

because questions

mass. For example.

help but not only also

the

sonographic

tender

directed
communication cific

examination
patient specific

sonography
cologic moid Asking

in detecting in diagnosing

spe-

Examination of the entire abdomen, from the axilla to the groin. in patients with acute abdominal of all
involves

findings

diverticulitis patients to

171or
point

appendicitis
out important the

[8] (Fig. 4).

most tender in conditions but do

and.
patient

conversely,
may lead

information
to a search feature sonographic

provided
for

by the

pain is more organs.

a sonographically

than

a routine

survey

a specific

region

can be especially

abdominal

The problem

examination
rational

sonographic Similarly.

(Fig.

3).
examination is closely

that typically A dual examimental

cause localized infarction

tenderness features.

guided.

not have conspicuous omental

sonographic

Segepiploic

approach

to the clinical

of that

par-

linked

with physical

examination.

19].

Fig. 2-24-year-old previously healthy man was admitted with classical presentation of acute appendicitis. No diarrhea was present WBC was 16,500!mm3. Immediate appendectomy was proposed. AD, Sonography shows mucosal inflammation ofterminal 1eum in transverse (A) and longitudinal (B) planes as well as enlarged mesenteric lymph nodes (C). Appendix (arrows) was small and measured 2.1 mm during compression. Surgery was cancelled. Three days later, Salmonella paratyphi B (D) was cultured from stool. a = iliac artery , v = iliac vein.

180

AJR:168,

January

1997

Sonography

and

the

Acute

Abdomen

appendagitis epiga.stric
or sigmoid

10), an incarcerated
a small rectus

spigelian
hematoma

or
[I I],

hernia,

diverticulitis

[ I 2, 13j are a few such diagnostic distance

lower

conditions found tender

(Figs. 5 and 6). hand. signs can be from the most the pain is someabdomen, duodenal a patient

On the other region.

at a considerable
in the

In appendicitis. with right a perforated lower track

times diffuse may present that causes the gastric colic gutter.
maximum site

ulcer because parethe distal

quadrant down obstruction

pain

contents
pain

the right
from in the

small-bowel
(Fig.

may cause

at a marked

distance

of obstruction

7), a stone

ureter may present the biliary may metastases

system a

with only
with

flank bowel
ileus,

pain,
or

air in
liver

small

obstniction maligmass. importance

indicate may

gallstone

indicate
with

an underlying
an appendiceal the

nancy in patients These examples

all emphasize

of examining the entire abdomen. If the anatomy is aberrant. especially case of

from the

Fig. 3-67-year-old in the removed

is tions.

woman with 10-year history of abdominal pain complained

of recurrent

urinary tract infec-

an inflamed
point where

appendix
the gridiron

far

incision

normally marked (Fig.

abdomen

made. on the
should similar

The skin be

appendix with in patients performed to gentle the distance structure probe. the disturbing images.
the extent

should with
with

be pencil

A, Sonography showed thickened small-bowel loops (b) with interloop fistula (black arrows). Adjacent bladder wall was locally irregular (white arrows). B, Small amount of air was found in dome of bladder (arrowhead). Only on specific questioning did patient recall episode of urinating air. She was diagnosed with Crohns disease with fistulization to bladder. fluid-filled abscesses bowel loops can be avoided or gas-containing (Fig. 10). With the

an indelible

8). Sonography

an acute graded
[

compression Compression transducer used bowel.

palpation from

14). the

shortens to the abnormal

patient in a left lateral air should specifically the lateral abdominal

decubitus position, free be looked for between wall and the liver.

and allows It is also effect

an organ

the use of a high-frequency to compress thereby or displace reducing

determining

gas-containing of Timing
Many

of the Sonographic
acute abdominal

Examination
conditions show a

gas on the sonographic also involves For instance,

of gallbladder

Compression

tendency
however,

toward
symptoms

spontaneous may recur of abdominal cases of is relieved, when reappear.

in biliary

resolution; later. pain Interare pre-

and its surrounding

hydrops

tissues

can be compressed. allows identification

of as assessment

compression rigidity
in

mittent 9).

episodes

as well

appendiceal
Finally,

appendicitis always pain.

(Fig.

dominantly seen in When the obstruction toms recurs,

This

obstruction. the sympobstruction

and urinary

compression

should

be applied to the In

resolve. scenario disease.

and

the

in a graded
hamper

manner

to minimize

the symptoms

If. despite the can

compression. sonographic be scanned

gas continues examination, with over the transducer the flank.

is seen and

stone

appendicitis. hernia,

intussusception,
small-bowel obstruc-

patient positioned

incarcerated

posterolaterally ventrally located

Fig. 4.-25-year-old woman complained of lower abdominal pain in pelvic region for 1 day. Transabdominal sonography was normal. Transvaginal sonography

this manner.

gas in partially

tion from adhesions. Sonographic findings during an episode of pain may differ significantly

revealed inflamed appendix (arrow).

Fig. 5.-Infarcted epiploic appendix. 40-year-old man had severe pain on pressure in left lower quadrant, suspect for sigmoid diverticulitis. Erythrocyte sedimentation rate was 36 mm!hr. A, At point of maximum tenderness, sonography showed 2.5-cm ovoid area of inflamed fat (arrowheads). B, CT scan confirmed diagnosis of infarcted epiploic
appendix (arrowheads).

AJR:168,

January

1997

181

Puylaert

et al. Fig. 6.-Otherwise healthy middle-aged woman presented with severe localized pain in right lower quadrant. She was suspected of having appendicitis. A, Sonography showed small, impalpable rectus hematoma (arrowheads). B, Rectus hematoma (arrowheads) was confirmed by CT scan. Appendectomy was cancelled.

Fig. 1.-Incarcerated obturator hernia. 86-year-old woman presented with small-bowel obstruction. A, Left-sided groin sonography revealed small, impalpable herniated bowel loop (asterisk) behind pectineus muscle. B, T2-weighted MR imaging confirms incarcerated obturator hernia (asterisk). Also note contralateral asymptomatic hernia. a
=

femoral

artery,

femoral

vein.

Fig. 8.-Inflamed appendix in unusually high position. A, Sonogram shows inflamed appendix in right upper quadrant. B. In view of its unusual position, location of appendix was drawn C. This location influenced site, size, and direction of incision.

on skin with indelible

pencil.

182

AJR:168, January

1997

Sonography from
sode

and

the

Acute

Abdomen

findings and from

during

immediately the findings For

an

after several

such

an epiafter

days

such
examined

an episode.

instance,
episode

if a patient is of biliary colic, a thickening Murphys of the sign,

sonogram gallbladder

may show wall,

hydrops,

a sonographic

and an impacted stone. A few days later, when the symptoms have subsided, all that is found is a morphologically ing
should

normal stone. be correlated

gallbladder Sonographic with

containfindings of
or

mobile
always

the course
bowel,

the symptoms in time. Dilatation obstruction ofthe gallbladder, kidney, appendix may the obstruction.
changes disappear

due to an

quickly However, the with the process sonographically when These impressive be documented

after relief of inflammatory of obstrucvisible for

associated
often remain

tion days long

explain

or weeks since why

even an can

the symptoms residual cholecystitis

have
changes

subsided.

or

appendicitis the sonogram

sonographiat the time of

cally in a patient

free ofsymptoms 16](Fig. I 1).

Preferably, the examination should be done during an episode of pain for two reasons. Not only is the chance of a diagnostic sonographic finding greater but it also guarantees optimal timing of possible surgery. In case of intennirtent episodes ofpain, the patient should be warned to seek immediate medical attention during the next episode so that sonography, and possibly surgery, can be performed without delay (Fig. 12).

Fig. 9.-Acute gallbladder hydrops. A and B, On compression of gallbladder, in longitudinal (A) and transverse (B) plane mild bulging (arrowheads) of anterior abdominal wall was noted, indicating hydrops with high pressure in lumen. No gallstones were visualized. At surgery, 3-mm obstructing stone in distal cystic duct was found.

Indirect fluid, cally however, guided pus, can puncture rapid bile, fluid,
(Fig.

Sonographic sonographic

Findings diagnoses such as appenare fairly with confi-

be helpful. carries differentiation and can

Sonographivirtually between laborafurther fluid, and no

Many

Sonographically In patients with

Guided an acute

Puncture abdomen, a small

risk and allows blood, tory

malignant

dicitis, renal straightfoaward

colic, or cholecystitis and can be made

and

additional distinguish

amount of free fluid may occur in both surgical and nonsurgical conditions and, as such, is nonspecific. Identifying the nature of the

investigation gastric
ascites

dence. However, tion is not well,

sonography.

sometimes the primary condior not at all, recognizable by cases, indirect sonographic

between

pancreatic 13).

In such

findings

may be of help.

Fig. 10.-Small-bowel obstruction with partially gas-filled loops. A and B, Ventral scanning yielded only air(A), whereas posterolateral

scanning clearly showed dilated loops (B).

Fig. 11.-50-year-oldwomanwith classic signs of cholecystitis 2 days earlier was completely free of symptoms when this sonogram was obtained. Gallbladder still showed considerable residual changes. 183

AJR:168,

January

1997

Puylaert

et al.

primary ocolitis.

bowel Crohns

wall diseases disease,

as infectious

ile-

or ischemia

I 15).

Other useful indirect findings are associated with abscesses, which occur when a gastrointestinal sealed
or

perforation Often the diverticulitis,

is not

effectively

off.

underlying Crohns

causedisease, In this

appendicitis,

a malignancy-can be cases of large, gas-containing determination abscessogram

neous drainage

determined. abscesses,

may done

be difficult

I 16, 17). An

some days after percutaand a repeated sonogram the underlying condition. is of inef-

may, as yet, reveal

Another indirect sonographic sign related to free perforation. If the process sealing the bowel has been completely fective and the bowel contents into the peritoneal cavity. first then Fig. 12.-Over 3 months, 59-year-old woman suffered from severe colicky attacks lasting 1-2 hr. Two earlier sonographic examinations performed during symptom-free intervals showed no abnormalities. Present examination, performed during attack, revealed intussusception. ileus
fluid-filled

are spilling a local and with of paralytic dilated

peristal-

a generalized will ensue.

bowel

peritonitis The
loops

presence
with absent

sis is an important

clue

and.

in most

cases, requir-

indicates a gastrointestinal perforation ing surgical treatment (Fig. 15). The most helpful to gastrointestinal occur in appendicitis,
ease, peptic

indirect findings are related pertration. such as may

diverticulitis. Crohns dis-

organ and, although be overlooked

spicuous feature

often
of inflamed

prominent,

can easily

on a sonogram. which graded is best observed compression fat, especially areas

The most confat is its noncom-

Normal

Sonographic
unusual to

Findings
find no sonographic

It is not abnormalities acute tive abdomen.

sonographic

ulcer disease, and bowel inesenteiy, protective and bowel

prevent

cancer.

In

pressibility,
intermittent ducer.

by applying with the transin advanced in the abdomiof the neigh-

whatsoever In patients requiring

examination

in patients with surgery,

can

with

an

all of these conditions,

omentum, site
attempt

migration of loops to the

occurs in of howel

a low clinical a negausually

Inflamed

suspicion

of disease

of

imminent
to seal offand

perThration cavity.
and

an

cases,

is well recognized streaky

mural

on a CT scan as hyper-

be

spillage

attenuating
Secondary

(dirty)

contents

into the peritoneal

The
omentum

migratare

nal fat(dirtyfat)(Fig. 14).

thickening

taken as confirmation that no condition requiring surgery exists. lf however, clinical findings and laboratory tests ity, further workup
occurs frequently suggest a serious abnormal-

ing, inflamed fatty mesentery recognized as amorphous choic, noncompressible concentrated fat is usually

masses tissue. around

This

of hypereinflamed

boring
citis,

bowel
is another

loops,
indirect

such may

as seen
This

in appendifinding can

is required.
in young

This

problem
in whom

sign.

women

the diseased

be confusing

and

be interpreted

as such

appendicitis

must be differentiated

from adnexi-

Fig. 13.-61-year-old woman was admitted with rapidly increasing pain over entire abdomen. She had suffered no trauma. A and B, Sonograms show free fluid around liver and inhomogeneous spleen. C, Sonography-guided puncture yielded blood. Surgery confirmed spontaneously ruptured spleen.

184

AJR:168, January

1997

Sonography

and

the

Acute

Abdomen

unnecessary localiceal ney

rise

laparotomy.

Thickening

ofthe

pye-

wall and local tenderness

clues to the diagnosis

over the kid[ I 8J. do not give

may provide
Two other and level nightmare.
to abnormal

diseases mesenteric

that initially findings ischemia

by

sonographic
diagnosed

are pan[19). Panserum.

elevated

creatitis creatitis amylase Mesenteric nostic found upper

arction

is usually

an

in

both

urine

and
can

ischemia,

however,

be a diagare or infbe fluid con-

When

no sonographic with symptoms,

cause

abnormalities

in a patient quadrant
or a pulmonary

severe

epigastric
should

a myocardial of pleural

sidered. region the first

embolism

A subtle amount of pulmonary

clue

or a be

consolidation pneumonia with (Fig. severe and

may 16). abdominal laboratory

to the diagnosis

of pulmonary

or early in a patient
both

If, Fig. 14.-Inflamed fat in sigmoid diverticulitis. A, Sonogram shows wall thickening of contracted sigmoid (5) and diverticulum surrounded by large areas of hyperechoic, noncompressible tissue (asterisks). B, This tissue represents fatty mesentery and migrated omentum, which was confirmed by CT scan.
symptoms,

sonographic

findings
cause

are repeatedly

normal.

a psychogenic be is
the

or functional bowel disorder should suspected. If the sonographic examination not conclusive,
tary study is a

the most
CT scan,

useful

complemenif

especially

patient

is obese

or is not suitable

for sonogra-

phy in other

respects.

Communication

with

the Clinician
surgeons have

For mote than a century,

taught

been man-

to rely on their clinical between

surgery and

impression conservative an acute

viewed

in their
abdomen. the ad-

decision agement

of patients

with

Understandably,

surgeons

have

vance ofsonography
perhaps

in this field with caution

and

clinical ogy has A B

even some distrust. The realization that astuteness is being challenged by technolc&tsed both

excitement
must A good and

and confusion
a good relarelationship starts have

[20}; therefore,

radiologists

Fig. 15.-i 1-year-old girl presented with right lower quadrant pain. A and B, Sonograms show dilated fluid-filled bowel loops over entire abdomen with complete absence of penstalsis during 10 mm of examination. No other abnormality was shown. Surgery by median incision showed generalized purulent peritonitis from perforated appendicitis.

tionship with surgeons. with mutual confidence

tion. mon Radiologist

good

communica-

and surgeon

should speak such as

acorn-

language.

Tenns

phlegmon, pseudoato
difficult cases,

perforation,
neulysm,

walled-offperforation, a radiologist
In

and ileuscan and a morphologic

mean differentthings
description

a surgeon tis. Normal appendicitis sonographic findings do not exclude or adnexitis. In this context, the sedimentation rate must by appendicitis, conspicuous periappendiceal that would not have in which
rate

and changes gone

extensive would unnoticed

therefore,

of the intni-

inflammatory be present

role of the erythrocyte

abdominal situation based on the sonographic findings should be given, and a single-term diagnosis should be avoided. ln such cases, the radiolo-

be emphasized, because in adnexitis it is usually high at the time of admission. If the etythrocyte
sedimentation rate is markedly elevated in a

during sonography. Another condition abnormalities are found erythrocyte sedimentation however, a condition this diagnosis requiting cal presentation.

no sonographic
ofa high is pyelonephritis;

gisi should ask the surgeon sonographic In the

ings history, should as

to be present sonographic
with the

at the find-

in the presence

examination. final
be physical

young and not too obese woman sonographic findings. adnexitis favored.
erythrocyte

with
is

normal
strongly

report,
integrated signs,

the

is usually surgery

made and

on clinito an

patients

The reasoning
sedimentation

is as follows:

if the high

It can, however,

masquerade lead

and

laboratory CT

data scan

rate had been

caused

as well

as the

results

of a possible

AJR:168, January

1997

185

Puylaert

et al. Fig. 16.-2O-year-old woman presented with severe right upper quadrant pain and marked leukocytosis. Patient was suspected of having cholecystitis or generalized pelvic inflammatory disease.
A, Sonographically. abdomen was normal.

Only abnormalities observed were some echolucent areas above diaphragm. B, On lateral chest radiograph, small posterobasal consolidation wasfound. Final diagnosis was right-sided basal pneumonia.

and other radiologic examinations. Liberal use and a clinical approach are the key points in sonography of the acute abdomen. Sonography
is a valuable tool to lower both and the the

Akuten Appendizitis. 6. Ooms HWA. Ho Puylaert JSurg 7. Broekman 1. Sigmoid JBCM. 1991:78:315-3

Ultraschall

Kang Ultrasound 18

You

PJ,

1989: 10: 17()-l76 Koumans RKJ, Br

I 3. Wilson nosis 14. Puylaert of

SR. The value acute JBCM. graded

of sonography of the

in the diagcolon. AiR

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and appendicitis.

1990:154:1199-1202
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