Uncommon and Unusual

Gastrointestinal Causes of the Acute

Abdomen: Computed Tomographic Diagnosis
Douglas S. Katz, MD,* Benjamin Yam, BS,* John J. Hines, MD,† Joseph P. Mazzie, DO,*
Michael J. Lane, MD,‡ and Maher A. Abbas, MD§

There is a wide variety of uncommon and unusual gastrointestinal causes of acute

abdominal and pelvic pain that may be prospectively diagnosed on computed tomog-
raphy. We demonstrate 10 such diagnoses and briefly review the current computed
tomography and clinical literature on intussusception occurring beyond early child-
hood, small bowel obstruction from internal hernia, cecal volvulus, intramural small
bowel hemorrhage, Boerhaave’s syndrome, gastrointestinal luminal foreign bodies,
small bowel diverticulitis, hemoperitoneum secondary to abdominal tumor; gallstone
ileus, and gallbladder torsion. Radiologists and clinicians need to be aware of these
disorders, particularly with the widespread utilization of computed tomography (CT) in
the management of patients with acute abdominal pain.
Semin Ultrasound CT MRI 29:386-398 © 2008 Elsevier Inc. All rights reserved.

I n this article, we review 10 uncommon or unusual gas-

trointestinal (GI) causes of acute abdominal and pelvic
pain that may be diagnosed prospectively on computed
tomography (CT). The diagnosis may be apparent in some
of these disorders, but the CT findings and correct corre-
sponding diagnoses may be subtler in others. This is not
intended to be a comprehensive illustration and literature
review of all less common or rare causes of the acute
abdomen but highlights entities which, while not encoun-
tered on a routine basis, may occasionally be found in a
busy CT practice which images patients with acute ab-
dominal and pelvic complaints. Radiologists need to be
aware of the CT findings of these disorders, and clinicians
need to be aware that, although uncommon or unusual,
with the widespread use of abdominal and pelvic CT, these
diagnoses can be established prospectively.
*Department of Radiology, Winthrop-University Hospital, Mineola, NY.
†Department of Radiology, Long Island Jewish Medical Center, New Hyde
Park, NY.
‡Department of Radiology, South Texas Radiology Group, San Antonio,
TX.
§Department of Surgery, Kaiser Permanente, Los Angeles, CA.
Address correspondence to: Douglas S. Katz, MD, Vice Chair, Department of
Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY,
11501. E-mail: dkatz@winthrop.org
Intussusception Occurring
Beyond Early Childhood
Intussusception of the bowel is a different entity in older
children and adults than in young children. When the colon
is the primary or sole portion of bowel involved, in up to 95%
of cases there is an identifiable pathologic leading point. This
point is a malignant tumor in between one-half and three-
quarters of colonic cases.1,2 Symptoms of colonic intussus-
ception in such patients may be acute, intermittent, or chro-
nic.2 The diagnosis should be established prospectively on
CT. Findings include a target- or sausage-shaped mass, with
the central portion representing the intussusceptum, sur-
rounded by eccentrically located fat, and then by the intus-
suscipiens. The leading point, particularly a lipoma, may be
identified (Fig. 1), but more frequently the underlying mass
may be difficult to distinguish from adjacent/edematous
bowel (Fig. 2).1,3 Surgical intervention is needed in the ma-
jority of colonic cases.
Pathologic processes underlie small bowel intussuscep-
tions in a minority of cases in older children and adults, eg,
due to small bowel metastases such as from melanoma, from
benign lesions such as a polyp or Meckel’s diverticulum, or in
transient intussusception such as may be seen in celiac dis-
ease or Crohn’s disease. However, the majority of such iso-
lated small bowel intussusceptions that are now identified on
a relatively routine basis on CT are transient and have no

386 0887-2171/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.sult.2008.06.007
Gastrointestinal causes of the acute abdomen
Figure 1 Large bowel intussusception due to a lipoma. A 61-year-old
woman with myeloma. (A) Initial abdominal CT scan, obtained for
myeloma staging, shows incidental right colonic lipoma (between
calipers). (B, C) CT scans for suspected right renal colic several
months later show intussusception related to the lipoma. Also note
the left iliac lesion related to the patient’s myeloma.
387
identifiable lead point (Fig. 3).4-8 They are presumably re-
lated to physiological intestinal peristalsis.3,4,6 Transient
small bowel intussusceptions without underlying leading
points are usually short (ⱕ4 cm) and nonobstructive.4-8 Most
cases can be managed conservatively. There is no consensus
on the utility of follow-up testing, such as repeat CT, small
bowel follow-through, CT enterography, or capsule endos-
copy.3 In longer segment/longer diameter small bowel intus-
susceptions, and when there is evidence of vascular compro-
mise and/or associated inflammatory changes on CT, more
aggressive management should be considered.5,8,9
Small Bowel Obstruction
from Internal Hernia
Internal hernia is a relatively rare cause of small bowel ob-
struction (SBO). It is related to congenital mesenteric defects
Figure 2 Ileocolic intussusception due to lymphoma. A 16-year-old
with intermittent right lower quadrant pain. (A, B) CT scans show
ileocolic intussusception in the right lower quadrant, without ob-
struction. An underlying mass cannot be identified. High-grade B-
cell lymphoma involving the terminal ileum and cecum was discov-
ered at emergency surgery.
388
Figure 3 Transient small bowel intussusception. A 49-year-old
woman with lower abdominal pain. CT scan shows short-segment
jejunal intussusception (between calipers), which was not identified
on a small bowel follow-through performed 2 days later (not
shown).
or prior surgery.10,11 The presentation ranges from asymp-
tomatic (with no associated obstruction) to intermittent
symptoms to acute small bowel obstruction with strangula-
tion. Prospective CT diagnosis may be difficult. Distinguish-
ing SBO secondary to internal hernia from closed loop SBO
due to adhesions can be challenging. The radiologist needs to
be aware of the entity and maintain a high index of suspicion
in the correct clinical setting (eg, a patient with no prior
abdominal surgery, or prior gastric bypass or hepatic trans-
Figure 4 Right paraduodenal hernia. A 50-year-old man with right upper quadrant pain and no previous surgical
history. (A, B) CT scans show a small bowel obstruction related to a cluster of small bowel loops in the right mid
abdomen. A right paraduodenal hernia was suspected on CT and confirmed at surgery.
D.S. Katz et al
plantation).10-13 SBO related to an internal hernia, whether
congenital or postsurgical, should be managed surgically.
Imaging of internal hernias using CT has been the subject
of several excellent recent reviews.14-16 The CT findings of
internal hernias particularly in the previously operated abdo-
men—and features which distinguish SBO related to internal
hernia from other etiologies and which may predict the spe-
cific type of internal hernia— continue to evolve.13,17
Internal hernias related to congenital mesenteric defects
are most commonly left and right paraduodenal hernias, her-
nias through the foramen of Winslow, and pericecal her-
nias.14 CT findings (Fig. 4) include clustered dilated small
bowel loops in a “sac-like” mass between the pancreas and
stomach or in their vicinity in left paraduodenal hernias. In
right paraduodenal hernias, loops of small bowel are noted
behind the superior mesenteric artery and inferior to the
third portion of the duodenum.10,14-16 Foramen of Winslow
hernias do not have an encapsulating membrane but are rel-
atively similar on CT to left paraduodenal hernias, with clus-
tered bowel loops in the lesser sac.16
Previously rare internal hernias are now well-described
complications following liver transplantation and Roux-en-Y
laparoscopic gastric bypass surgery. The most common type
in most gastric bypass series has been the transmesocolic type
(ie, at the mesenteric defect created to perform the gastroje-
junostomy),11,17 although the Peterson type (herniation of
small bowel behind the Roux loop, in a retrocolic or antecolic
position) was more common in a recent series.13 CT findings
of transmesocolic hernias include multiple small bowel loops
cephalic to the transverse mesocolon between the stomach
and spleen, a high position of the distal jejunal anastomosis,
an ascending course of tightly clustered vessels in the mes-
entery, and a dilated efferent jejunal loop.17 In the series
composed primarily of Peterson’s hernias, mesenteric swirl-
ing combined with a mushroom shape of the mesentery were
the best predictor on CT compared with a group of control
Gastrointestinal causes of the acute abdomen 389

Figure 5 Cecal volvulus. A 48-year-old woman with left lower quadrant pain. (A, B) CT scans show a distended cecum
in the left upper quadrant, with associated large bowel obstruction. The terminal ileum is located posterior to the cecum
(B, arrow). (Color version of figure is available online.)

patients.13 In transmesenteric hernias following liver trans-
plantation, clustered small bowel loops adjacent to the ab-
dominal wall without overlying omental fat and centrally
displaced colon were the most common CT findings.12 Bowel
obstruction secondary to internal hernia following gastric
bypass requires urgent operative intervention.
Cecal Volvulus
Colonic volvulus causes up to 10% of large bowel obstruc-
tions. Untreated, this closed-loop obstruction can lead to
colonic ischemia and infarction, which may be fatal. Up to
25% of the population have failure of peritoneal fixation,
allowing the proximal colon to be more mobile.18 Sigmoid
volvulus is the most common type of colonic volvulus. Cecal
volvulus is less common. Transverse colonic volvulus is the
rarest form.
Plain films may show the classic “coffee bean” appearance of
cecal volvulus, a dilated inverted U-shaped formation produced
by overlapping limbs of colon. However, plain films are equiv-
ocal in up to one-half of cases, with nonspecific findings. Al-
though a contrast enema is diagnostic, radiologists need to rec-
ognize cecal volvulus on CT, as it may be the first test performed
or may follow nondiagnostic plain films.18
There are surprisingly few publications on the CT findings
of cecal volvulus. Initial reports noted colonic obstruction,
torsion of the colon around the mesocolon with a “whirl”
sign, tapered narrowing of the efferent and afferent loops,
and the “coffee bean” appearance (Figs. 5 and 6).18 Multipla-
nar reformations may be helpful.19 There is usually marked
dilatation of the cecum, although it may not be initially ob-
vious that the cecum is the dilated portion of bowel. In about
one-half of cases, the cecum twists in the axial plane and
remains in the right lower quadrant, whereas in the other

Figure 6 Cecal volvulus. A 21-year-old woman with abdominal pain. (A, B) CT scans show a dilated cecum in the
midline of the abdomen anteriorly (arrows, B), with associated swirling of the collapsed terminal ileum (arrow, A) and
mesentery, and collapse of the descending colon. (Color version of figure is available online.)
390
Figure 7 Intramural small bowel hemorrhage. A 64-year-old man on
coumadin with markedly elevated INR and diffuse abdominal pain. (A,
B) CT scans through the lower abdomen following oral but not IV
contrast administration demonstrate a segment of thick-walled small
bowel with mildly hyperdense mural attenuation (white arrows) rep-
resenting acute hematoma. A small amount of hemorrhage infiltrates
the adjacent small bowel mesentery (*). (C) CT scan through the pelvis
demonstrates a small volume of hemoperitoneum (h).
D.S. Katz et al
Figure 8 Intramural small bowel hemorrhage. A 76-year-old woman
with abdominal pain and upper gastrointestinal bleeding, on cou-
madin. Non-enhanced CT scan shows hemorrhage in the anterior
and posterior walls of the proximal jejunum (between calipers).
There is also edema of the abdominal wall.
half, the cecum twists and inverts, migrating into the left
upper quadrant. A recent series of 10 patients classified the
former type as the “axial torsion” type (with a clockwise whirl
sign); the latter was classified as the “loop type” (with a coun-
terclockwise whirl sign). The CT appearance of a cecal bas-
cule, a distended cecum which folds on itself anteriorly with-
out torsion, was also reported.19 If there is bowel
strangulation, mesenteric edema, bowel thickening, and
pneumatosis may be seen.18
Cecal volvulus requires operative intervention, with no
established role for endoscopic reduction. A right hemicolec-
tomy is performed when the cecum is ischemic. A cecopexy,
fixation of the cecum to the abdominal wall, is performed
when the cecum is viable.
Intramural Small
Bowel Hemorrhage
Intramural small bowel hemorrhage is relatively rare but is
likely underdiagnosed. It can be trauma-related or can occur
spontaneously. In adults, spontaneous hematoma is usually
related to anticoagulation or an underlying bleeding disor-
der. It may also be secondary to ischemia or closed loop
obstruction.20-22 Gastrointestinal bleeding occurs in half or
fewer patients. Symptoms are usually vague and subacute,
and some patients are asymptomatic. The correct diagnosis is
often unsuspected and delayed.20,22
CT findings are best seen on non-enhanced images, as IV
contrast may obscure the hyperdensity within the bowel
wall. There is homogeneous and symmetric small bowel wall
thickening, usually involving a single site within the duode-
Gastrointestinal causes of the acute abdomen 391

num or proximal jejunum, or less commonly the ileum, with

variability of the average length of the segment of involve-
ment (Figs. 7 and 8).20-23 Patients are usually managed con-
servatively. The prognosis is guarded if greater than one-half
of the small bowel length is involved.23 Repeat CT as early as
several days may show findings of resolution.

Figure 10 Unexpected jejunal foreign body on non-enhanced CT

performed for suspected left renal colic. A 16-year-old female with
left flank pain for several days. CT scan shows small vertically ori-
ented metallic density in a proximal jejunal loop, which appeared to
extend through the bowel wall posteriorly. A short-segment wire
was removed by a pediatric surgeon through a pediatric endoscope,
and the patient did not require subsequent surgery.

Boerhaave’s Syndrome
Esophageal intramural hematoma and frank esophageal
perforation (Boerhaave’s syndrome) have a variety of eti-
ologies, including iatrogenic (approximately 75%, eg, fol-
lowing endoscopic procedures) and self-induced (partic-
ularly postemetic, following excessive food and/or alcohol
intake). Mucosal injury often occurs at the esophagogas-
tric junction, with associated hemorrhage (Mallory–Weiss
tear). A transmural perforation (Boerhaave’s syndrome)
may occur into the mediastinum, typically on the left side
posterolaterally.24 Other thoracoabdominal emergencies
may be suspected clinically, such as aortic dissection or
myocardial infarction.
Although plain films may show evidence of perforation,
with subsequent confirmation on an esophagram, CT has
utility to rule in or exclude the diagnosis (Fig. 9). CT
findings include pneumomediastinum/mediastinal or
pleural air-fluid levels, evidence of communication be-

Figure 9 Boerhaave’s syndrome. An 81-year-old man with sudden

onset of chest pain. (A, B) CT scans of lower thorax with abdominal
(A) and lung (B) window settings. Bilateral pleural effusions (*),
pneumomediastinum (black arrows), and bilateral pneumothoraces
(ptx) are noted. The left effusion is high in density (81 HU), consis-
tent with extravasation of oral contrast from the esophagus. (C)
Image from an esophagram performed with water-soluble contrast
several hours after CT demonstrates marked contrast extravasation
from the esophagus into the mediastinum (*) and into both pleural
spaces (black arrows). e ⫽ esophagus.
392 D.S. Katz et al

Figure 11 Unexpected ileal foreign body on CT performed for suspected bowel ischemia. A 78-year-old woman with
right abdominal pain. (A, B) CT scans show a subtle vertically oriented linear density which was correctly identified
prospectively as a fishbone, which had perforated the adjacent ileum and resulted in inflammatory changes. Following
CT, the patient underwent emergency surgery.

tween the esophagus and mediastinum (especially when
water-soluble oral contrast is given), pericardial effusion,
esophageal thickening, and associated inflammatory
changes.25,26
Most submucosal esophageal hematomas are iatrogenic.
Some are posttraumatic, and others are related to antico-
agulation or bleeding disorders. CT demonstrates submu-
cosal thickening with an attenuation consistent with hem-
orrhage. Intramural hematoma is usually managed
conservatively, whereas the majority of patients with Boer-
haave’s syndrome need emergent surgery.24,27 Conserva-
tive management is possible in a minority of patients, if
there is a combination of a contained tear, minor symp-
toms, no pleural contamination, and no systemic infection
(eg, with a small tear of the cervical esophagus following
an endoscopic procedure).24
GI Luminal Foreign Bodies
Few reports of CT identification of nonmetallic luminal GI
tract foreign bodies have been published. The diagnosis of
GI tract perforation related to an ingested foreign body is
usually not established prospectively without cross-sec-
tional imaging.28 There may be a substantial lag time be-
tween ingestion and the development of symptoms, and
for nonmetallic foreign bodies (eg, fishbones) the object(s)
may be obscured by contrast media.28,29 The radiologist,
therefore, needs to be aware of these potential pitfalls.
Correspondingly, we have recently identified several GI
tract foreign bodies on CT, where the diagnosis was not
suspected clinically (Figs. 10 and 11).
Although affected patients are commonly elderly, neu-
rologically compromised, or alcoholics, GI tract foreign
bodies may be seen in otherwise healthy adults. The ma-
jority (80-90%) pass without complication, but perfora-
tion may occur anywhere along the GI tract, most com-
monly at physiologic or pathologic sites of narrowing.30
Free air, localized pneumatosis, adjacent inflammatory
changes, bowel obstruction, and other complications are
demonstrated on CT, along with the foreign body. Com-
mon causes of perforation include fish or chicken bones,
and toothpicks.29,31
In a recent series of seven patients with fishbone perfo-
ration of the GI tract, the clinical diagnosis was not appar-
ent in any of the patients. The correct diagnosis was estab-

Figure 12 Duodenal, jejunal, and ileal diverticulitis. A 78-year old woman with lower abdominal pain, nausea, and
vomiting; 67-year-old woman with abdominal pain; and 88-year-old woman with metastatic breast cancer, now with
bloody diarrhea, respectively. (A, B) Initial CT scan with oral contrast only, shows duodenal diverticulum (between
calipers) containing gas and a lith with central gas, with surrounding inflammatory changes (A). CT scan several days
later (B) shows progressive soft-tissue swelling and inflammatory change in the same region related to duodenal
diverticulitis. (C, D) CT scans with oral contrast only, show free gas under the diaphragm (C) and a prominent jejunal
diverticulum that contains feces-like material and is associated with small bowel thickening and inflammatory changes
in the adjacent fat (D). (E, F) CT scans with oral and IV contrast show diverticulitis of the terminal ileum, with
diverticular disease and inflammatory changes.
Gastrointestinal causes of the acute abdomen 393
394 D.S. Katz et al

Figure 13 Meckel’s diverticulitis. A 13-year-old male with abdominal pain and Guaiac-positive stool. (A) CT scan
through the mid abdomen demonstrates the mouth of the diverticulum as a thick-walled structure (black arrows)
adjacent to normal small bowel. Note that this proximal portion of the diverticulum opacifies with oral contrast. Several
small pockets of extraluminal gas are present (arrowhead) adjacent to the diverticulum. (B) CT scan at a slightly lower
level shows inflammation of the peridiverticular fat, and avid mural enhancement of the diverticulum (black arrows) is
noted. Perforated Meckel’s diverticulitis was confirmed at laparotomy.

lished prospectively on CT in five of the patients, and the
diagnosis was evident retrospectively in the other two.28
Small Bowel Diverticulitis
With the exception of Meckel’s diverticula, small bowel
diverticula are acquired and involve only the mucosal and
submucosal layers, usually along the mesenteric border.
The pathogenesis of small bowel diverticulosis is unclear,
although intestinal dyskinesis and high intraluminal pres-
sures have been implicated. They are typically found in
older patients, often incidentally on imaging studies. Du-
odenal diverticula are the most common and are solitary,
whereas small bowel diverticula in other locations are of-
ten multiple.32-34 Small bowel diverticulitis is almost never
suspected clinically, and previously was almost never di-
agnosed prospectively, until the advent of routine CT im-
aging for acute abdominal pain. Patients present with in-
termittent pain or an acute abdomen. Perforation,
bleeding, or fistula formation may occur.32
CT findings of small bowel diverticulitis include a round or
oval collection containing air and other feces-like material but
usually not oral contrast, representing an outpouching on the
mesenteric side of the bowel, with associated inflammatory
changes and thickening of the adjacent bowel. There may also
be an associated abscess in cases of frank perforation as well as

Figure 14 Perforated Meckel’s diverticulitis. A 4-year-old boy with severe abdominal pain. (A, B) CT scans show a right
lower quadrant abscess with an associated tubular structure representing the portion of the diverticulum which has not
perforated (arrows, A) and inflammatory changes. A normal or abnormal appendix cannot be identified separate from
this process. Perforated Meckel’s diverticulitis with secondary appendicitis was found at surgery. (Color version of
figure is available online.)
Gastrointestinal causes of the acute abdomen 395

Figure 15 Hemorrhagic hepatocellular carcinoma. A 67-year-old man with severe acute abdominal pain, with no known
history of hepatitis or cirrhosis. At emergency laparotomy a large amount of acute hemoperitoneum and an actively
bleeding hepatic mass were found. The liver lesion was oversewn and biopsy of the lesion revealed hepatocellular
carcinoma. (A) CT scan performed shortly after surgery shows a heterogeneously enhancing mass in the medial left
hepatic lobe (black arrows) extending to the liver surface. Acute hemoperitoneum is present around the liver and spleen
(*). Note small pockets of pneumoperitoneum secondary to recent laparotomy (white arrow). (B) CT scan at slightly
lower level demonstrates a second hepatic mass (black arrows) extending to the hepatic surface with hemorrhage (*)
adjacent to the tumor and in the left upper quadrant. The inferior portion of the first lesion (white arrow) extends into
a thrombosed left portal vein (arrowheads).

adjacent diverticula in jejunal and ileal diverticulitis.32-35 The CT
findings are characteristic in our experience (Fig. 12).
The role of initial nonoperative management is not well
established, as there are few reported cases diagnosed pro-
spectively with CT. The risk of recurrence or other compli-
cations following conservative management after initial CT
identification has also not been determined.
In contrast, Meckel’s diverticulum is congenital (from in-
complete closure of the omphalomesenteric duct), contains
all three intestinal layers, and is found along the antimesen-
teric side of the ileum. Diverticulitis occurs from obstruction,
peptic ulceration of ectopic gastric mucosa, or torsion. Meck-
el’s diverticulitis may simulate appendicitis clinically and on
CT (Figs. 13 and 14), but the diagnosis can be established if
the diverticulum is identified on CT as being separate from
the appendix and not contiguous with the cecal base.36,37
Rarely, Meckel’s diverticula may contain a lith or liths.38
In the largest series of CT findings of Meckel’s diverticulitis
reported to date,36 11 patients had blind-ending pouches of
variable size (short axis, 1.5 to 6 cm; long axis, 2 to 7 cm)
with mural thickening. The diverticula contained gas, fluid,
or particulate material, but not oral contrast. There was mural
enhancement and inflammation of the adjacent fat. The loca-
tion was usually located in the midline but was also in the
right lower quadrant in a minority, with a variable location
relative to the terminal ileum (either superior or inferior).
A separate normal appendix was identified in seven pa-
tients, and there was SBO in five.36 Definitive management is
surgical.

Figure 16 Unexpected hemorrhagic hepatocellular carcinoma. An
80-year-old man with a history of bladder cancer, now with severe
abdominal pain. CT scan shows an exophytic left hepatic mass
(between calipers) which subsequently proved to be hepatocellular
carcinoma, with associated hemoperitoneum.
Hemoperitoneum
Secondary to Abdominal Tumor
Although hemoperitoneum secondary to abdominal tumor is
an uncommon scenario in Western countries, it is a relatively
common presentation in parts of Africa and Asia. It is usually
396 D.S. Katz et al

related to capsular rupture of a hepatocellular carcinoma

(HCC) (Fig. 15). Occasionally, hepatic adenomas, metastases
(eg, hypervascular metastases such as melanoma, but also
from colon and lung, among others), or angiosarcomas can
also present with hemoperitoneum, as may other GI tract
tumors (such as GI stromal tumors).39-41 Patients present
with abdominal pain and signs of acute blood loss (hypo-
tension, tachycardia), increased abdominal girth, anemia,
and peritonitis. Bleeding related to HCC may occur at
initial presentation, and the diagnosis not suspected until
CT is performed (Fig. 16). Identification of the underlying
tumor may be challenging, depending on the extent of
intrahepatic hemorrhage and the size and extent of tu-
mor.39 HCC is generally highly vascular. Tumor necrosis
can lead to rupture of blood vessels penetrating the he-
patic capsule, although the mechanism by which HCCs (or
hepatic metastases) rupture is likely multifactorial and is
not entirely established.40,42
Rapid diagnosis is essential, especially in ruptured he-
patic malignancy, where the mortality is high even with
timely intervention. Long-term survival is poor, and he-
patic arterial embolization is an appropriate alternative to
surgery in some patients.42,43 Nonmalignant hepatic le-
sions are typically resected, as are other nonhepatic hem-
orrhagic tumors.

Gallstone Ileus
Gallstone “ileus” is bowel obstruction secondary to a gall-
stone, which has eroded into the gastrointestinal tract as a
result of chronic cholecystitis. The gallstone (or occasionally
gallstones) usually erodes into the bowel at the level of the
duodenum. The obstruction occurs at a site of bowel narrow-
ing, especially the ileocecal valve, and less likely at the duo-
denal–jejunal junction, at the sigmoid colon, or at a patho-
logic site of stricture.44-46 Rarely, obstruction occurs in the
stomach or proximal duodenum (Bouveret’s syndrome).47,48
The CT findings of gallstone ileus are characteristic and are
the equivalent of Rigler’s triad (Fig. 17): bowel obstruction,
pneumobilia (in the gallbladder/bile ducts), and a ra-
diopaque stone at the transition zone of dilated to collapsed
bowel. The triad is not present in all patients, even on CT.
The pneumobilia is variable and the gallstone is difficult to
visualize if not well calcified.44,45,49 In a series of 27 patients
with gallstone ileus, with retrospective comparison of CT and
plain films findings, pneumobilia and an ectopic stone were
seen in 82% on CT, with Rigler’s triad present in 78% on CT,
whereas the triad could be identified on plain films in only
15%.50 In a series of 40 patients with gallstone ileus by the
same authors, there were five with multiple endoluminal Figure 17 Gallstone ileus. A 61-year-old man with known type B
gallstones. Stone size was variable but usually measured aortic dissection and acute abdominal pain. (A) CT angiogram dem-
onstrates pneumobilia (black arrow). (B) CT angiogram at slightly
greater than 2.5 cm.50 The morbidity and mortality of gall-
lower level shows pockets of gas within the gallbladder lumen
stone ileus may be substantial, especially in elderly patients. (black arrows). (*) Duodenum. (C) CT angiogram through lower
Treatment is surgery. As with other bowel obstructions, the abdomen shows multiple fluid-filled loops of small bowel (*) and
CT findings can be used by the operating surgeon as a intraluminal gallstone at the transition point (white arrow). Note
roadmap. collapsed distal small bowel (small white arrows).
Gastrointestinal causes of the acute abdomen 397

Gallbladder Torsion
Gallbladder torsion (a.k.a. volvulus) is rare and rarely cor-
rectly diagnosed preoperatively. In a review of 400 cases,
only four such patients were identified prospectively prior to
surgery. Gangrenous changes were found at surgery and pa-
thology in half.51 Torsion may be incomplete (⬍180 degree
twist) or complete. First reported in 1898 by Wendell as the
“floating gallbladder,” gallbladder torsion is usually seen in
older women (3:1 ratio).51 Predisposing factors include a
long mesentery, a gallbladder without mesenteric attach-
ments, large gallstones which may cause mesenteric elonga-
tion, kyphosis, and vigorous gallbladder peristalsis, although
the true etiology is unknown. The clinical and radiological
findings are similar to that of usual acute cholecystitis.52
However, there are radiologic findings which when com-
bined with the awareness of the entity may permit prospec-
tive diagnosis on sonography or particularly on CT.52-54 The
most suggestive imaging findings are an unusual position of
the gallbladder, especially a horizontal lie; location of the
cystic duct to the right of the gallbladder; and a conical struc-
ture at the gallbladder neck (Fig. 18).52,53,55 Treatment is
emergency surgery.

Summary
This potpourri of uncommon and unusual causes of the acute
abdomen as demonstrated by CT is not intended to be all-
inclusive, but reflects what we believe to be representative of
entities which, while not encountered on a routine basis, can
occasionally be identified in radiology practices where CT
imaging of patients with acute abdominal and pelvic com-
plaints occurs on a daily basis. Radiologists need to be aware
of these disorders so that appropriate patient management
may occur prospectively.

References
1. Huang BY, Warshauer DM: Adult intussusception: diagnosis and clin-
ical relevance. Radiol Clin North Am 41:1137-1151, 2003
2. Azar T, Berger DL: Adult intussusception. Ann Surg 226:134-139, 1997
3. Kim YH, Blake MA, Harisinghani MG, et al: Adult intestinal intussus-
ception: CT appearances and identification of a causative leading point.
Radiographics 26:733-744, 2006
4. Warshauer DM, Lee JKT: Adult intussusception detected at CT or MR
imaging: clinical-imaging correlation. Radiology 212:853-860, 1999
5. Lvoff N, Breiman RS, Coakley FV, et al: Distinguishing features of
self-limiting adult small-bowel intussusception identified at CT. Radi-
ology 227:68-72, 2003

Figure 18 Gallbladder torsion. An 86-year-old woman with nausea,

vomiting, and abdominal pain. (A, B) Non-enhanced CT scans show
dilated gallbladder fundus (A, between calipers) and neck (B, be-
tween calipers), with a transverse lie and a funnel-shape of the neck.
(C) CT scan at a slightly lower level shows gallbladder distension, a
gallstone, and pericholecystic edema. Gallbladder torsion/volvulus
was correctly identified prospectively based on CT and confirmed at
emergency laparoscopic surgery.
398
6. Rea JD, Lockhart ME, Yarbrough DE, et al: Approach to management of
intussusception in adults: a new paradigm in the computed tomogra-
phy era. Am Surg 73:1098-1105, 2007
7. Sandrasegaran K, Kopecky KK, Rajesh A, et al: Proximal small bowel
intussusceptions in adults: CT appearance and clinical significance.
Abdom Imaging 29:653-657, 2004
8. Tresoldi S, Kim YM, Blake MA, et al: Adult intestinal intussusception:
can abdominal MDCT distinguish an intussusception caused by a lead-
ing point? Abdom Imaging 33:582-588, 2008
9. Park SB, Ha HK, Kim AY, et al: The diagnostic role of abdominal CT
findings in adult intussusception: focused on the vascular compromise.
Eur J Radiol 62:406-415, 2007
10. Zissin R, Hertz M, Gayer G, et al: Congenital internal hernia as a cause
of small bowel obstruction: CT findings in 11 patients. Br J Radiol
78:796-802, 2005
11. Garza E, Kuhn J, Arnold D, et al: Internal hernias after laparoscopic
Roux-en-Y gastric bypass. Am J Surg 188:796-800, 2004
12. Blachar A, Federle MP, Dodson SF: Internal hernia: clinical and imag-
ing findings in 17 patients with emphasis on CT criteria. Radiology
218:68-74, 2001
13. Lockhart ME, Tessler FN, Canon CL, et al: Internal hernia after gastric
bypass: sensitivity and specificity of seven signs with surgical correla-
tion and controls. AJR Am J Roentgenol 188:745-758, 2007
14. Takeyama N, Gokan T, Ohgiya Y, et al: CT of internal hernias. Radio-
graphics 25:997-1015, 2005
15. Hong SS, Kim AY, Kim PN, et al: Current diagnostic role of CT in
evaluating internal hernia. J Comput Assist Tomogr 29:604-609, 2005
16. Martin LC, Merkle EM, Thompson WM: Review of internal hernias:
radiographic and clinical findings. AJR Am J Roentgenol 186:703-717,
2006
17. Reddy SA, Yang C, McGinnis LA, et al: Diagnosis of transmesocolic
internal hernia as a complication of retrocolic gastric bypass: CT imag-
ing criteria. AJR Am J Roentgenol 189:52-55, 2007
18. Moore CJ, Corl FM, Fishman EK: CT of cecal volvulus: unraveling the
image. AJR Am J Roentgenol 177:95-98, 2001
19. Delabrousse E, Sarlieve P, Sailley N, et al: Cecal volvulus: CT findings
and correlation with pathophysiology. Emerg Radiol 14:411-415, 2007
20. Lane MJ, Katz DS, Mindelzun RE, et al: Spontaneous intramural small
bowel haemorrhage: importance of non-contrast CT. Clin Radiol 52:
378-380, 1997
21. Macari M, Chandarana H, Balthazar E, et al: Intestinal ischemia versus
intramural hemorrhage: CT evaluation. AJR Am J Roentgenol 180:177-
184, 2003
22. Abbas MA, Collins JM, Olden KW, et al: Spontaneous intramural small-
bowel hematoma: clinical presentation and long-term outcome. Arch
Surg 137:306-310, 2002
23. Abbas MA, Collins JM, Olden KW: Spontaneous intramural small-
bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol
179:1389-1394, 2002
24. Vial CM, Whyte RI: Boerhaave’s syndrome: diagnosis and treatment.
Surg Clin North Am 85:515-524, 2005
25. Fadoo F, Ruiz DE, Dawn SK, et al: Helical CT esophagography for the
evaluation of suspected esophageal perforation or rupture. AJR Am J
Roentgenol 182:1177-1179, 2004
26. Ghanem N, Altehoefer C, Springer O, et al: Radiological findings in
Boerhaave’s syndrome. Emerg Radiol 10:8-13, 2003
27. Yen HH, Soon MS, Chen YY: Esophageal intramural hematoma: an
unusual complication of endoscopic biopsy. Gastrointest Endosc 62:
161-163, 2005
28. Goh BKP, Tan YM, Lin SE, et al: CT in the preoperative diagnosis of fish
bone perforation of the gastrointestinal tract. AJR Am J Roentgenol
187:710-714, 2006
29. Goh BKP, Chow PKH, Quah HM, et al: Perforation of the gastrointes-
tinal tract secondary to ingestion of foreign bodies. World J Surg 30:
372-377, 2006
30. Williams C, McHenry CR: Unrecognized foreign body ingestion: an
unusual cause for abdominal pain in a healthy adult. Am Surg 70:982-
984, 2004
D.S. Katz et al
31. Coulier B, Tancredi MH, Ramboux A: Spiral CT and multi-detector-
row CT diagnosis of perforation of the small intestine caused by in-
gested foreign bodies. Eur Radiol 14:1918-1925, 2004
32. Coulier B, Maldague P, Bourgeois A, et al: Diverticulitis of the small
bowel: CT diagnosis. Abdom Imaging 32:228-233, 2007
33. Gore RM, Ghahremani GG, Kirsch MD, et al: Diverticulitis of the duo-
denum: clinical and radiological manifestations of several cases. Am J
Gastroenterol 86:981-985, 1991
34. Greenstein S, Jones B, Fishman EK, et al: Small-bowel diverticulitis: CT
findings. AJR Am J Roentgenol 147:271-274, 1986
35. Macari M, Faust M, Liang H, et al: CT of jejunal diverticulitis: imaging
findings, differential diagnosis, and clinical management. Clin Radiol
62:73-77, 2007
36. Bennett GL, Birnbaum BA, Balthazar EJ: CT of Meckel’s diverticulitis in
11 patients. AJR Am J Roentgenol 182:625-629, 2004
37. Elsayes KM, Menias CO, Harvin HJ, et al: Imaging manifestations of
Meckel’s diverticulum. AJR Am J Roentgenol 189:81-88, 2007
38. Pantongrag-Brown L, Levine MS, Buetow PC, et al: Meckel’s en-
teroliths: clinical, radiologic, and pathologic findings. AJR Am J Roent-
genol 167:1447-1450, 1996
39. Lucey BC, Varghese JC, Anderson SW, et al: Spontaneous hemoperito-
neum: a bloody mess. Emerg Radiol 14:65-75, 2007
40. Mortele KJ, Cantisani V, Brown DL, et al: Spontaneous intraperitoneal
hemorrhage: imaging features. Radiol Clin North Am 41:1183-1201,
2003
41. Cegarra-Navarro MF, Corral de la Calle MA, Girela-Baena E, et al:
Ruptured gastrointestinal stromal tumors: radiologic findings in six
cases. Abdom Imaging 30:535-542, 2005
42. Kim PT, Su JC, Buczkowski AK, et al: Computed tomography and
angiographic interventional features of ruptured hepatocellular carci-
noma: pictorial essay. Can Assoc Radiol J 57:159-168, 2006
43. Hsieh JS, Huang CJ, Huang YS, et al: Intraperitoneal hemorrhage due to
spontaneous rupture of hepatocellular carcinoma: treatment by hepatic
artery embolization. AJR Am J Roentgenol 149:715-717, 1987
44. Loren I, Lasson A, Nilsson A, et al: Gallstone ileus demonstrated by CT.
J Comput Assist Tomogr 18:262-265, 1994
45. Swift SE, Spencer JA: Gallstone ileus: CT findings. Clin Radiol 53:451-
454, 1998
46. Lassandro F, Romano S, Ragozzino A, et al: Role of helical CT in
diagnosis of gallstone ileus and related conditions. AJR Am J Roentge-
nol 185:1159-1165, 2005
47. Singh AK, Shirkhoda A, Lal N, et al: Bouveret’s syndrome: appearance
on CT and upper gastrointestinal radiography before and after stone
obturation. AJR Am J Roentgenol 181:828-830, 2003
48. Pickhardt PJ, Friedland JA, Hruza DS, et al: CT, MR cholangiopancre-
atography, and endoscopy findings in Bouveret’s syndrome. AJR Am J
Roentgenol 180:1033-1035, 2003
49. Reimann AJ, Yeh BM, Breiman RS, et al: Atypical cases of gallstone ileus
evaluated with multidetector computed tomography. J Comput Assist
Tomogr 28:523-527, 2004
50. Lassandro F, Gagliardi N, Scuderi M: Gallstone ileus: analysis of radio-
logical findings in 27 patients. Eur J Radiol 50:23-29, 2004
51. Hinoshita E, Nishizaki T, Wakasugi K, et al: Pre-operative imaging can
diagnose torsion of the gallbladder: report of a case. Hepatogastroen-
terology 46:2212-2215, 1999
52. Aibe H, Honda H, Kuroiwa T, et al: Gallbladder torsion: case report.
Abdom Imaging 27:51-53, 2002
53. Chou CT, Chen RC, Yang AD, et al: Gallbladder torsion: preoperative
diagnosis by MDCT. Abdom Imaging 32:657-659, 2007
54. Matsuhashi N, Satake S, Yawata K, et al: Volvulus of the gallbladder
diagnosed by ultrasonography, coronal magnetic resonance imaging
and magnetic resonance cholangio-pancreatography. World J Gastro-
enterol 28(12):4599-4601, 2006
55. Quinn SF, Fazzio F, Jones E: Torsion of the gallbladder: findings on CT
and sonography and role of percutaneous cholecystostomy. AJR Am J
Roentgenol 148:881-882, 1987