TheACUTEABDOMEN

TheroleofthePlainFilmAbdominal
Series
MIZucker,MD

AdrZLecture

TheAbdominalSeries
Forallacuteabdominalcomplaintswhere
plainfilmimagingisindicated,geta
COMPLETEabdominalseries
Exceptions:Suspectedrenalcalculusor
foreignbody,whereasingleviewisOK
CTandultrasoundareoftenperformed
afterplainfilms

AbdominalSeries
Indications:
Highestyield:Presentationssuggestiveof
freeairorobstruction
Notverygoodformasses,ascites,
organomegaly,biliarytractdisease,GI
bleedingandvagueabdominalcomplaints
Yieldishigherintheelderly

TheAbdominalSeries
Erectchest,APsupineanderectabdomen
Or,ifpatientunabletosit/stand:
supinechest,supineandleftlateral
decubitusabdomen
Forcalculusorforeignbody:APsupine
abdomen

TheErectChest
Bestforfreeair
Toevaluateforintrathoracicabnormalities
presentingwithabdominalcomplaints,
especiallypneumonia(morecommonin
kids)

SupineAbdomen
Bestforabdominaldetail:Organs,bones
andjoints,calcifications,fatandgaspattern

ErectAbdomen
Forairfluidlevelsandlittleelse

LeftLateralDecubitusAbdomen
Substituteforerectchest(freeair)anderect
abdomen(airfluidlevels)inapatient
unabletositorstand

Indicationsforasingleerect
abdomenfilmONLY
NONE
None
None
None

TheCheckList

Bonesandjoints
Calcifications
Organs
Fat
Gas:Inbowelandoutsideofbowel

Amemoryaid

Firstorgans,bones,andstones,
Thenmasses,fat,andgas.
Dontforgetthecornerzones,
Andyoullalwayscoveryoursubject

TheNormalAbdominalSeries

Chest
Supineabdomen
Erectabdomen
Leftlateraldecubitusabdomen

Chest

SupineAbdomen

ErectAbdomen

LeftLateralDecubitusAbdomen

Dontforgettolookfor
pneumonia

GAS
Inthegut,andelsewhere

PNEUMOPERITONEUM
FREEAIR:PerforatedGut

FreeAir
Bestviews:Erectchestandleftlateral
decubitusabdomen
Erectabdomenislesssensitive
Supineabdomenisinsensitive

HowSensitive?
Plainfilmsare85%sensitiveforfreeair
Theoreticalthresholdis2cc
CTismuchmoresensitiveandistheGold
Standard

FreeAir:ErectChest
Airunderthediaphragm
Usuallyontheright
Occasionallyonlyseenontheleft

FreeAir:ErectChest

FreeAir:ErectChest

FreeAir:ErectChest

FreeAir:LeftLateralDecubitus
Rightsideup,leftsidedown
Patientwhocantsitorstand
Airunderrightabdominalwall

FreeAir:LeftLateralDecubitus

FreeAir:SupineAbdomen
Doublebowelwallsign
Falciformligamentsign

DoubleWallsign

FalciformLigamentsign

Pneumoretroperitoneum
Fromperforationofposterior
extraperitonealportionsofduodenumor
colon
Extensionfromorthroughthemediastinum

Pneumoretroperitoneum

AirinBiliarySystem
Bileducts
Gallbladder

AirinBiliarySystem
Usuallysecondarytosurgeryonbileducts
Canbeduetobiliarybowelfistulafrom
infectionorneoplasm
Rarely,canbeduetoinfection

AirinBileDucts

AirinGallBladder

PortalVenousAir
Asignofdeadordyingbowel

PortalVenousAir

TheGUT
GasandFluid
TooMuchandTooLittle

TheGasPattern
Canbespecificforobstruction
Often,nonspecific:Generalileus,focal
ileus,ischemia,orobstruction
Apaucityofgasmaybeduetovomitingor
fluidfilledbowel

OBSTRUCTION
Smallbowel
Colon

OBSTRUCTION
Smallbowelobstructionmuchmore
commonthancolon:70:30

SmallBowelObstruction:
Causes
Adhesions80%
Hernia15%
Tumors,intussusception,midgutvolvulus,
etc.

SmallBowelObstruction:
Findings
Stepladderdilatedbowelloopsonsupine
view
Stepladderairfluidlevelson
erect/decubitusviews
Stretchsignonsupineview
Stringofpearlssignonerect/decubitus
views

HowBigisBig?
Inanadult,anyvisiblesmallbowelis
abnormal,butsmallamountsoftennot
significant.Kidsnormallyhavesmall
amounts.
Jejunumover3cmandileumover2cm
diameterisveryabnormal,butnotspecific
forobstruction

Air,FluidorBoth?
Smallbowelcanbedistendedbyeitherair
orfluidorboth
Fluidfilledbowelmaybemoresignificant
thanairfilledbowel,butoftenthe
significanceisthesame

AirFilledSmallBowel

FluidFilledSmallBowel

AirFluidLevels
Alwaysabnormalinsmallbowel,butnot
specific;oftennormalincolon
Theheightofthefluidlevels,sameor
different,isNOThelpfulindistinguishing
ileusfromobstruction

SmallBowelAirFluidLevels

WhatisDilated?
Ifsmallbowelandcolondilatedequally,
probablynotsmallbowelobstruction:
nonspecificILEUS
Ifsmallbowelsignificantlymoredilated
thancolon,suggestsSBO
SomegasincolondoesNOTexcludeSBO

Ileus

ClassicSmallBowelObstruction,
Supine

ClassicSmallBowelObstruction,
Erect

StretchSign:Supine

StringofPearlsSign:Erect

SBO:Hernia

COLONObstruction
Causes

Carcinomaofthecolon80%
Volvulus5%
Diverticulitis5%
Fecalimpaction5%
Everythingelse5%

ColonObstruction:Carcinoma

ColonObstruction:Volvulus
5%oftotal
80%sigmoid
20%cecum

Volulus:Sigmoid

Volvulus:Cecum

ColonObstruction:
Measurements
Thececumisthemostdistensiblepartof
thecolon
Acecumof9cmdiameteriscausefor
concern
Acecumof11cmisimpendingperforation

DistendedCecum

OtherEmergencyConditionsof
theGut
Toxicmegacolon:Crohn,UC;5cm
transversecolonisimpendingperforation
Enterocolitis:C.diff.andothermicrobes
Ischemia

ToxicMegacolon

AwordonThumbprinting
Itmeansthickenedbowelwall
ItcanoccuracutelyinC.diff.orischemia
orhemorrhage
Chronically,itcanbeseenininflammatory
boweldiseaseandneoplasmandafew
otherlesscommondiseases

C.diff.Enterocolitis

IschemicBowelDisease

Arterialemboli:A.fib.,MI
Arterialthrombi:ASCVD
Venousthrombi:Hypercoag.,neoplasm
Nonocculsivemesentericischemia:Low
flowstates

Ischemia:Findings

Normalgaspattern
Nonspecificileus
Thumbprinting
Gasinbowelwall
Gasinportalveinsystem
Freeair

Ischemia:Thumbprinting

Ischemia:CT

ACUTEAPPENDICITIS

AcuteAppendicitis:Findings

Normal
Focalileus
Appendicolith
Mass
Freeairisveryrare

FocalIleus

Appendicolith

AcuteAppendicitis:CT

AcuteAppendicitis:CT

GallBladderDisease

Cholelithiasis

Cholelithiasis:Ultrasound

PANCREATITIS
Acute

PANCREATITIS:Findings
Normal
Generalnonspecificileus
Focalileus:Sentinelloop,coloncutoff
sign
PancreaticcalculiarefoundinCHRONIC
pancreatitis,notacute

FocalIleus

ChronicPancreatitis

AbdominalAorticAneurysm

AAA
Plainfilmsarenotsensitive,butcanbe
diagnostic
Calcifiedwallsofaortacanallow
measurementoflumen
AAAifover3cmAPdiameter
UltrasoundandCTaremuchmoresensitive

AAA

AAA:CT

Afewmore
Theoddandtheinteresting

Echinococcuscyst

Ascariasis

Ascariasis

ForeignBody:Battery

ForeignBody:Battery

TongueOrnamentMisadventure

BodyPackerorMule

CustomerofBodyPacker

???

GOODBYE

Copyright2004
MIZucker,MD