TOPIC DISCUSS

ACUTE ABDOMEN ON
PLAIN RADIOGRAPHS

PRESENTER:
VENNY HILLERY WAHYUNI (I11111021)

CONSULENT:
DR. FENNIE RUFINI, SP. RAD

UNIVERSITAS TANJUNGPURA HOSPITAL

Outlines:
Preface SBO
Abdominal plain Intussusception

radographs series LBO

Pneunoperitoneum Sigmoid volvulus
Ileus Paralytic Caecal volvulus

Sentinel Loop Bowel Ischemia &

Toxic Megacolon infarction
Abdominal
calcification
Acute Abdomen

Defined as clinical syndrome characterized by

acute pain abdomen of sudden onset often
requiring emergency medical or surgical treatment
diseases involving ;
Biliary tree
Solid viscera

intestine, genitourinary system

Pelvic organs in females

Clinical Diagnosis
Characterizing the pain is the key
Onset, duration, location, character
Visceral pain dull & poorly localized
i.e. distension, inflammation or ischemia
Parietal pain sharper, better localized
Sharp RUQ pain(cholilithiasis), LLQ
pain(diverticulum)
Kidney / ureter flank pain
Other History

GI symptoms Drinking history (pancreas)

Nausea, emesis (? Prior surgeries (adhesions
bilious or bloody) SBO, still have gallbladder &
Constipation,
appendix)
obstipation (last BM or History of hernias
flatus) Urine output (dehydrated)
Diarrhea (? bloody) Constituational Sx
Both Nausea/Diarrhea Fevers/chills
present Sexual history
Change in eating?
NSAID use (perf DU)
Jaundice, acholic stools,
dark urine
Clinical Diagnosis

Location of pain by organ

RUQ
Gallbladder

Epigastrum
Stomach

Pancreas

Mid abdomen
Small intestine

Lower abdomen
Colon, GYN pathology
Clinical Diagnosis
Think Broad Categories for DDx

Inflammation
Obstruction
Ischemia
Perforation (any of above can end here)
Offended organ becomes distended

Lymphatic/venous obstrux due to pressure

Arterial pressure exceeded ischemia

Prolonged ischemia perforation

The Abdominal Series
For all acute abdominal complaints where plain film
imaging is indicated, get a complete abdominal
series
Exceptions: Suspected renal calculus or foreign
body, where a single view can to do
CT and ultrasound are often performed after plain
films
The Abdominal Series

The Erect Chest

Best for free air

To evaluate for
intrathoracic
abnormalities
presenting with
abdominal complaints,
especially pneumonia
(more common in kids)
The Abdominal Series

Supine Abdomen

Best for abdominal

detail: Organs, bones
and joints,
calcifications, fat and
gas pattern
For calculus or foreign
body: AP supine
abdomen
The Abdominal Series

Erect Abdomen

For air-fluid levels and

little else
The Abdominal Series

Left Lateral Decubitus Abdomen

Substitute for erect

chest (free air) and
erect abdomen (air-
fluid levels) in a
patient unable to sit or
stand
Inspect on:
Lateral margin of
ascending and
descending colon
Solid visceral Organs
and psoas line
Abnormal Gas location
Bones and joints
Calcifications
 In the gut, and
elsewhere
Can be specific for
obstruction
Often, nonspecific:
General ileus, focal
ileus, ischemia, or
obstruction
A paucity of gas may
be due to vomiting or
fluid-filled bowel
Pneumoperitoneum
Etiology

Perforated viskus
Pneumoperitoneum Necrotizing enterocolitis
with peritonitis Ischemia infarc bowel
Abdominal trauma
Thoracic
Positive pressure ventilation
Pneumomediastinum/pneumotoraks-COPD
Asthma
Abdomen
Pneumoperitoneum Post laparotomy
without peritonitis
Pneumatosis cystoides coli/ intestinalis
Divertikulosis jejunum
Endoscopy
Paracentesis/peritonealdialisis/laparoskopi
Bone marrow transplantation
Erect
Supine

Signs:
Right upper quadrant gas
Riglers (double wall sign)
Urachus
Triangular air
The cupola sign
Football or air dome
 LLD

Posisi Lateral dekubitus kiri. Terdapat udara bebas di antara dinding abdomen dengan
hepar (panah putih). Ada cairan bebas di rongga peritoneum (panah hitam).
MASSIVE PNEUMOPERITONEUM
FOOTBALL SIGN Cupola Sign
 PNEUMOPERITONEUM
FALCIFORM LIGAMENT SUBHEPATIC GAS BUBBLE
Triangle Sign Triangle Sign
Riglers sign Pneumo-left decubitus
Adynamic Ileus
 Stasis of bowel
contents because of
decreased or absent
peristalsis.
The terms adynamic
ileus, paralytic ileus,
and nonobstructive
ileus
 Diffuse symmetric,
predominantly gaseous
Distension of bowel
The small bowel, stomach, and
colon are proportionally
dilated without an abrupt
transition.
More bowel loops are dilated
Occasionally, adynamic ileus
may result in A gasless
abdomen with dilated loops of
bowel that are lled only with
uid.
Sentinel Loop
 segment of intestine that
becomes paralyzed and
dilated
alerts one to the presence
of an adjacent
inammatory process
short segment of
adynamic Ileus that
appears as an isolated
loop of distended intestine
Toxic Megacolon
 extreme dilation of all or a
portion of the colon.
peristalsis is absent and the large
bowel loses all tone and
contractility.
Progressive abdominal distension
and is toxic, febrile, and
obtunded.
The bowel wall becomes like
wet blotting paper, and the risk
of perforation is extreme.
Radiographs
Distension of the colon
with absent haustra.
Dilation of the
transverse Colon up to
15 cm diameter is
often the most striking
nding.
diameter of the colon
Exceeds 5 cm and the
mucosa appears
Mechanical Bowel Obstruction
 Stasis of bowel contents above a focal lesion.
The goal of imaging is to conrm the presence of
obstruction, identify its level, and demonstrate its
cause.
The lumen of the bowel proximal to the obstruction
progressively dilates .Compromise of blood supply
may occur
Complete Obstruction, partial Obstruction. Simple
Obstruction, Strangulation obstruction
SMALL BOWEL OBSTRUCTION
 Present with crampy
abdominal pain &
distention, vomiting.
Findings :
dilated loops of SB (>3 cm)
small bowel airuid

airuid levels at differing

heights (>5 mm)
Two Or more airuid
levels
Stepladder or hairpin
loops of small bowel
Small bowel vs Large bowel dilatation

Radiological Small bowel Large bowel

Findings
Haustra Absent Present
Valvulae conniventes Present in jejunum Absent
Number of loops many Few
Distribution of loops Central Peripheral
Radius of curvature Small Large
of loop
Diameter of loop 30-50mm 50mm+
Solid faeces Absent May be
present
Air Filled Small Bowel Fluid Filled Small Bowel
Small Bowel Obstruction

Supine Erect
Intussusception
Intussusception
Ileocolic, ileoileal, colocolic or jejunojejunal
Soft tissue mass surrounded by crescent of air
Target sign due to peritoneal fat
Barium enema diagnostic (claw sign)
Sausage shaped or target mass on CT
Intussusception

Plain - Supine Enema

LARGE BOWEL OBSTRUCTION
 The cecum dilates to
the greatest extent
When the cecum
exceeds 10 cm in
diameter high risk
for perforation
Most colonic
obstructions occur in
the sigmoid colon
Conventional radiographs
Dilation of the colon from the cecum to the point of
obstruction.
The colon distal to the obstruction is devoid of gas.
Airfluid levels distal to the hepatic exure are
strong evidence of obstruction unless the patient has
had an enema.
Sigmoid volvulus
 The sigmoid colon twists
around its mesentery, resulting
in a closed-loop obstruction.
The proximal colon dilates
while the rectum empties
The sigmoid colon appears as
a large gas-lled loop without
haustral markings, arising from
the pelvis and extending high
into the abdomen and often to
the diaphragm.
Caecal Volvulus
 Cecal volvulus is a closed-
loop obstruction that may
result in ischemia, necrosis,
and perforation
Radiographic ndings are
coffee bean-shaped loop of
gas-distended bowel having
haustral markings directed
toward the LUQ
apex of the cecum in the LUQ

cecal distension D > 10 cm

collapse of the distal colon.

BOWEL ISCHEMIA & INFARCTION
 Bowel ischemia, potentially leading to infarction
Insufcient blood supply to small or large bowel
Causes include arterial occlusion of the mesenteric
arteries by thrombus, embolus, volvulus, etc
 Findings of bowel ischemia include
circumferential or nodular thickening (>5mm) of the
bowel wall with inltration of low-density edema or
high-density blood, resulting from mucosal injury
thumbprinting resulting from this nodular inltration of
the bowel wall
dilatation of the bowel lumen (>3cm for small bowel;
>5 cm for colon; >8cm for cecum);
pneumatosis intestinalis (see following paragraph);
 edema or hemorrhage into the mesentery;
Engorged mesenteric vessels;

thrombosis of mesenteric arteries or veins;

poor enhancement of the bowel wall along its

mesenteric border, which is evidence of ischemia
Poor or absent mucosal enhancement with thinning of
the bowel wall, which is evidence of bowel infarction
ascites
Ischemia: Thumbprinting
Pneumatosis intestinalis
 presence of gas within the bowel wall
It may occur as a benign entity without clinical signi
cance or may be an important nding of bowel
ischemia
It is a radiographic sign, not a disease.
ABDOMINAL CALCIFICATIONS
Gallstones and Gallbladder
 about 15% of gallstones contain sufcient calcium to
be identied on conventional radiography.
Most calcied gallstones contain calcium bilirubinate
and have a laminated appearance with a dense
outer rim and more radiolucent center.
 Calcications in the
gallbladder wall ( porcelain
gallbladder ) are plaque-
like and oval in
conguration conforming to
the size and shape of the
gallbladder.
Milk of calcium bile is a
suspension of radiopaque
crystals within gallbladder
bile.
Urinary Calculi
 Most characteristic are
the staghorn calculi,
which assume the
shape of the renal
collecting system
REFERENCES
Frant, William E; Helms, Clyde. Fundamentals
of Diagnostic Radiology, fourth edition. USA:
Lippincots William and Wilkins. 2012
Fox, Christian. Clinical Radiology Emergency.
New York: Cambridge Medicine. 2008
Daffner, Richard; Hartmann Mathew. The
Essential Clinical Radiology, Fourth edition.
USA: Lippincots William and Wilkins. 2017
THANK YOU