Even in hospitals with a wide range of diagnostic facilities it can be difficult to rapidly assess and diagnose an abdominal emergency, therefore it is often hard for a first aider to assess abdominal … Cases in Radiology: Abdominal Emergency. Imaging may also used in cases of infectious colitis to assess for complications such as colonic strictures, bowel gangrene, and perforation. Phytobezoars are composed of fruit or vegetable matter, commonly oranges and persimmons. Clinical history is very important in helping to establish preoperative diagnosis ( Fig. Treatment in patients with toxic megacolon may include operative intervention with colectomy and treatment of associated complications. The small bowel has a central location in the abdomen. He is recognized both locally and internationally as an engaging radiology educator. On CT, abnormally increased mucosal and serosal enhancement of affected colonic segments, bowel wall thickening, and ascites are suggestive of infectious colitis ( Fig. Complications of Salmonella infection include bowel perforation, toxic megacolon, gangrenous cholecystitis, and massive lower GI bleeding. As in all cases of IBD, CT (and increasingly MRI) is employed for determining disease activity. In the absence of a focal transition point, dilated loops are nonspecific and may be due to other conditions such as IBD, scleroderma, or ischemia. It affects multiple organs and has been called pseudo-Whipple disease because of clinical, histologic, and radiologic similarities. As opposed to sigmoid volvulus, in which the cause is usually acquired, the most common predisposing factor to cecal volvulus is an abnormal embryologic connection of the right colon to retroperitoneum resulting in increased mobility of the cecum. Contrast-enhanced computed tomography shows a large crater in the lesser curvature posterior wall with associated wall thickening. The most common benign causes of colocolic intussusception are lipomas, followed by adenomatous polyps, whereas colonic adenocarcinoma is the most common malignant cause. The lesser curvature of the stomach is at the right, posterior aspect of the organ, whereas the greater curvature of the stomach lies to the left and anteriorly. The diagnosis of cecal volvulus may be confirmed on contrast enema or CT. On contrast enema examination a beaklike tapering of the cecum is seen at the level of the volvulus, and contrast usually does not pass into the proximal colon or small bowel. On CT a whirl sign may be visualized in which twisting of the sigmoid colon (see Fig. As opposed to ulcerative colitis (UC), rectal involvement is very rare in CD. Although US is often used in the diagnosis of intussusception in children, its role in the assessment of the small bowel in the adult population is very limited, particularly in the United States. Patients with typhlitis typically present with abdominal pain, fever, nausea, and diarrhea. 13-17 ). Pay in AUD instead, Online access to all course content for 3 months, Online access to all course content for 12 months, Individuals, groups and institutions can purchase all-access passes to Radiopaedia.org online courses. The SMA supplies the jejunum and ileum. Gastroduodenal Crohn disease (CD) is rare, causing clinical symptoms in 0.5% to 4% of all patients with CD. Rapid and accurate imaging and diagnosis is essential in the appropriate management of patients who present in the emergency setting with acute nontraumatic GI conditions. In addition, signs of obstruction may also be seen, including proximal bowel dilatation with distally collapsed loops. Small bowel carcinoid is a relatively rare cause of SBO because the primary lesion is often occult, and it usually will manifest as spiculated mesenteric masses with calcification resulting from a desmoplastic reaction ( Fig. A false diagnosis of colonic obstruction, particularly in patients with obstructive symptoms, may lead to inappropriate surgical exploration. Although the cause is not entirely clear, genetic susceptibility, host immunity, and environmental factors have been implicated. Weight loss, malabsorption, and perianal fistulas and fissures are also frequently observed. 13-40 ). As such, one important space to examine for extraluminal fluid and gas is the right anterior pararenal space, which immediately abuts the descending and proximal transverse duodenum. Emergency Radiology is a top rated Springer Nature journal. Functional disturbances that affect bowel motility, such as scleroderma, celiac disease, and cystic fibrosis, can cause transient intussusception. Computed tomography may readily identify complications of sigmoid volvulus, including bowel ischemia or perforation. More commonly, in the chronically affected patient, fibrosis may also cause luminal narrowing and obstruction. It can present on CT as an intramural mass that narrows the lumen. On plain radiography, dilated colon (dilation being a caliber greater than 6 cm and 9 cm in the cecum) is seen. Updated 27 July 2020 with 4 new videos and 50 review questions. Multiple conditions can result in small bowel dilatation (or abdominal distention) and be confused with SBO, particularly before clinical and radiologic information are integrated. Computed tomography and MRI may identify disease, localize and characterize the severity and extent of disease, indicate the presence of acute complications, assess the severity of inflammation, and monitor disease progression. Available ONLY to: In contrast to the detailed mucosal evaluation afforded by barium fluoroscopy, CT findings of infectious esophagitis are nonspecific and insensitive, demonstrating a sensitivity of approximately 55% in one study. Other imaging findings include mucosal “cobblestoning,” thickening folds, pseudopolyps, ulcers (including postbulbar ulcers in the duodenum), and strictures. Gastritis has many potential underlying causes, including Helicobacter pylori infection, nonsteroidal antiinflammatory medications, and alcohol. Crohn disease can affect any part of the GI tract but predominantly affects the small bowel (up to 80% of cases) and right colon. The fundus is the most dependent portion of the stomach and is subsequently the most common site for layering intraluminal contents, notably blood products. Small bowel obstruction can occur during the acute phase of CD when the intense acute transmural inflammation causes narrowing of the bowel lumen, during the chronic phase due to fibrotic stenosis, postoperative adhesions, incisional hernias, and exacerbation of the inflammatory condition (acute flare). The duodenum is the shortest segment, with retroperitoneal location and lacking a mesentery. Role of radiology in Abdominal Emergencies. Ultrasound in Abdominal Emergencies Dr/Ahmed Bahnassy Consultant Radiologist Riyadh Military Hospital 2. Benign lesions such as lipomas, adenomatous polyps, colitis, epiploic appendagitis, and postoperative adhesions, as well as malignant lesions such as metastatic disease, primary malignancy, and lymphoma, may act as lead masses causing intussusception. In cases of continued occlusion of the colonic vasculature without reperfusion, the bowel wall may remain hypodense with nonenhancement of the bowel wall after intravenous contrast administration. Medications such as anticholinergics, chemotherapy, and opiates have been associated with the development of toxic megacolon, and various procedures, including colonoscopies and barium enemas, have been implicated as causes. Chronic perforation of the duodenum, similar to that of the esophagus, may result in fistulization to nearby structures, including small and large bowel, bile ducts, kidneys and ureters, inferior vena cava (IVC), and aorta. Differentiation between partial and early SBO can be challenging in the absence of clinical information. On imaging, full-thickness perforation may result in pneumomediastinum, pleural effusions, and leak of oral contrast into the mediastinal and/or pleural spaces ( Fig. This condition most frequently occurs in the setting of an abdominal aortic aneurysm (AAA), either arising as a primary event or a complication of surgical repair. If the band slips distally, it may surround a larger portion of the stomach and lead to gastric outlet obstruction. In addition, imaging findings of septic thrombophlebitis may be visualized on CT, including thrombus in mesenteric and portal veins. On CT the cause can be identified, and imaging appearances vary depending on whether colonic malignancy, acute diverticulitis, volvulus, or other pathologic process is present. 13-54 ). This conglomerate of findings should prompt a search for an adjacent hyperenhancing nodule representing a gastrinoma, although these may be difficult to identify on routine portal venous phase CT and may require multiphase phase CT, endoscopic ultrasonography (EUS), or octreotide scan to aid in detection. Small bowel obstruction occurs in the late phase of radiation enteritis, most often in the distal small bowel as a result of adhesive and fibrotic changes that develop several months after therapy. The use of rectal contrast may be necessary for proper detection of perianal fistulas. Sepsis from a perirectal abscess usually resolves after antibiotic treatment and surgical drainage; however, in approximately 25% of patients the abscess cavity does not resolve completely, and the infection decompresses to the skin. 13-7 ). A narrow pedicle can be formed leading to torsion of the loops and producing a small bowel volvulus. Epiploic appendagitis represents acute inflammation or infarction of an epiploic appendage. Although not an emergency per se, stricture of the esophagus can cause esophageal obstruction (including impaction of food boluses as discussed earlier) and presentation to the ED. However, as mentioned previously, emergent MRI is usually not required for this indication. Larger ulcers are seen with cytomegalovirus and human immunodeficiency virus (HIV) esophagitis. Infectious colitis refers to colonic inflammation caused by a variety of bacterial, viral, fungal, or protozoan infections. 13-19 ). Despite abundant research in this field, it remains a diagnostic and therapeutic challenge. Reflux esophagitis may manifest with strictures, as well as reticular-appearing mucosa distally, indicating Barrett esophagus. Magnetic resonance enterography can be particularly useful in young patients that require serial examinations. A “beak” sign is seen at the site of the torsion as a fusiform tapering. Complications of esophageal perforation include mediastinitis, pneumonia (from direct spread of infection or from aspiration), and empyema/abscess formation. Differentiation between emphysematous gastritis and more benign gastric emphysema may be difficult, but the latter is much more common, is typically seen in relatively asymptomatic patients, and appears with more linear intramural gas with no wall thickening to suggest gastritis ( Fig. Despite overall low diagnostic accuracy and specificity, the kidney, ureter, and bladder (KUB) radiographic examination is still sometimes used as an initial imaging examination in patients with abdominal symptoms. The imaging appearance of groove pancreatitis may overlap with pancreatic adenocarcinoma considerably, but groove pancreatitis classically manifests with low-attenuation cystic areas (“cystic degeneration”) in the descending duodenal wall and soft tissue in the pancreaticoduodenal groove resulting from fibrosis. Normal gastric band orientation is assessed with the phi angle, which is increased with a slipped band. Spanning 25 to 30 cm in length, the esophagus deviates to the left in the neck, to the right in most of the thorax, and then back to the left as it joins the gastroesophageal junction. Computed tomography diagnosis relies on the identification of a blind-ending, tubular, round, or oval structure in the right lower quadrant or periumbilical region, with surrounding inflammation. Multiplanar reformations (MPRs) and postprocessing techniques aid in a confident diagnosis and can be helpful to depicting findings. On radiography, ileocecal dilatation can be seen with thumbprinting secondary to edema. Characteristic imaging features include reversible bowel and mesenteric edema, characterized by multiple dilated small-bowel loops with regular thickened mucosal folds, a stacked-coin appearance with bowel wall thickening, and thumbprinting. Direct visualization with endoscopy or the use of barium enema is typically contraindicated in cases of suspected typhlitis given the high risk for bowel perforation. Possible causes of benign esophageal strictures include long-standing gastroesophageal reflux, radiation, chronic medication-induced esophagitis, nasogastric intubation, epidermolysis bullosa, and eosinophilic esophagitis. The underlying pathologic process in emphysematous gastritis is mucosal disruption and invasion of the gastric wall by a gas-producing organism, particularly Escherichia coli . Complications, including diverticular perforation with frank abscess formation, fistulas, (e.g., vesicocolonic or colocolonic among others), pyelophlebitis, or liver abscesses, may also be readily visualized with CT. A pericolic abscess appears as a hypoattenuating, pericolic collection with peripheral enhancement, often containing air or an air-fluid level. It is characterized by stricture formation and obstruction. When found in older children and adults, it should trigger a search for a lead point, such as an underlying neoplasm, inciting adhesion or foreign body. Conversely, primary lymphoma of the small bowel, even when extensive or annular, is a soft tumor and does not generally cause obstruction unless it is associated with adhesions or posttreatment change ( Fig. The most characteristic findings include mucosal hyperenhancement, submucosal edema, and bowel wall thickening. The utility of US for the diagnosis of acute appendicitis is highly operator dependent, and this modality is limited in obese patients and in the presence of gas-filled bowel. The organism tends to inhabit the duodenum and jejunum. Affected patients may present clinically with symptoms of proximal bowel obstruction, namely, severe abdominal pain and bilious vomiting. A potential advantage over CT that has been proposed is the characterization of malignant versus benign strictures. The nitrous oxide created from the inflammation is believed to inhibit smooth muscle tone, resulting in bowel distention. Similar to those with aortoesophageal fistulas, affected patients may have a “herald bleed” preceding life-threatening voluminous hemorrhage. Plain abdominal radiographs have limited utility in the diagnosis of acute appendicitis. The use of oral contrast for the diagnosis of SBO is controversial. Patients with toxic megacolon are typically quite ill with abdominal pain and tenderness, fever, leukocytosis, dehydration, altered mental status, and tachycardia. Patients with infectious colitis may be found to have electrolyte imbalances and leukocytosis. Radiation serositis can lead to narrowing of the lumen and abnormal peristalsis. Acutely, obstruction from peptic ulcer disease occurs because of mucosal ulceration and submucosal edema. Watch Now. Atlas Of Complicated Abdominal Emergencies: Tips On Laparoscopic And Open Surgery, Therapeutic Endoscopy And Interventional Radiology (With Dvd rom) 1st Edition, (PDF Version) $ 79.99 $ 25.99 Iron Physiology and Pathophysiology in Humans (Nutrition and … The “coffee bean” sign refers to the inverted U shape of the sigmoid colon with a dense white line formed by the apposed colonic walls, which is directed from the pelvis to the right upper quadrant. Infectious esophagitis may have characteristic findings on barium fluoroscopy depending on the causative pathogen. Although a strict size limit for normal appendices, similar to ultrasonographic imaging, is not applicable to CT given the lack of compression, acutely inflamed appendices are typically dilated and approach or exceed 1 cm in diameter. Clinical presentation. Occasionally a “whirl” sign of the mesenteric vessels can be seen, reflecting the rotation of the bowel loops around the fixed point of obstruction. Uncommonly, fistulas between the aorta and duodenum may result from vasculitis or radiation. Coronal volume-rendered image obtained from computed tomography (CT) enterography in a patient with small bowel obstruction (SBO) depicts the small bowel anatomy and fold pattern. 13-47 ). Computed tomography can help determine whether small or large bowel is affected, assess the location and severity of obstruction, and identify the cause and potential complications. Patients who have undergone organ transplantation also have an increased risk for developing bezoars, which is hypothesized to be secondary to decreased gastric motility, either due to vagus nerve injury or a side effect of cyclosporine. To assess patterns of use of abdominal imaging in the emergency department (ED) from 1990 to 2009.We retrospectively reviewed data on adult ED patients treated between 1990 and 2009 at our university-affiliated quaternary care institution. Gastrointestinal involvement sometimes mimics an acute abdomen or rarely can cause life-threatening hypovolemic shock. Although typically found in locally advanced gastric cancer, a focal ulcerated malignancy may perforate if the ulcer crater is deeply penetrating. Chronic perforation of the stomach complicates 1% to 3% of patients with gastric bands and results from erosion of the band into the stomach lumen. Imaging findings of aortoesophageal fistulas include a focal outpouching of the aorta toward the esophagus, adjacent esophageal wall thickening, and extraluminal gas within or abutting the aortic wall ( Fig. Imaging Non-traumatic Abdominal Emergencies in Pediatric Patients is a very well-written book. The increasing rate of obesity in the United States has resulted in a rising number of bariatric surgery techniques, one of which is gastric banding. Acute diverticulitis represents the most common cause of vesicocolonic fistulas, which often occur along the left posterolateral aspect of the bladder in cases of sigmoid diverticulitis and may be suspected based on the presence of intravesicular air and focal bladder wall thickening adjacent to an inflamed diverticulum. Gastric outlet obstruction due to gallstones, termed Bouveret syndrome , is a rare subset of gallstone ileus that presents classically with a triad of pneumobilia, an ectopic gallstone, and bowel obstruction ( Fig. Image quality on the PC version is much better than the Web version. Note that the band has extraluminal gas surrounding it. The focus of your assessment process will be to accurately perform a physical examination and SAMPLE history to describe the condition and identify potentially serious conditions such as shock The decompressed terminal ileum free in 125 low and middle-income countries organs will be organising a number causes! 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