Abdominal pain is one of the most frequent reasons that elderly people visit the emergency department (ED). Although imaging findings are often nonspecific, including mural thickening, mesenteric fat stranding, and moderate mesenteric lymphadenopathy, the clinical history and distribution can be helpful in narrowing the differential diagnosis. In patients with Ogilvie syndrome, CT readily demonstrates marked colonic distention with a long segment of relative transition to more collapsed bowel occurring in the absence of an obstructing lesion. 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. This course teaches key concepts in the interpretation of abdominal imaging (see course topics) and is ideal for health professionals involved in the imaging and management of emergency abdominal conditions. Abscesses are identified as loculated low-attenuation fluid collections, possibly containing foci of air or an air-fluid level, with peripheral enhancement. 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. Perforation related to gastric banding can be seen acutely in 0.1% to 0.8% of patients and may have a varied clinical presentation. Diagnosis is made by identifying an ovoid metallic object impacted at the transition point. In the absence of appropriate treatment, there may be progressive colonic inflammation with transmural necrosis, perforation, and even death. 13-38 ). The majority of aortoesophageal fistulas result from aortic disease fistulizing to the esophagus, such as from rupture of a descending thoracic aortic aneurysm or an infected aortic graft. The acute abdomen The acute abdomen is a medical term used to describe a patient who presents with sudden onset of severe abdominal pain sometimes accompanied by nausea, vomiting, diarrhea, abdominal distension, and even hypotension or shock. Although most esophageal foreign bodies pass spontaneously, 10% to 20% of cases require endoscopic removal and approximately 1% undergo surgery for treatment. Although a relative minority of duodenal diverticula cause symptoms, up to 1% of patients will have a complication from a duodenal diverticulum that requires treatment, including diverticulitis, perforation, and obstruction in the case of intraluminal diverticula. Comorbidities include psychiatric conditions, advanced age, and institutionalization in medical facilities. Not uncommonly, UC is first diagnosed when patients present with these symptoms to the ED. The clinical presentation and imaging findings of esophageal perforation depend on the thickness of the esophageal tear. Some of the more commonly encountered causes of infectious colitis include Campylobacter jejuni , Yersinia enterocolitica , Salmonella typhi , and Clostridium difficile . When the hair extends from the stomach into the small and/or large bowel this has been termed Rapunzel syndrome ( Fig. 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. The increased serum gastrin levels stimulate peptic acid secretion and lead to duodenal mucosal ulceration. Although SBO can result from intrinsic obstruction from submucosal implants, such as from malignant melanoma and breast cancer, it most often occurs in the setting of peritoneal carcinomatosis, when extensive serosal disease will determine extrinsic compression and/or circumferential involvement at the transition point ( Fig. 13-32 ). It is typically located in the distal ileum approximately 2 feet from the ileocecal valve. Extraintestinal manifestations include mesenteric inflammatory changes and the presence of phlegmon, abscess, or lymphadenopathy. 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. Online case-based review of abdominal emergency radiology featuring over 6 hours of video recordings by Dr Vikas Shah, Dr Jeremy Jones and Dr Andrew Dixon. Finally, MRI and T1- and T2-weighted images demonstrate a small pericolic mass that exhibits fat signal. Although the imaging findings are nonspecific, the self-limited nature of the infectious process can help make the distinction from other causes of bowel wall thickening. Although CT has largely replaced barium enema, imaging findings that have been well described on barium studies include a narrowed bowel lumen and focal or diffuse bowel wall thickening. Hematoma can mimic neoplasm and result in significant luminal narrowing. These findings, along with a lack of vascular invasion, help differentiate between groove pancreatitis and adenocarcinoma of the pancreaticoduodenal groove ( Fig. A fistula results from an abscess derived from an infection originating in the anal canal glands at the dentate line. Acutely, obstruction from peptic ulcer disease occurs because of mucosal ulceration and submucosal edema. In addition, surrounding inflammatory changes with a thin hyperattenuating rim due to thickening of the visceral peritoneum may be identified. Imaging of Gastrointestinal and Abdominal Emergencies in Binge Drinking. Patients with decreased gastric motility, such as those who have undergone gastric surgery, are predisposed to formation of phytobezoars, which may also pass into the small bowel and cause obstruction more distally as well. Treatment of duodenal diverticulitis may be operative or nonoperative (i.e., antibiotics), depending on the clinical condition and stability of the patient. Gastric volvulus requires at least 180 degrees of rotation and gastric outlet obstruction. The treatment of patients with typhlitis typically includes high doses of antibiotics and intravenous fluids to prevent transmural necrosis and perforation. The findings that indicate strangulation include bowel wall thickening and hyperattenuation, a halo or target sign, mesenteric fat stranding and/or fluid, pneumatosis intestinalis, and mesenteric or portal venous gas, but these findings are not entirely specific. Adynamic ileus is associated with bowel distention that may include the colon, in addition to the small bowel and stomach. Ingested foreign bodies may be a cause of gastric or small bowel obstruction and often fall into two major categories: trichobezoars and phytobezoars. In the acute stage, bowel wall thickening greater than 3 mm is the most consistent cross-sectional imaging finding ( Fig. In the presence of abscesses, percutaneous drainage under CT guidance is favored over surgery. Note that the band has extraluminal gas surrounding it. 13-8 ). 13-33 ). Imaging findings of intramural perforation include a “double-barrel esophagus” caused by an intraluminal flap separating the true and false lumens, which may be accentuated with oral contrast, creating what has been also been termed a mucosal stripe sign . The most common presenting symptoms in patients with CD include chronic diarrhea and abdominal pain. The frequency of this examination differs among hospitals and physicians. Typical radiographic views include supine and upright views of the abdomen and an upright chest radiograph. In addition, depending on the underlying cause, air-fluid levels, pericolic inflammation, and mesenteric lymphadenopathy may also be visualized on CT in cases of infectious colitis. On CT a distended colon with a markedly thickened and nodular bowel wall and submucosal edema may be seen ( Fig. Multiplanar reformations (MPRs) and postprocessing techniques aid in a confident diagnosis and can be helpful to depicting findings. Closed-loop obstruction can result ( Fig. In addition, the fluid within the distended loops of bowel acts like a natural neutral oral contrast, as long as nasogastric tube decompression is not performed before imaging ( Fig. Inflammation of the stomach is most commonly diffuse, but it can also be focal process. 13-14 ). 13-22 ). It can be secondary to intraperitoneal seeding, hematogenous spread, or direct extension from an adjacent visceral malignancy. The vascular supply of the small and large bowel is supplied by the celiac trunk, which provides the blood supply from the distal esophagus to the descending duodenum; the SMA, which supplies the distal duodenum, jejunum, ileum, and the large bowel to the splenic flexure; and the inferior mesenteric artery (IMA), which supplies the more distal colon. 13-2 ). The clinical diagnosis of infectious colitis is based on visualizing the organisms in stool cultures, blood cultures, and/or serologic studies. The epiploic appendages may become inflamed or torsed, resulting in infarction. However, because of its overlap with malignant causes of gastric outlet obstruction, exclusion of an underlying mucosal lesion is often warranted. 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. Appropriate diagnosis and subsequent treatment rely on accurate imaging diagnosis and radiologists’ familiarity with the vast spectrum of GI diseases. Computed tomography should be performed with intravenous contrast. Computed tomography findings depend on the length, degree of distention, and orientation of the closed loop but include a characteristic fixed radial distribution of several dilated, usually fluid-filled bowel loops with stretched and prominent mesenteric vessels converging toward a point of torsion. Patients typically present with abdominal pain, nausea, and vomiting, and in patients with an underlying malignancy, weight loss, palpable abdominal mass, melena, and constipation may be seen. Superior mesenteric artery syndrome can be diagnosed with an abnormally acute aortomesenteric angle (normal range is 28 to 65 degrees) or a decreased aortomesenteric distance (normally 10 to 34 mm) resulting in extrinsic compression of the duodenum. T2 hyperintensity is typically absent in these fibrotic regions, unless there is associated mural inflammation and edema ( Fig. Special Section on ER Abdominal Imaging. Acute colonic obstructions are emergencies requiring early detection to prevent complications such as perforation or ischemia. Most often, an adhesion or hernia will cause partial or complete occlusion of a segment of bowel loop at two adjacent points. Strangulation is defined as closed-loop obstruction associated with intestinal ischemia, and its occurrence depends on the time and degree of rotation of the incarcerated loops. Similar to esophageal dissection, full-thickness esophageal perforation may be iatrogenic, such as from surgery, stricture dilatation, stenting, or thermal injury. Like sigmoid volvulus, patients are at increased risk for developing bowel ischemia, and cecal volvulus is associated with a high morbidity, especially in cases of late presentation. Esophagitis can arise from a number of causes, including infection, radiation, gastroesophageal reflux, and medications. 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. Clinically patients may present with normal serum amylase and lipase levels. 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. In the setting of ischemic colitis, pneumatosis intestinalis or the presence of portomesenteric venous air is highly suggestive of frank bowel wall necrosis. Disadvantages include operator variability and incomplete evaluation of the small bowel due to intervening gas and obese habitus. The two subsets of gastric volvulus are organoaxial and mesenteroaxial, although many are seen as a combination of these. The findings are usually transient and segmental, returning to normal after an acute attack. Colonic diverticula are small, focal outpouchings that occur at weak areas of the bowel wall, typically between the mesenteric and antimesenteric teniae where the vasa recta penetrate the circular muscle layer of the bowel wall. 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. Large bowel obstruction usually warrants surgical exploration, particularly when complications such as perforation or ischemia are present. Inflammatory diseases (Crohn, tuberculosis), Neoplastic diseases (adenocarcinoma, gastrointestinal stromal tumor, lymphoma, metastatic disease), Hematoma (anticoagulants, blood dyscrasia, trauma). The inflammation involves the mucosa, but unlike uncomplicated colitis, in cases of toxic megacolon the inflammation extends through the submucosa and serosa of the bowel wall. The use of oral contrast for the diagnosis of SBO is controversial. Appendectomy is the treatment of choice in simple acute appendicitis, and laparoscopic appendectomy is increasingly common. Perforation of peptic ulcers within the duodenal bulb and stomach remains one of the most common causes of GI perforation, warranting close examination of the stomach and proximal duodenum for ulcers when free intraperitoneal gas is identified on CT ( Fig. In 15% to 20% of patients with UC a fulminant form of the disease may develop that is characterized by extensive inflammation with severe symptoms and colonic dilatation. As opposed to ulcerative colitis (UC), rectal involvement is very rare in CD. There are no clear guidelines when or when not to request an abdominal X-ray (AXR). Associated fibrosis, which can result from chronic inflammation, may demonstrate delayed contrast enhancement on CT and magnetic resonance imaging (MRI). The diagnosis should not be excluded even in the absence of prior surgery because adhesions can occur as a result of prior peritonitis. Thumbprinting manifests as smooth, round, polypoid, and scalloped filling defects projecting into the colonic lumen, which correspond to thickened mucosal folds related to submucosal edema or hemorrhage. 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. The SMA supplies the jejunum and ileum. Bacterial-induced colitis, which typically persists for 1 to 2 weeks and up to 1 month, may require antibiotic treatment. Immunocompromised patients can be affected with systemic infection with Mycobacterium avium-intracellulare . It is a chronic autoimmune disorder induced in genetically susceptible individuals after ingestion of gluten proteins. Freed will thoroughly review all imaging aspects of your case and correlate with clinical history made available to the interpreting radiologist at the time of imaging. In early disease, mucosal edema and hyperemia are encountered, and with disease progression the mucosa develops punctate ulcers that enlarge and may extend into the lamina propria. Primary small bowel neoplasms are rare. The diagnosis of closed-loop obstruction is crucial because it carries a higher risk for strangulation and bowel infarction. Mural stratification with a target appearance consisting of intense enhancement of the mucosa, hypoattenuation of the submucosa, and an outer enhancing muscularis propria may be identified (see Fig. However, as mentioned previously, emergent MRI is usually not required for this indication. On imaging studies the findings of malrotation are the same as those seen in childhood: a duodenum that does not cross the spine, reversal of the relationship between superior mesenteric artery (SMA) and vein, colon situated on the left side of the abdomen, and small bowel on the right. PDF | On Jul 1, 2009, Ghina A Birjawi and others published Emergency abdominal radiology: The acute abdomen | Find, read and cite all the research you need on ResearchGate 13-16 ). Ischemic colitis is the most common vascular disorder of the GI tract and is caused by compromise of the mesenteric vascular supply. They are visible as wall-enhancing structures. A false diagnosis of colonic obstruction, particularly in patients with obstructive symptoms, may lead to inappropriate surgical exploration. It is a C-shaped structure that extends to the ligament of Treitz. In chronic UC the colon becomes foreshortened, and featureless, with the loss of haustral folds, and exhibits luminal narrowing. Duodenal peptic ulcers are more common than gastric ulcers, typically solitary, and located in the duodenal bulb in 5% to 11% of patients. 13-39 ). Ileocolic or ileocecal intussusception is often associated with small bowel metastatic disease; the most common primary malignancies include melanoma, breast, and lung. Similar to CD, UC is more common in white and Jewish populations and in northern Europe and North America. Typical morphologic changes include diffuse bowel wall thickening, strictures and fistula formation, tethering, and impaired peristalsis. Age>65 Immunocompromised (e.g. In contradistinction, the presence of fluid within the root of the sigmoid mesentery, visualization of an offending diverticulum, preservation of the expected mural enhancement pattern, and a relatively long segment of circumferential colonic wall thickening favor the diagnosis of acute diverticulitis. 13-55 ) and the mesentery is present and “beaking” due to tapered narrowing of the afferent and efferent bowel loops may be seen. Iatrogenic SBO can occur as a result of endoscopic capsule retention because they have been used more often in the evaluation of the small bowel, particularly in patients with CD. On imaging, full-thickness perforation may result in pneumomediastinum, pleural effusions, and leak of oral contrast into the mediastinal and/or pleural spaces ( Fig. In the setting of SBO, it can be performed without oral contrast administration, because the retained intraluminal fluid serves as a natural negative contrast agent (and delays transit of any ingested contrast). January 2017, issue 1 In addition, full-thickness tears may occur from vomiting (Boerhaave syndrome), caused by incomplete cricopharyngeal relaxation and increased intraluminal pressure. 13-28 ). The potential advantages of ultrasonography (US) include widespread availability, fast, dynamic real-time acquisition, low cost, and lack of ionizing radiation. 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. Perforation of GI lymphoma is most commonly seen in the small bowel, but gastric lymphoma may also perforate; perforation is seen in a higher percentage of T-cell lymphoma involving the GI tract than with B-cell lymphoma ( Fig. Experienced with providing radiology expert-witness consulting in medical malpractice cases, Dr. Intraluminal rugal folds in the stomach are most prominent in the gastric fundus and body. 1999 Nov;213(2):321-39. doi: 10.1148/radiology.213.2.r99nv01321. Progressive narrowing of the afferent and efferent limbs of colon is seen, leading to a whirl sign, which represents a tight twisting of the mesentery and “beaking” due to tapered narrowing of the afferent and efferent bowel loops. Crohn disease is more common in white and Jewish populations and in northern Europe and North America and typically occurs in the second and third decades of life, affecting both sexes equally. It is usually associated with anticoagulant therapy, iatrogenic intervention, or trauma. 13-23 ). 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 … Hernias are the most common cause of SBO in developing countries. Complications are more common in jejunoileal diverticula than duodenal diverticula and, similar to their colonic counterpart, include bleeding, intestinal obstruction, and diverticulitis. Patients typically present with acute or insidious onset of abdominal pain, nausea, abdominal distention, and obstipation. In cases of suspected ischemic colitis the mesenteric vessels should be closely scrutinized for obstructing arterial or venous thrombi. Finally, a central “dot” of increased attenuation within the inflamed appendage may be identified and represents an engorged or thrombosed central vein. It may be asymptomatic or characterized by diverse symptoms of malabsorption with varying severity. 13-58 ). The small bowel has always been a challenging organ for clinical and radiologic evaluation. Mesenteric fluid or hemoperitoneum is often associated with bowel wall hemorrhage or injury ( Fig. These include (1) confirming (or excluding) SBO and elucidating alternative diagnoses in the absence of SBO; (2) assessing complexity/severity of the obstruction (simple versus closed-loop, complete versus partial, low-grade versus high-grade), and identifying the presence of complications (strangulation, perforation); (3) determining the presence and location of the transition point; and, whenever possible, (4) establishing the underlying cause ( Box 13-1 ). Computed tomography findings demonstrate wall thickening more often involving the proximal small bowel and stomach, similar to that of giardiasis. 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. This type of gastric volvulus is more commonly associated with diaphragmatic defects and vascular compromise. The goal of this section is to provide an overview of the normal bowel anatomy, discuss the diagnostic approach, and describe common examples of SBO and inflammation. Initially the neck of a colonic diverticulum becomes obstructed by stool, undigested food particles such as seeds, or inflammation, eventually resulting in microscopic or macroscopic perforation and inflammation, contamination, and infection of the pericolic fat. Updated 27 July 2020 with 4 new videos and 50 review questions. Aphthous ulcers with a target appearance, deep fissuring ulcers, and lymphoid hyperplasia are characteristic findings on colonoscopy. 13-56 ). However, oral contrast delays the diagnosis in the emergency setting and is generally not tolerated by obstructed patients presenting with nausea and vomiting. Patients with acute diverticulitis typically present with left lower quadrant pain and fever. Emergency Radiology Question: Is the abdominal x-ray dead? This section will review the pathophysiology and pertinent imaging features of nontraumatic emergencies that affect the colon and the appendix. This condition can be seen after instrumentation, foreign body impaction, or forceful vomiting. 13-30 ). Furthermore, CECT is the imaging modality of choice to detect complications of acute appendicitis such as appendiceal perforation and periappendiceal abscess formation. Gastric adenocarcinoma is complicated by perforation in 0.4% to 6.0% of cases and is more common in patients older than 65 years of age. Four major forms of intussusception have been described, including enteroenteric, ileocolic, ileocecal, and colocolic. ED abdominal x-rays, in one observational study, lead to a change in management only 4% of the time. Acute appendicitis on US is seen as a noncompressible, thick-walled, dilated, blind-ending tubular structure in the right lower quadrant measuring 7 mm or more in diameter with graded compression, with or without a visible appendicolith. The visceral and parietal peritoneum enclose the large potential space referred to as the peritoneal cavity . Adhesions are typically not seen, and the diagnosis is one of exclusion. Bouveret syndrome has a high mortality rate and is typically treated surgically. 13-9 ). The duodenum is the most common site for aortoenteric fistulas, owing to the proximity of these two structures in the retroperitoneum. Of note, the topics of trauma, ischemia, and hemorrhage involving these organs will be discussed in other chapters. Cecal bascule refers to abnormal positioning of the cecum in the midabdomen secondary to loose mesenteric attachment, which results in folding of the cecum. Careful and systematic travel through the bowel loops in multiple planes is the key to success. He has taught abdominal and emergency imaging at several national and international courses and has a particular passion for delivering radiology education using social media and new technology. In addition, free intra-abdominal air and bowel obstruction may readily be excluded on plain abdominal radiographs. Acute and chronic inflammation, such as CD and radiation enteritis, can lead to fibrosis, strictures, and, in more severe cases, obstruction. Endometrial implants may manifest as contiguous or penetrating soft tissue nodules along the antimesenteric border of the bowel wall. Contrast-enhanced computed tomography shows a large crater in the lesser curvature posterior wall with associated wall thickening. 13-41 and 13-42 ). It is estimated to affect approximately 5% of women of reproductive age. Duodenal diverticula are relatively common and have been found in up to 5% of the population undergoing barium studies. On CT a target or double-halo appearance due to mural stratification is commonly identified. Other common pathogens that often affect the small bowel, typically the distal ileum and cecum, include Yersinia , Campylobacter , and Salmonella species ( Fig. 13-51 ). Crohn disease, unlike UC, is patchy and segmental with skip lesions and transmural involvement. Contrast-enhanced CT of the abdomen and pelvis is currently the study of choice in patients with suspected acute diverticulitis, which manifests with pericolic inflammation, engorgement of the adjacent mesenteric vasculature, and focal colonic wall thickening with or without abscess formation ( Fig. Special Section on Dual Energy CT. February 2017, issue 2. There is no exact point of transition between the jejunum and ileum, but differences in their usual location, caliber, fold pattern, and degree of vascularity allow distinction between the two. Radiopaedia is proud to be able to provide this online course for free in 125 low and middle-income countries. The findings of various types of vessel injury include laceration, rupture with active haemorrhage, occlusion and, for arteries formation of aneurysm, pseudoaneurysm, dissection or fistula. Although early changes, such as aphtoid ulceration, are beyond the resolution of MR, it can be useful in the evaluation of fixed stenoses and segmental dilatation and to detect adhesions. , and exhibits luminal narrowing have a varied clinical presentation affected adult with. Herpes esophagitis typically presents with multiple small ulcers represented by pooled barium antimesenteric border within an segment. Involved in the abdominal wall at sites of congenital weakness or previous surgery )... 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