ACUTE ABDOMEN
ABNORMAL GAS COLLECTIONS
TERRENCE C. DEMOS, MD
DEPARTMENT OF RADIOLOGY
OR
GAZ
ACUTE ABDOMEN EXAMINATION
• RADIOGRAPHS
–
–
–
–
LEFT LATERAL DECUBITUS ABDOMEN
UPRIGHT ABDOMENT
UPRIGHT CHEST
SUPINE ABDOMEN
PNEUMOPERITONEUM
FREE AIR
SENSITIVITY OF IMAGING STUDIES
• COMPUTED TOMOGRAPHY
99%
• LATERAL UPRIGHT CHEST RADIOGRAPH
98%
• AP UPRIGHT CHEST RADIOGRAPH
80 - 90%
• LEFT DECUBITUS ABDOMEN RADIOGRAPH 80- 90%
• SUPINE ABDOMEN RADIOGRAPH
?
PNEUMOPERITONEUM
SENSITIVITY OF IMAGING STUDIES
• RADIOLOGIC DEMONSTRATION DEPENDS ON:
–
–
–
–
VOLUME OF FREE AIR
TIME INTERVAL BEFORE IMAGING
TYPE OF IMAGING
CONDUCT OF IMAGING EXAMINATION
• AS LITTLE AS ONE CC CAN BE DEMONSTRATED
• 10% OF PATIENTS WITH PERFORATED ULCERS DO
NOT DEMONSTRATE PNEUMOPERITONEUM
UPRIGHT CHEST
PNEUMOPERITONEUM
UPRIGHT RADIOGRAPHS
UNDER RIGHT HEMIDIAPHRAGM
UPRIGHT ABD CENTRAL TENDON
AND HEMIDIAPHRAGM
FREE AIR…….DECUBITUS VIEW
GAS BETWEEN LIVER AND BODY WALL
BUT MAY ALSO BE IN OR ONLY IN THE PELVIS
ACUTE ABDOMINAL PAIN
UPRIGHT AP CHEST & LEFT LATERAL DECUB NEGATIVE
PNEUMOPERITONEUM
SUPINE RADIOGRAPHS
GAS BUBBLE ON LIVER SURFACE
FREE AIR
CENTRAL TENDON
FREE AIR
CENTRAL TENDON
RIGLER’S SIGN
BOTH SIDES OF BOWEL WALL VISIBLE
DOUBLE WALL SIGN
MASSIVE PNEUMOPERITONEUM
FOOTBALL SIGN
FALCIFORM LIGAMENT
GAS BUBBLE OVER LIVER
FALCIFORM LIGAMENT
PNEUMOPERITONEUM
SUBHEPATIC GAS BUBBLE
DIVERTICULITIS
PNEUMOPERITONEUM
ANTERIOR ABDOMINAL WALL
ANATOMIC FOLDS
FREE AIR
INFERIOR EPIGASTRIC VESSELS
(LATERAL UMBILICAL LIGAMENTS)
FREE AIR 2 DAYS AFTER OHT
CT 3 DAYS LATER:
DIVERTICULITIS
PNEUMOPERITONEUM
WITH PERITONITIS
• PERFORATED VISCUS
–
–
–
–
–
ULCER
NEOPLASM
BOWEL OBSTRUCTION
ISCHEMIC BOWEL
TRAUMA
• TRAUMA
• PERITONITIS
– GAS FORMING ORGANISM
PSEUDO-PNEUMOPERITONEUM
CENTRAL TENDON GAS
YES, BUT JUST THE STOMACH
GAS UNDER THE RIGHT HEMIDIAPHRAGM
HEPATIC FLEXURE ANTERIOR-SUPERIOR TO LIVER
SUBDIAPHRAGMATIC FAT
SIMULATING FREE AIR
FREE AIR OR NOT FREE AIR?
THAT IS THE QUESTION
PNEUMOTHORAX SIMULATES FREE AIR
GAS IN SUBPHRENIC ABSCESS
SIMULATES FREE AIR
RETROPERITONEAL GAS
SIMULATES FREE AIR
RETROPERITONEAL GAS
RETROPERITONEAL GAS
IMAGING
• LITTLE CHANGE IN POSITION OR SHAPE WHEN
COMPARING SUPINE, UPRIGHT, DECUB RADIOGRAPHS
• BUT FREE INTRAPERITONEAL GAS IS FREELY MOBILE
• TENDS TO STAY IN ONE RETROPERITONEAL COMPARTMENT
• DUODENAL PERFORATION…..RUQ ANTERIOR PARARENAL SPACE
• SIGMOID DIVERTICULITIS….. LLQ
• PERIRENAL ABSCESS…………. PERINEPHRIC SPACE
• OFTEN FORMS LINEAR, CURVILINEAR GAS COLLECTIONS
49-YEAR-OLD MAN WITH FEVER AND DIARRHEA
FOR 2 WEEKS. HE HAS INFECTED URINE
RETROPERITONEAL GAS
IMAGING
• BENEATH DIAPHRAGM CAN SIMULATE PNEUMOTHORAX
• BUT MEDIAL, LATERAL, LOW NOT DIRECTLY UNDER APEX AS FREE AIR
– DIFFERENTIATE BY OBTAINING UPRIGHT OR DECUBITUS VIEWS
• LARGE VOLUME OF GAS CAN OUTLINE
RETROPERITONEAL STRUCTURES
• KIDNEY, LIVER MARGIN, PSOAS, FLANK STRIPE
• RETROPERITONEAL GAS CAN EXTEND
• CEPHALAD TO MEDIASTINUM
• FASCIAL PLANES OF BODY WALL AND EXTREMITIES
• INTO PERITONEAL CAVITY
RETROPERITONEAL GAS
13-YEAR-OLD GIRL WITH CROHN’S DISEASE
HAS SUBACUTE FEVER AND ABD PAIN
RETROPERITONEAL GAS
EXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT
ABDOMINAL PAIN 4 HOURS AFTER
COLONOSCOPY AND BIOPSY
EXTENSIVE RETROPERITONEAL GAS
BAROTRAUMA
MEDIASTINUM – RETROPERITONEUM – FREE AIR
RETROPERITONEAL GAS
CAUSES
• IATROGENIC
– SURGERY
– DIAGNOSTIC PROCEDURE
• TRAUMA
– PENETRATING
– RUPTURED VISCUS
• RETROPERITONEAL DUODENUM, COLON, RECTUM
• PERFORATED BOWEL
• SECONDARY TO TUMOR, INFECTION, OBSTRUCTION, NECROSIS
• CAUDAL EXTENSION OF PNEUMOMEDIASTINUM
• GAS WITHIN ABSCESS
BOWEL WALL GAS
PNEUMATOSIS OF COLON
INFANT
ADULT
NECROTIZING ENTEROCOLITIS
ISCHEMIC COLITIS
WHAT IS THE ABNORMALITY
HERE?
USE LUNG WINDOWS TO LOOK FOR GAS
72-YEAR-OLD WOMAN WITH DIARREHA
FOR 2 DAYS
NORMAL PHYSICAL EXAMINATION
58-YEAR-OLD WOMAN
MILD ABDOMINAL PAIN FOR 2 DAYS
DIFFERENTIAL DIAGNOSIS?
SCLERODERMA,
GAS IN COLON WALL
PNEUMATOSIS 2 DAYS AFTER SEGMENTAL SB RESECTION
RESOLVED SPONTANEOUSLY,
DISCHARGED AFTER 1 WEEK
BOWEL WALL GAS MAY BE INNOCUOUS
ASYMPTOMATIC 40-YEAR-OLD MAN
BENIGN STEADY STATE PNEUMATOSIS
ISCHEMIC BOWEL
ISCHEMIC BOWEL
IMAGING SIGNS
– DILATION
• PSEUDOOBSTRUCTION
– BOWEL WALL
• THICKENED
• PNEUMATOSIS
• UNENHANCING
– GAS IN VESSELS
• MESENTERIC, SMV, PORTAL VEINS
– OBSTRUCTED VESSELS
• SMA, SMV
– HIGH DENSITY CLOT ON UNENHANCED CT
– FILLING DEFECTS ON CT WITH IV CONTRAST
– ASCITES, FREE AIR AFTER PERFORATION
ACUTE ONSET OF ABDOMINAL PAIN
SMA EMBOLIS
ISCHEMIC COLITIS IN TWO PATIENTS
ISCHEMIC SB AND COLON
THICKENED MUCOSAL FOLDS
SBO
ISCHEMIC BOWEL
AT SURGERY: SB TWISTED UNDER
ADHESION WITH OBSTRUCTI0N &
SEGMENT OF DEAD BOWEL
61-YEAR-OLD MAN WITH PROSTHETIC
AORTIC VALVE HAS ACUTE GI BLEEDING
ISCHEMIC COLITIS
ISCHEMIC SMALL BOWEL
ETIOLOGY ?
SMV CLOT
47-YEAR-OLD WOMAN 2 WEEKS AFTER MI
ACUTE ABDOMINAL PAIN
OCCULT BLOOD + STOOL
SMA EMBOLIS FROM MURAL THROMBUS
BILE DUCT GAS
BILE DUCT GAS
• IATROGENIC
– BILE DUCT SURGERY
– SPHINCTEROTOMY
• BILIARY FISTULA
–
–
–
–
GALLSTONE ERODING INTO BOWEL
DUODENAL ULCER
UPPER ABDOMINAL MALIGNANCY
TRAUMA
• CHOLANGITIS
– GAS FORMING ORGANISM
BILE DUCT GAS
BILE DUCT GAS
CHUNKY AND CENTRAL
59-YEAR-OLD MAN
HISTORY OF DUODENAL ULCER
BILE DUCT GAS AND SBO
SBO GALLSTONE ILEUS
GALLSTONE ILEUS
GALLSTONE ILEUS
GALLSTONE ILEUS
BILE DUCT GAS, SBO, STONE
GALLSTONE ILEUS
86-YEAR-OLD MAN ABD PAIN, VOMITING X 2 DAYS
NO HISTORY OF PRIOR SURGERY AND NO HERNIAS
82-YEAR-OLD MAN COMES TO ER
ABDOMINAL PAIN AFEBRILE, NORMAL WBC
ABD 1 DAY LATER
THE 82-YEAR-OLD MAN NOW HAS THE
DIAGNOSIS OF SBO AND A CT STUDY IS DONE
73-YEAR OLD MAN
SIGNED OUT AMA AFTER UGI
ONE YEAR LATER
ADMITTED WITH
ABD PAIN, VOMITING
75-YEAR-OLD WOMAN
NAUSEA AND VOMITING X 1 DAY
GALLBLADDER COLON FISTULA
49-YEAR-OLD MAN
WITH INTRACTABLE DIARRHEA
RADIOGRAPH 2YEARS EARLIER
GALLBLADDER GAS
GALLBLADDER GAS
• GALLBLADDER LUMEN
– GALLBLADDER-BOWEL FISTULA
– GALLSTONE ILEUS
– EMPHYSEMATOUS CHOLECYSTITIS
• GALLBLADDER WALL GAS
– EMPHYSEMATOUS CHOLECYSTITIS
EMPHYSEMATOUS CHOLECYSTITIS
EMPHYSEMATOUS CHOLECYSTITIS
EMPHYSEMATOUS CHOLECYSTITIS
38 Emph Chole
53-YEAR-OLD WOMAN
RUQ PAIN AND FEVER
SUPINE
UPRIGHT
LEFT LAT. DECUBITUS
2 WEEKS POST HEART TRANSPLANT
FEVER AND ABDOMINAL PAIN
PREOPERATIVE RADIOGRAPH
PORTAL VEIN GAS
SMALL BOWEL ISCHEMIA
GAS IN MESENTERIC AND PORTAL VEINS
48 SubPhrenic Abs CT
65-YEAR-OLD MAN
ABDOMINAL PAIN, NORMAL PX
PORTAL VEIN GAS
DELICATE AND PERIPHERAL
36-YEAR-OLD MAN
MULTIPLE CONGENITAL ANOMALIES
FEVER , WBC 17.8, 15 BANDS
ISCHEMIA OF SB AND STOMACH
ISCHEMIC BOWEL
MESENTERIC VEIN GAS
ABSCESS
ABSCESS
• SUSPECT AN ABSCESS WHEN RADIOGRAPHS SHOW
A GAS COLLECTION THAT IS ABNORMAL BECAUSE
OF PERSISTENCE ON MULTIPLE VIEWS
• GET HISTORY, PX, LAB DATA BY CONSULTATION
WITH ORDERING MD AND BY LOOKING IN EMR
• CONFIRM WITH CROSS-SECTIONAL IMAGING
APPENDICEAL ABSCESS
RETROCECAL APPENDIX
ABNORMAL GAS… UNCHANGED ON MULTIPLE VIEWS
SIGMOID DIVERTICULITIS
GAS FILLED “DIVERTICULUM
GIANT ABSCESS
2 WEEKS AFTER ANEURYSM SURGERY
8 DAYS POST LEFT HEMICOLECTOMY
TEMP 39.1, WBC 16,OOO 15 BANDS
PERIHEPATIC
ABSCESS.
CONNECTION
TO BOWEL
SHOWN BY UGI
SUBPHRENIC ABSCESS
FEVER 10 DAYS AFTER
ABDOMINAL SURGERY
CROHN’S DISEASE WITH ABSCESS
54-YEAR-OLD WOMAN TRANSFERRED
WITH PERSISTENT FEVER AND ELEVATED WBC
POST DIVERTICULAR ABSCESS DRAINAGE
47-YEAR-OLD WOMAN HAS FEVER, WBC 29.6
7 DAYS POST HEMICOLECTOMY
PERCUTANEOUS DRAINAGE OF
ABSCESS
ABSCESS WITH FISTULA TO SMALL BOWEL
SHOWN BY DELAYED SCANNING
PERITONITIS
THICKENED, ENHANCING PERITONEUM
PANCREATIC ABSCESS
PANCREATIC GAS
• GAS IN PANCREATIC BED
– ABSCESS
– POST PANCREATIC DRAINAGE PROCEDURE
• PERCUTANEOUS OR SURGICAL
– PUESTOW PROCEDURE
– PSEUDOCYST
– PANCREATIC FISTULA
PANCREATITIS WITH ABSCESS
LESSER SAC ABSCESS
GAS IN PANCREATIC ABSCESS
PANCREAS-GAS BUT NO ABSCESS
POST PUESTOW PROCEDURE
PANCREAS-COLON FISTULA
LESSER SAC
LESSER SAC
GASTRIC ULCER
PERFORATION INTO LESSER SAC
GALLBLADDER IN LESSER SAC
GAS IN LESSER SAC
PERFORATED GASTRIC ULCER
CULTURE
HISTORY OF RADIOLOGY
INTERMITTENT ABDOMINAL PAIN FOR 3 WEEKS
TAKING NSAIDS FOR 2 MONTHS
68-YEAR –OLD MAN
SUDDEN ONSET OF SEVERE ABDOMINAL PAIN