Imaging, 21 (2009), 1–19
The role of imaging in the management of adults with non-
traumatic acute abdominal pain
1
J T SMITH, MbChB, MRCP, FRCR and 2C PARCHMENT-SMITH,
1
Consultant Radiologist, St James’s University Hospital, Beckett Street, Leeds, West Yorkshire LS9
7TF, UK and 2Consultant Colorectal Surgeon, Pinderfields Hospital, Aberford Road, Wakefield,
West Yorkshire WF1 4DG, UK
Summary
N Accurate imaging of the acute abdomen makes the diagnosis and excludes
important diagnoses
N Accurate imaging alters management
N It helps consent/counselling
N Accurate imaging allows surgeon to plan procedure
Abstract. Abdominal pain is one of the most common
reasons for visits to the accident and emergency department.
The sudden onset of severe abdominal pain requiring
emergency medical or surgical treatment (the so-called ‘‘acute
abdomen’’) can be a symptom of various disease processes.
Some of these processes can be life-threatening and several
require rapid diagnosis and clinical intervention to avoid
significant morbidity and mortality. This paper has been co-
written by a teaching hospital consultant radiologist and a
district general colorectal surgeon. The article aims to help the
on-call radiologist to review the ways in which imaging can
assist diagnosis of the causes of the acute abdomen and to
explain how this can affect the immediate management. The
article also aims to demonstrate the surgeon’s view on the
benefits and limitations of various imaging modalities and to
clarify the indications for imaging in this patient group.
The indications for imaging in the patient are changing
all the time. This is because of advances in radiology,
advances in surgery, increasing subspecialisation and
patients demanding an increasingly high standard of
clinical care. It is difficult to believe that ultrasound and
CT were introduced into Leeds in 1978 and 1979
respectively, and impossible to imagine which imaging
technologies will be regarded as standard in another 30
years’ time when most of the trainees reading this paper
will still be practising. Before ultrasound and CT became
available, clinical history, examination and plain films
formed the basis of the decision whether or not to operate.
There was acceptance of a certain number of ‘‘negative
laparotomies’’ in patients for whom surgery was useless
and ‘‘open and close laparotomies’’ in patients for whom
surgery was hopeless. Nowadays, the technology exists to
make the diagnosis and avoid an unnecessary, inap-
propriate or delayed operation. It is becoming difficult for
surgeons to justify operating ‘‘blind’’ when the diagnosis
may require no surgery, radiological treatment, specialist
surgery or palliation rather than a laparotomy.
Table 1 helps to illustrate how the prompt correct
diagnosis of the cause of the acute abdomen may
Imaging, Volume 21 (2009) Number 1
BSc, MbChB, FRCS
DOI: 10.1259/imaging/
28719515
’ 2009 The British Institute of
Radiology
significantly alter the immediate management of the
patient. Depending on the radiological and clinical diag-
nosis, management can be conservative, medical, radiolo-
gical, surgical or palliative. In addition, even if the decision
has been made clinically that surgery is indicated, in the
cardiovascularly stable patient, imaging can help the
surgeon counsel and consent the patient. Imaging can also
help the surgeon plan the correct surgery (e.g. reconsider
radical resection if widespread thoracic and bony metas-
tases are diagnosed pre-operatively) and assess the optimal
timing of the operation. Finally, in these days of subspecia-
lisation, pre-operative imaging can help ensure that the
right surgeon is present or available to perform the opera-
tion required, be it repair of a perforated gastric cancer, a
perforated colonic cancer or a leaking aortic aneurysm.
The radiologist should appreciate by looking at
Table 1 that the disparate causes of the acute abdomen
make targeted imaging difficult. Not knowing whether
the symptoms are arising from the urological, gynaeco-
logical, vascular or gastrointestinal organs means that it
is not always possible to specify the modality or even the
area to be imaged. This is probably why CT is often the
investigation of choice: if it excludes the likely diagnosis
it will often simultaneously identify the correct one.
The surgeon and radiologist should consider several
questions when discussing the best imaging for the acute
abdomen:
N What is the most likely clinical diagnosis and the
differentials? What is the best imaging modality to
differentiate between these?
N Why are we doing this? What are the current manage-
ment plans for the patient and how would the imaging
change that?
N When should the scan be done? When would surgery
be performed? Tonight? First thing in the morning?
N Who wants the scan and to whom should the
radiologist convey the result? This should ideally be
the person in the position to make the decision about,
and perform, the surgery.
1
 J T Smith and C Parchment-Smith

Table 1. Management of the acute abdomen depending on diagnosis

Diagnosis Immediate management
Non-specific abdominal pain Conservative (analgesia only)
Uncomplicated renal colic
Urinary tract infection
Uncomplicated cholecystitis
Uncomplicated diverticulitis
Uncomplicated pancreatitis
Pelvic inflammatory disease Medical (e.g. analgesia,
Uncomplicated adhesional bowel obstruction fluid, +/2 antibiotics)
Sealed perforated duodenal ulcer in unfit but stable patient
Crohn’s disease
Small infarcts of spleen, liver or kidney
Infected renal tract obstruction
Empyema of gallbladder Radiological intervention/drainage
Stentable obstructing colon cancer
Diverticular (or other) abscess
Acute appendicitis
Perforated viscus
Diverticulitis
Colon cancer
Gastric or duodenal ulcer
Surgery
Gastric cancer
Ectopic pregnancy
Non-adhesional bowel obstruction
Ischaemic bowel
Operable malignancy
Leaking abdominal aortic aneurysm
Disseminated malignancy
Malignancy in a patient not fit for resection Palliative treatment
Panenteric irreversible ischaemia

N How can imaging be done practically and safely? Has
the patient been resuscitated adequately? Has she had
a pregnancy test? What is his/her renal function?
Should we give intravenous (iv) contrast? Should we
give oral contrast? Might we have to proceed directly
to radiological intervention or surgery? What is the
clotting (if drainage/intervention may be required)?
Because they are common and important diagnoses that
might require surgical intervention, the authors have
looked at the following surgical conditions in detail from
both a radiological and surgical perspective.
Appendicitis
Appendicectomy is one of the commonest emergency
general surgical operations. Many general surgeons have
now adopted the diagnostic laparoscopy in the manage-
ment of right iliac fossa pain, proceeding to a laparoscopic
appendicectomy if the appendix is inflamed. This
approach also facilitates a wash-out if the diagnosis is
pelvic inflammatory disease or a ruptured ovarian cyst. If
an unexpected diagnosis such as diverticulitis, perforated
duodenal ulcer or Meckel’s diverticulitis is encountered, it
can be dealt with either laparoscopically or through a
targeted open incision. The majority of healthy young
patients with a short history of right iliac fossa pain,
low-grade fever and systemic upset who are found to
have guarding and rebound tenderness could, therefore,
reasonably proceed to laparoscopy without imaging.
The role of imaging in the management of acute
appendicitis
In the well, young female patient with less convincing
symptoms and abdominal signs, a transvaginal pelvic
and transabdominal ultrasound scan could reasonably be
requested to exclude gynaecological and biliary pathology
and to attempt visualisation of the appendix. In these
patients, a normal appendix on ultrasound, gynaecological
pathology such as cystic ovarian disease and an improving
clinical picture often help avoid operative intervention.
Similarly, in very young children with unconvincing signs,
a normal transabdominal ultrasound scan of the appendix
with a settling clinical picture is reassuring and could avoid
unnecessary appendicectomy. Laparoscopy is less com-
monly performed by non-paediatric surgeons for sus-
pected appendicitis in children than in adults.
There is a group of patients with suspected appendi-
citis for whom urgent pre-operative CT imaging is
useful. This group includes patients who are difficult to
assess, patients for whom surgery might pose significant
risk or patients in whom, for some reason (including age,
anaemia or history of weight loss), other diagnoses are
thought to be likely. Thus, obese, demented or elderly
patients or those with significant co-morbidity, mental
handicap, atypical history or signs may require pre-
operative CT imaging. Although ultrasound has the
advantage of avoiding ionising radiation and would
therefore be the investigation of choice in children,
young women and pregnant women, CT is more useful
in the older patient group for several reasons: it is better

2 Imaging, Volume 21 (2009) Number 1

Imaging in the management of non-traumatic acute abdominal pain
Table 2. Suggested management of different presentations of appendicitis
Clinical presentation
Likely appendicitis in an unwell young man or woman
Likely appendicitis in an unwell child
Possible appendicitis in a well young female
Possible appendicitis in a well young man
Possible appendicitis in a well child
Possible appendicitis in an unwell elderly patient
Possible appendicitis in a well elderly patient
Peritonitis in an unstable septic patient
at assessing complications, including perforation; it is
able to detect the retroperitoneal appendix; it can
visualise the appendix better than ultrasound in the
obese; it can make an alternative diagnosis more often
than ultrasound; and it can allow for staging if
malignancy is diagnosed. In patients with renal failure
or nausea, CT can be completed without oral or iv
contrast whilst maintaining a high degree of diagnostic
accuracy [1–6]. The main differentials would be any of
the diagnoses in Table 1, particularly non-specific
abdominal pain (i.e. a normal scan), ovarian or tubal
pathology, Crohn’s disease, perforated caecal cancer or
other perforated viscus and diverticulitis (either in a
right-sided sigmoid loop, right colon or Meckel’s
diverticulitis). If malignant pathology is found, a staging
scan of the chest completed simultaneously will help
decide which operation, if any, is indicated.
In cases of delayed presentation, a non-tender appen-
dix mass in a clinically stable patient may require
conservative treatment with antibiotics and a delayed
‘‘interval’’ appendicectomy 3 months later after a
colonoscopy. The reasoning is that, if the appendicitis
has been ‘‘walled off’’ by omentum and inflamed bowel
and is settling, immediate surgery would be difficult and
might require a laparotomy or right hemicolectomy. As
the patient has not got peritonitis and the natural history
of these cases is to gradually settle down, the conserva-
tive approach is usually preferred. There are exceptions.
Occasionally these patients can develop complications
needing intervention, such as abscess formation, bowel
obstruction or perforation.
Table 2 summarises the suggested management of
different presentations of appendicitis.
Imaging in acute appendicitis
N Appendicectomy is one of the commonest emer-
gency abdominal operations
N There is a role for both ultrasound and CT
N Ultrasound is useful in young women and children
N CT is useful in patients who are difficult to assess,
elderly or obese
N CT identifies complications and alternative diagnoses
N Non-contrast CT is highly diagnostic
CT imaging of acute appendicitis: top tips
It is important for the radiologist to consider a
diagnosis of acute appendicitis in every patient who
undergoes acute imaging of the abdomen and pelvis.
Imaging, Volume 21 (2009) Number 1
Suggested management
Laparoscopy
Appendicectomy
Transvaginal ultrasound and transabdominal ultrasound
Wait and see/transabdominal ultrasound
Transabdominal ultrasound
Urgent CT
Prompt CT
Resuscitation and surgery
Trainees should attempt to locate the caecal pole and
appendix in all acute cases. The appendix is of variable
length and may lie behind the liver or low in the pelvis. It
might even be in the left side of the abdomen in, for
example, the patient with a malrotated or unusually
sited bowel.
Radiological signs of appendicitis include dilated
appendix measuring .6 mm in diameter, peri-appendi-
ceal inflammatory change, inflamed enhancing wall,
abscess or adjacent fluid, appendicolith and caecal wall
thickening (Figure 1). Two further signs include the
arrowhead and caecal bar signs, which are essentially
variations of the above signs.
Challenges for the radiologist in diagnosing acute
appendicitis
The radiologist faces several challenges in diagnosing
acute appendicitis. First, in patients who are thin and have
limited intra-abdominal fat, CT can struggle to identify the
inflamed appendix [7]. Also, typhlitis is a catch diagnosis
that presents in immunosuppressed patients. Typhlitis is
typically centred on the caecum rather than the appendix
and usually responds to non-surgical management.
Atypical appendix sites can also pose a challenge to the
radiologist, as can rare causes of secondary appendicitis.
For example, primary tumours of the appendix, caecal
tumours and metastases can all cause appendicitis. Clues
pointing towards a primary appendix tumour include focal
mass in primary adenocarcinomas and calcification in
carcinoid tumours [8]. A very dilated smooth fluid-
containing appendix would be suggestive of a mucocele.
Caecal tumours can present with either circumferential or
focal enhancing masses. Metastases causing appendicitis
are rare but may be considered if there is peritoneal
metastatic disease or a focal mass in a patient with an
established diagnosis of cancer (Figure 2). It is, of course,
important for the radiologist to communicate any suspicion
of malignancy directly in person to the surgical team, as
this could significantly influence who carries out the
surgery, when it is performed and through which incision.
Such findings would also influence pre-operative counsel-
ling of the patient and family (including warning about
possible stoma formation) and booking of suitable high-
dependency post-operative care that might not have been
necessary after a simple laparoscopic appendicectomy, but
might be needed after a right hemicolectomy and ileostomy
formation. Finally, the radiologist needs to consider the
case of complicated appendicitis. In such cases, the
radiologist should look out for and comment on signs of
abscess formation, bowel obstruction or perforation.
3

Figure 1. Acute appendicitis. Dilated fluid-filled tubular
appendix within the right iliac fossa with small appendicolith
and extensive surrounding inflammation.
Perforated viscus
Any part of the intestinal tract can perforate from a
variety of causes (Table 3) [9]. In the absence of trauma,
two common sites of perforation are the first part of the
duodenum, secondary to peptic ulcer disease, and the
sigmoid colon, often secondary to diverticulitis.
The role of imaging in the management of a
perforated viscus
In a patient with a clinically perforated viscus who is
cardiovascularly stable, CT imaging is useful for several
reasons.
First, CT may confirm perforation and determine the
cause. This may influence whether the surgeon decides on
4 Imaging, Volume 21 (2009) Number 1
J T Smith and C Parchment-Smith
a laparoscopic procedure or open laparatomy and could
influence their initial incision. Traditionally, laparotomy is
undertaken, but recently laparoscopic approaches to both
perforated peptic ulcers and diverticular disease have
been gaining favour. High-risk patients with significant
co-morbidity and a sealed perforated peptic ulcer without
generalised peritonitis may be treated conservatively with
antibiotics and proton pump inhibitors. Similarly, a sealed
perforated diverticulitis resulting in a localised pericolic
abscess with a few flecks of air but no sign of generalised
peritonitis might settle with radiological drainage or
conservative management.
In addition to possible identification of the cause, CT
imaging can occasionally reveal a surprise that signifi-
cantly alters management, such as a leaking abdominal
aortic aneurysm or disseminated metastatic malignancy.
Finally, CT could prevent an unnecessary laparotomy
in a patient with a suspected perforation, but in whom
abdominal pain is due to a cause that does not
necessitate surgery, such as pancreatitis, non-perforated
diverticuitis, cholecystitis, renal or ureteric stones, sickle
cell crisis or diabetic ketoacidosis.
There are three things the on-call surgeon wants to
know when asking for a CT on a patient who he or she
suspects has a perforated viscus:
N Is there radiological evidence of a perforation?
N If so, can you tell what has perforated?
N If not, can you see any other cause for the patient’s
acute severe abdominal pain?
Role of CT in diagnosis of suspected perfo-
rated viscus
N Confirms perforation
N Can determine the site
N Reveals alternative diagnosis
Figure 2. Acute appendicitis second-
ary to obstructing ovarian metasta-
sis. The distal appendix is fluid-filled
with an enhancing wall. Note the
1.5 cm obstructing enhancing ovar-
ian metastasis and peri-appendiceal
inflammation (courtsey of Dr Tim
Perren and Dr John Spencer).
Imaging in the management of non-traumatic acute abdominal pain

Table 3. Cause of perforation of the abdominal viscus

Site of perforation Cause

Oesophagus Cancer
Instrumentation
Trauma, vomiting
Duodenum Peptic ulcer
Colon Diverticular disease
Carcinoma
Radiation damage
Crohn’s disease
Ischaemia
Tropical infections (typhoid, amoebic infections, tuberculosis)
Small bowel Trauma
Foreign bodies
Crohn’s disease
Leukaemia
Lymphoma
Peptic ulcer (from ectopic gastric mucosa, e.g. in the Meckel’s diverticulum)
Meckel’s diverticulitis
Potassium chloride tablets (terminal ileum ulceration)

CT imaging of the perforated viscus: top tips intraperitoneal free fat can mimic free gas (‘‘pseudo free
gas sign’’) and must be considered when ovarian
In the absence of obstruction, most centres advise CT dermoids are present (Figure 4). Fat will have a
with iv contrast 1 h after bowel preparation with positive Hounsfield unit (HU) of between 2200 and 250 and
contrast media. Radiologists on call should be encour- pockets of free gas will have, much higher negative
aged to tailor their protocol to answer the most value. Small locules of gas within the upper anterior
important question at hand. The longer the oral bowel abdominal wall soft tissues following trauma must not
preparation, the better the colon is visualised. This be mistaken for intraperitoneal free gas. A high index
enhancement is at a cost of delaying a diagnosis in a of suspicion of trauma is advised, especially in the
potentially less common but acutely life-threatening intoxicated patient with an unreliable clinical history.
disease (e.g. a leaking abdominal aortic aneurysm). In Gas within fistulating interloop bowel disease is often
cases of clinically suspected perforation about which a secondary to Crohn’s disease. Here, several loops of
senior surgeon is concerned, but where there is no bowel will be thickened, angulated and hyperaemic.
evidence of free gas on plain film, a prompt non-contrast
study would detect small volume free gas accurately. If
the diagnosis is still not clear, a repeat study with full
oral bowel preparation plus iv contrast would often Challenges for the radiologist in diagnosing a
clarify the diagnosis. perforated viscus
When trying to identify free gas, the radiologist must When diagnosing a perforated viscus, the radiologist
review each organ and compartment on both bony and faces two key challenges. First, detecting small volume
lung windows to look for small volume free gas that free gas is challenging and requires careful review of the
might be inconspicuous on soft tissue windows. Some
colleagues advocate inverting the CT image and feel the
free gas becomes more conspicuous. This is not practised
by the author, who spends time reviewing the lung
windows to try to identify small volumes of free gas.
When free gas is confirmed, careful inspection of both
the first part of the duodenum and sigmoid colon is
required (Figure 3). Spillage of oral contrast in the
presence of a full-thickness bowel wall defect confirms
the site of perforation. The volume and position of free
gas is not specific to either duodenal or sigmoid causes,
but if there is a lot of free gas large bowel perforation is
more likely. Upper GI perforation is more likely if
periportal free gas is demonstrated [10]. It is important to
measure the density of free fluid using a region-of-
interest tool. The authors have seen oral contrast diluted
in large volume free fluid incorrectly diagnosed as dense
ascites, thereby missing the diagnosis of perforation, Figure 3. Perforated first part of the duodenum secondary
with oral contrast spilling into the peritoneal cavity. to non-steroidal anti-inflammatory drugs. Note the free gas,
Inflamed periduodenal or sigmoid fat is a pointer thickened duodenum with surrounding free fluid and
towards the site of perforation. Although very rare, spillage of oral contrast.

Imaging, Volume 21 (2009) Number 1 5

 J T Smith and C Parchment-Smith

Figure 4. ‘‘Pseudo free gas sign’’. A fat-fluid level is seen in the right upper quadrant. An ovarian dermoid rupture secondary to
pelvic sepsis was confirmed at surgery.

duodenum, sigmoid, liver hilum and the anterior upper
abdominal compartments. Second, making a diagnosis of
perforation in the post-operative abdomen is a common
and difficult scenario. The vast majority of carbon
dioxide insufflated at laparoscopy becomes rapidly
absorbed, and it is unusual to see a lot of free gas a
few days after an operation. Radiologists are advised to
use positive oral contrast and to review the imaging with
the surgeon who has completed the operation, as they
will have a good idea of sites of iatrogenic damage or
possible complications.
antibiotics (Figure 5). An outpatient colonoscopy after a 4
week recovery period will exclude a more sinister large
bowel pathology.
The role of imaging in acute diverticulitis
CT is the imaging modality of choice in acute
diverticulitis. The aim would be to confirm the diagnosis,
exclude the differential diagnoses and exclude any of the
following complications:

N Localised perforation leading to pericolic abscess or

Diverticulitis
Diverticulae can occur anywhere throughout the bowel,
but are most common within the sigmoid colon. Diverticular
disease is symptomatic diverticulosis. Diverticulitis is
inflammation of the diverticulae (a bit like early appendi-
citis), causing pain, tenderness and fever. Patients admitted
with uncomplicated diverticulitis may have a CT scan to
exclude more life-threatening causes of an acutely peritonitic
abdomen. Once the diagnosis has been confirmed, these
patients normally settle in a couple of days on intravenous
phlegmom. This complication delays recovery and
could necessitate radiological, laparoscopic or open
surgical drainage. If the perforation is small and has
sealed and there is not frank faecal peritonitis, then a
stoma can be avoided by delaying the resection until
the contamination has settled, perhaps months later,
with or without percutaneous drainage, which might
be helpful to settle the attack.
N Fistula formation (typically to the bladder, vagina or
uterus). This is not an acute emergency, but the
presence of a fistula might affect the management of

Figure 5. Acute diverticulitis. The sigmoid colon is thickened over a long length with no mass or rolled edges. Note the
hypervascular sigmoid mesenteric arcade.

6 Imaging, Volume 21 (2009) Number 1

Imaging in the management of non-traumatic acute abdominal pain
an acute attack. It is certainly an indication that a
partial bladder resection or hysterectomy might be
needed at surgery, which is useful to know pre-
operatively (Figure 6).
N Perforation leading to faecal peritonitis. This diag-
nosis must be communicated urgently in person
to the senior surgeon on call, as it usually necessitates
a prompt laparotomy with resection of the per-
forated diverticular segment, washout of the faecal
contamination, oversewing or exteriorising of the
rectal stump and formation of an end-colostomy
(Hartmann’s procedure).
N Large bowel obstruction, usually subtotal and gradual
owing to a chronic diverticular stricture with super-
imposed constipation. Diverticular obstruction pre-
senting acutely is relatively rare and raises the
possibility of a sigmoid malignancy. Large bowel
obstruction is treated by prompt surgery or colonic
endoluminal stenting, although the latter is more
successfully used to treat malignant strictures.
N Small bowel obstruction resulting from a loop of small
bowel getting stuck onto a diverticular mass.
Pinpointing both the grade and site of obstruction
influences the timing and type of surgery planned and
provides a useful map for the surgeon.
N Bleeding (surprisingly, not often associated with
inflammation) is invariably intraluminal and usually
settles. Diverticular bleeds are occasionally recurrent
and rarely require surgery. In the case of a patient
with a massive gastrointestinal (GI) bleed, an urgent
oesophagogastroduodenoscopy (OGD) to exclude
upper GI bleed followed by lower GI endoscopy
(often non-diagnostic due to a colon full of blood
obscuring the view) is mandatory [11]. If the bleeding
continues and the patient is compromised, a CT
angiogram to localise the bleeding followed by
targeted surgery (if the patient is fit) or mesenteric
embolisation may be required.
Figure 6. Complex diverticular disease. Note local perforation and colo-vesicle fistulation with gas in the bladder.
Imaging, Volume 21 (2009) Number 1
Complications of diverticular disease
N Perforation (localised or free)
N Fistula
N Large and small bowel obstruction
N Bleeding
CT imaging in acute diverticulitis: top tips
Radiological signs include pericolic fat stranding/
inflammation, the presence of diverticulae, focal bowel
wall thickening, muscle wall hypertophy, free gas,
ascites and contrast spillage. Pericolic fat stranding/
inflammation has been reported to be 100% sensitive
[12]. All of these signs may be seen in other complicated
disease processes, such as colitis or tumour, and, if
conservative treatment is curative and the imaging
is not specific to one disease process, interval imaging
plus or minus colonoscopy is advised to exclude occult
tumour. The fact that malignancy cannot be excluded
and that direct endoscopic visualisation at some stage is
recommended should be included in the radiologist’s
report.
Challenges for the radiologist in diagnosing acute
diverticulitis
Both colonic cancer and diverticular disease are
common and can occur synchronously. Identifying a
sigmoid tumour in the sigmoid colon that contains
multiple diverticula can be very difficult. CT findings
suggestive of diverticulitis include fluid in the root of the
mesentery, vascular engorgement, pericolonic inflamma-
tion and an involved segment .10 cm [13, 14]. An
abrupt zone of transition with normal bowel, enlarged
pericolic lymph nodes and mural thickness .1.5 cm
favours colonic carcinoma [14].
7
 J T Smith and C Parchment-Smith

Table 4. Causes of mechanical small bowel obstruction of resolution by conservative measures. Further manage-
ment of small bowel obstruction depends on the cause.
Site of obstruction Cause
An incarcerated abdominal wall or groin hernia
Extrinsic Adhesions (commonly paraumbilical, femoral or inguinal) with
Hernia associated small bowel obstruction should be clinically
Volvulus evident on examination and usually requires immediate
Inflammatory masses surgery to avoid strangulation of the hernia contents; CT
Neoplastic masses imaging is therefore not required here. The exception to
Congential bands this rule is large incisional hernias, for which the patient
Intrinsic Crohn’s disease
is likely to be treated as if they had an adhesional
Carcinoma
Tuberculosis obstruction. CT imaging in a patient with a tender, red,
Congenital atresia hot, irreducible hernia is very likely to allow time for a
Intussusception clinically strangulated hernia to perforate and should be
Luminal Gallstones undertaken only after full discussion with the surgeon
Foreign bodies with ultimate responsibility for the patient. This is a
Polypoid tumours good example of an experienced radiologist helping the
Bezoars surgeon by knowing when not to agree to a junior
Parasites request for a CT. In agreeing to CT imaging of a patient
with small bowel obstruction, it is always worth asking
the referring surgeon (politely) if the groins have been
Small bowel obstruction examined, especially if the patient is obese, elderly or
Vomiting, abdominal distension and passing little or demented, as a small strangulated femoral hernia can
no flatus or faeces are the hallmarks of small bowel easily be missed clinically in these circumstances. If a
obstruction. The diagnosis is usually confirmed by the tender irreducible hernia is found on re-examination, the
surgical team on review of the plain abdominal radio- patient should have surgery rather than CT.
graph. The development of abdominal pain and tender- If small bowel obstruction is not caused by a hernia,
ness or systemic signs such as fever, tachycardia and CT imaging can be invaluable in assisting with further
leucocytosis may indicate bowel ischaemia due to management. Table 5 summarises the difference that
strangulation. A myriad of causes can result in obstruc- imaging findings can make to the management of a patient.
The main aim of imaging a patient with small bowel
tion (Table 4), but the three commonest causes are
obstruction is to identify the cause and level of obstruction.
abdominal wall or groin hernias, right-sided colonic
It is also important to look for complications of small bowel
cancer and adhesions (Figure 7).
obstruction, such as bowel ischaemia and perforation.
Some radiologists (and, indeed, some surgeons) are of
the opinion that a plain abdominal film demonstrating
Role of imaging in the management of small bowel small bowel obstruction in a virgin abdomen is an
obstruction indication for surgery and, therefore, a CT scan is
Initial emergency management of small bowel obstruc- superfluous. The authors think this is an outdated view.
tion has traditionally been called ‘‘drip and suck’’. To these clinicians we ask: if their 70-year-old mother
was admitted with small bowel obstruction, would the
Intravenous fluid resuscitates a dehydrated patient with
admitting surgeon be able to tell confidently the cause of
intraluminal fluid sequestration, vomiting and inability
the obstruction prior to surgery? Metastatic ovarian
to absorb enteral fluids. Early passage of a nasogastric
cancer causing multilevel small bowel obstruction, a
(NG) tube is thought to reduce the likelihood of
small ileocaecal tumour with no liver or lung metastases,
aspirating the gastric contents and to improve chances
a large proximal transverse colon cancer invading
the liver with multiple metastases, a congenital band
adhesion obstructing the distal ileum and a gallstone
ileus might each present in a very similar manner in an
elderly lady with a virgin abdomen, and each would be
managed very differently (Table 5).

CT imaging in small bowel obstruction: top tips

Figure 7. High-grade small bowel obstruction secondary to
adhesions.
The key to imaging is to identify surgical causes and to
communicate these quickly and clearly to the surgical
team. Cases requiring urgent surgery are strangulated
hernia, closed-loop adhesional obstruction or volvulus,
malignancy, gallstone ileus or intussusception.
Most strangulated hernias will be detectable clinically
and are commonly sited within the inguinal, umbilical
or femoral region, or at the site of previous surgical
scar (incisional hernia). Hernias that remain clinically
difficult to diagnose include the rarer positioned

8 Imaging, Volume 21 (2009) Number 1

Imaging in the management of non-traumatic acute abdominal pain

Table 5. Causes of small bowel obstruction and their suggested management

Cause of obstruction Suggested management

Abdominal wall or groin hernia (excluding some Immediate surgery by general surgeon on call (within the hour if
incisional hernias) strangulated)
Operable right-sided colon cancer Colonic resection by colorectal surgeon
Inoperable right-sided colon cancer (due to patient Consideration for defunctioning stoma, colonic stenting or palliative
factors or disease extent) care after discussion with patient and family
Band adhesion Prompt open or laparoscopic surgery
Band adhesion with signs of bowel ischaemia or Urgent open or laparoscopic surgery
closed-loop volvulus
Extrinsic metastatic disease Referral to relevant oncologist and palliative care
Consideration for stenting or defunctioning
Post-surgical adhesions or large incarcerated Conservative treatment ‘‘drip and suck’’ unless prolonged or signs of
incisional hernias ischaemia
Intussusception Usually in children or young adults, may be reduced radiologically in
paediatric patients. Otherwise, usually treated surgically
Gallstone ileus Prompt surgery with small bowel enterotomy/resection and removal
of stone but not cholecystectomy

abdominal wall and the internal hernia. Rarer sites of
hernia include Spiegelian, lumbar and obturator
(Figure 8). Internal hernias can occur in both the virgin
and non-virgin abdomen and are typically found in
natural internal ‘‘tunnels’’ connecting different compart-
ments, in iatrogenic-induced holes or weakness follow-
ing surgery (Figure 9).
Adhesions are not detectable on imaging [15, 16].
Locating a transitional point within the bowel where
proximally dilated fluid-/gas-filled bowel is followed
immediately by collapsed normal bowel suggests the
point of adhesional obstruction. The larger the calibre of
dilated small bowel, the more likely it is to be obstructed
at surgery. Small bowel calibre of 2.5 cm and above on
CT correlates with surgically proven obstruction [16].
Strangulated bowel may be seen as a complication of
hernia, adhesional pathology or as a complication of
mesenteric pedicle rotation (Figure 9). CT signs of
strangulated obstruction include poor or no enhance-
ment of the bowel wall, a serrated beak, large volume of
ascites, diffuse mesenteric changes and unusual patterns
of mesenteric vasculature. A combination of these
insensitive but specific signs results in an overall CT
accuracy of 85% in correctly diagnosing strangulated
small bowel [17]. Further signs include a ‘‘C’’- or ‘‘U’’-
shaped dilated loop of small bowel, generally unhealthy
either thinned or thickened walls, target sign and
presence of stagnant small bowel contents or ‘‘small
bowel faeces sign’’. Poor or delayed wall enhancement
and the presence of intramural gas (pneumatosis) are
signs of ischaemia within the bowel. When the bowel is
twisted on its mesenteric axis the arteries and vein are
also twisted, giving a characteristic ‘‘whirled’’ or ‘‘whirl-
pool’’ type of appearance [18]. Twisted or volved bowel
is more common in patients with long mesenteric
pedicles or when the bowel is not correctly sited or
fixed down, owing to congenital variations.
The caecum must be reviewed to try and look for a
tumour. Imaging findings include circumferential or
focal caecal wall thickening, local lymph nodes and
metastatic disease.
Intraluminal causes of obstruction are less common
causes of small bowel obstruction. Intussusception can
cause small bowel obstruction and, typically, is second-
ary to lymphoid hyperplasia in children and submucosal
metastases, tumours or polyps in adults.
Another cause that becomes more common with age is
gallstone ileus. Small bowel obstruction, intraluminal

Figure 8. High-grade small bowel obstruction caused by an incarcerated right obturator foramen hernia. Review of the hernia
sites is mandatory in CT-confirmed small bowel obstruction.

Imaging, Volume 21 (2009) Number 1 9

 J T Smith and C Parchment-Smith

Figure 9. Strangulated incarcerated internal hernia. Note the twisted (whirl sign) small bowel mesentery. The small bowel
vascular pedicle extends through a defect in the sigmoid colon mesentery. The small bowel within the pelvis is dilated, fluid-
filled and thick-walled, with reduced wall enhancement. The pelvic loops were confirmed to be ischaemic at surgery.

gallstone and pneumobilia are the classic signs described
by Rigler on plain film but occur in only 35% of cases
[19, 20]. The intraluminal gallstone might appear as a
‘‘Mercedes-Benz’’ sign on plain film, indicative of
fissuring intrastone gaseous formation [21]. CT signs
are highly sensitive and specific, but the reader must be
aware of the pitfall of calling a gallstone a tumour when
the gallstone contains a density identical to that of soft
tissue [22].
Radiologists are encouraged to interrogate all acute CT
using the multiplanar reconstruction (MPR) facilities avail-
able on all new scanners. This analysis can improve the
accuracy of the report and certainly increases confidence in
the diagnosis and exclusion of small bowel obstruction [23].

Figure 10. Gallstone ileus. There is gas within the biliary radicals and gallbladder, small bowel obstruction and an intraluminal
gallstone causing small bowel obstruction.

10 Imaging, Volume 21 (2009) Number 1

Imaging in the management of non-traumatic acute abdominal pain
Challenges for the radiologist in diagnosing small
bowel obstruction
The radiologist must identify CT imaging findings that
suggest small bowel compromise that is unlikely to
respond to conservative surgical measures and commu-
nicate these findings quickly to the surgeon so he/she can
integrate these CT findings with the clinical picture. Senior
surgical clinical assessment in conjunction with senior
radiology reporting is paramount to the provision of high-
quality care. CT reported by international experts in
supertertiary referrals have reported an 83% sensitivity in
detecting strangulated obstruction and advise a low
threshold for exploratory laparotomy when unexplained
disparities exist between equivocal CT findings and a
deteriorating clinical picture in patients with possible small
bowel obstruction or mesenteric infarction [24]. Other
authors, however, have reported very poor sensitivity
(15%) but high specificity (94%) in detecting ischaemia
prospectively [25]. The authors must again stress the
importance of the good teamwork that is required to
optimise clinical care in managing patients with diagnoses
that are difficult to make both clinically and radiologically.
Large bowel obstruction
Although we are including this important surgical
problem in this paper, most patients presenting with
uncomplicated large bowel obstruction do not have
severe abdominal pain. The presenting symptoms are
more commonly abdominal distension and gradual or
complete inability to pass faeces and flatus. The
commonest causes are bowel cancer and sigmoid
volvulus. Less common causes of obstruction include
inflammatory bowel disease, caecal volvulus, faecolith
and complicated diverticular disease (Figure 11). The
colon can occasionally be obstructed by extrinsic masses.
The management of large bowel obstruction depends on
three things: the cause of the obstruction, the consequences
of the obstruction and the condition of the patient.
The cause of the obstruction
Historically, acute large bowel obstruction was an
indication for laparotomy. Nowadays, not all large bowel
Figure 11. Large bowel obstruction secondary to descending colon faecolith. Note the oedematous dilated thick-walled caecum
that was found to be non-viable at surgery.
Imaging, Volume 21 (2009) Number 1
obstruction needs immediate surgical intervention.
Sigmoid and caecal volvulus can be temporarily or
permanently alleviated by endoscopic decompression.
Acute diverticulitis causing subtotal obstruction may
resolve as the diverticulitis is treated with antibiotics. A
malignant left-sided obstructing cancer may be stented
in an endoscopic, radiological or combined procedure.
Segments of the large bowel that have become narrowed
owing to active Crohn’s disease may respond rapidly to
one of the range of medical treatments now used by
gastroenterologists. There are, however, still many cases
in which the above procedures are not appropriate, not
available or not successful, and in these cases surgery is
the treatment of choice. The aim of emergency surgery in
the acutely obstructed colon is to achieve decompression.
This can be achieved in one of three ways:
N Simply creating a defunctioning proximal stoma (and
dealing definitively with the obstructing lesion at a
later date when the patient is not acutely unwell).
N Resection of the obstructing lesion and exteriorising
the bowel.
N Resection of the obstructing lesion and primary
anastomosis.
The actual and potential consequences of the
obstruction
The major risk of large bowel obstruction is upstream
perforation and faecal peritonitis, which has a reported
morbidity of up to 50% in some series. The site of per-
foration is usually the caecum. This is because of Laplace’s
law, which explains how the maximum dilatation will
occur in the part of a tube that has the largest diameter to
start with. Perforation can also occur at the site of the
obstructing pathology. Perforation is more likely to occur
imminently if there is a competent ileocaecal valve, because
the large bowel is unable to decompress retrogradely into
the small bowel (so-called ‘‘closed-loop obstruction’’). Thus,
the grade of obstruction, the presence of a closed loop, the
diameter of the caecum and any evidence of impending
caecal perforation would usually be helpful in making the
decision whether to pursue conservative options, to operate
promptly or to operate immediately (Figures 11 and 12).
11

Figure 12. Obstructing primary hepatic flexure mucinous adenocarcinoma. Note the rolled edge of the primary tumour. The
caecum is dilated, thick-walled and found to be non-viable at surgery.
The condition of the patient
The patient’s fitness for surgery is crucial in deciding
the best course of action. Similarly, evidence of terminal
or irresectable disease might influence management.
The role of imaging in the management of large
bowel obstruction
For successful management of large bowel obstruction,
the surgeon wants to know four things from the
radiologist: Is the obstruction mechanical or functional?
If mechanical, what is the diagnosis? Can it wait until
morning? Is it a stentable lesion?
Is it mechanical or functional?
If there is no mechanical blockage, the diagnosis is
often pseudo-obstruction, a type of ileus of the large
bowel. This condition is common in elderly or bedridden
patients, those on psychotropic medication and in
patients with neurological problems (e.g. spinal injuries)
or metabolic disturbances. Unless there is impending
perforation or ischaemia, surgery is rarely needed. If the
clinical history and plain films suggest a sigmoid
volvulus or pseudo-obstruction, endoscopy would
usually be the imaging modality of choice and is usually
therapeutic. This can be difficult, however, owing to an
obscured view and a capacious distal bowel full of liquid
faeces, so radiological imaging is sometimes needed. A
water-soluble enema will exclude mechanical obstruc-
tion and can be therapeutic, but a CT will give
extraluminal information and allow visualisation of the
right colon. If a water-soluble enema is agreed upon, the
radiological trainee is well advised to don his/her
surgical scrubs and avoid suede shoes.
If it is a mechanical obstruction what is the
diagnosis?
Are there any radiological features that can help us to
differentiate between volvulus, diverticular stricture,
Crohn’s and cancer? If a tumour is identified, it is
important to locate the position as accurately as possible,
as this might influence the surgery and also give the
12
J T Smith and C Parchment-Smith
surgeon an idea of which procedure would be appro-
priate and how difficult the procedure will be. These
issues are helpful in planning the operation and
consenting the patient and family. The risks of prolonged
surgery and the risks of a stoma are different for
different cases. An obstructing ascending colon cancer,
for example, would need a straightforward right hemi-
colectomy with a good chance of a primary anastomosis.
By contrast, a distal sigmoid cancer with signs of a non-
viable caecum would need a subtotal colectomy includ-
ing an anterior resection with a higher chance of
exteriorisation. If colorectal stenting is an option, it is
helpful to mention the exact site and length of the
tumour, its relationship to flexures and whether there is
distal faeces.
Can it wait until morning?
Clinical assessment is the only thing to tell a surgeon
whether a patient needs to go to theatre, but radiology
helps with the overall assessment. The radiological
features that would prompt a surgeon to operate
immediately would include free gas, gas in the bowel
wall, a closed-loop obstruction (or competent ileocaecal
valve) with a grossly distended caecum or any features
of bowel ischaemia.
Is it a stentable lesion?
Bowel cancers in the distal half of the large bowel that
are short and in a relatively straight segment are likely to
be successfully treated by endoluminal stenting. Benign
strictures, extrinsic strictures, proximal strictures, stric-
tures .10 cm in length and those on a corner (like the
splenic flexure) may be stentable, but will be less
straightforward.
CT imaging of large bowel obstruction: top tips
CT is our preferred method of imaging patients with
suspected large bowel obstruction. It can accurately
identify the cause and stage in often frail elderly patients
at one sitting in an examination that could take only
2 min. CT with additional selective prone and/or
Imaging, Volume 21 (2009) Number 1
Imaging in the management of non-traumatic acute abdominal pain

Figure 13. Caecal volvulus. Imaging-specific findings of whirl sign indicative of twisting of the vascular pedicle and dilated
caecal pole in the left abdomen. Note the stretched and displaced terminal ileum on the coronal views.

decubitus scanning using iv contrast alone is highly
effective in the diagnosis of mechanical large bowel
obstruction and it is suggested that it should replace
contrast enema as the initial imaging method [26]. The
radiologist is encouraged to interrogate the image starting
from known anatomical landmarks, such as the ileocaecal
valve or rectum, and to follow the bowel around in an
attempt to identify a mass or transition point.
As mentioned above, it is important to document the
suspected nature, length and position of the obstructing
lesion, and it is helpful to include its relationship to
flexures and distal bowel contents. Do not forget to
perform CT of the thorax if cancer is suspected, as
inoperable metastases might alter the management.
If the large bowel is dilated, it is important to review the
wall of the bowel to try to detect intramural gas, particularly
in the caecum, as this is the commonest site to perforate.
Include the diameter of the caecum in the report.
A sigmoid or caecal ‘‘whirl sign’’ from twisting of the
mesentery is specific to a volvulus (Figure 13) [27–29].
Sigmoid volvulus is a closed-loop obstruction, with the
dilated loop appearing as an inverted U-shape. The
opposition of the medial walls of the obstructed efferent
and afferent loops gives a characteristic ‘‘coffee bean’’
appearance. The sigmoid loop can be positioned as high
as D10 in either the left or right upper quadrants. The
loops taper down and twist in the left lower quadrant. The
smooth tapering of the sigmoid colon (beak sign)
described on barium enemas, as well as the position of
the dilated sigmoid colon anterior and superior to the
transverse colon detected on plain film (‘‘northern
exposure sign’’), are additional signs that can be trans-
posed to CT (Figure 14) [30].
Half of cases of caecal volvulus, are secondary to
rotation in the axial plane either clockwise or anti-
clockwise, and appear within the right lower quadrant.
The other half of cases twist and invert with the caecum
positioned in the left abdomen and may resemble a
coffee bean sign. The ileum is twisted and the appendix
may be gas filled [31, 32].
Challenges for the radiologist in diagnosing large
bowel obstruction
Short segment fibrotic tumours can be imperceptible on
CT images and might require endoscopic or water-soluble
correlation. Differentiating pseudo obstruction from true
mechanical obstruction can be difficult using CT in
isolation. Again, correlating endoscopy or water-soluble

Figure 14. Sigmoid volvulus. The dilated sigmoid colon is positioned anterior and superior to the transverse colon (northern
exposure sign). Note the twisted sigmoid colon mesentery sandwiched between the stretched efferent and afferent sigmoid
limbs.

Imaging, Volume 21 (2009) Number 1 13


techniques are advised. Pseudo obstruction is very
common in patients with medical or post-surgical disease
processes and usually resolves with conservative treat-
ment. CT imaging in either or both the left lateral
decubitus or prone position may dilate a bowel segment
up and therefore suggests ileus rather than consistent
narrowing of true mechanical obstruction. In patients in
whom the clinical suspicion is of pseudo obstruction rather
than mechanical obstruction, water soluble enema could
be completed instead of CT, as it will be not only
diagnostic but therapeutic as well. A dilated caecum
should be inspected carefully for the presence of intra-
mural gas. Faeces lying against the posterior wall of the
caecum can trap intraluminal gas that could be mistaken
for intramural gas. One should review the lateral and
anterior caecal wall in an attempt to identify non-
dependent intramural gas. Further views in the lateral or
prone position can be very helpful in this scenario.
Acute mesenteric ischaemia
Ischaemic small bowel is usually a result of
mechanical small bowel obstruction, such as adhesions
or internal or external herniae (described above), or
Figure 15. Superior mesenteric artery (SMA) embolus causing small bowel ischaemia in a patient with atrial fibrillation. Note
the normal appearance of the proximal SMA but with occlusive embolus 1 cm distally. Compare and contrast the normal
enhancing third part of duodenum supplied by the celiac axis and the ischaemic non-enhancing jejunum and ileum supplied by
the occluded SMA.
14
J T Smith and C Parchment-Smith
acute mesenteric ischaemia. Acute mesenteric ischae-
mia usually occurs as a result of the occlusion of the
superior mesenteric artery by embolus, thrombosis or
systemic low-flow states such as shock (Figure 15). The
classic presentation is an arteriopath with severe acute
abdominal pain out of proportion with the clinical
findings. Bloody stool, diarrhoea and nausea can also
occur. High white blood cell count, hyperamylasae-
mia and metabolic acidosis are late signs and pre-
dict a poor prognosis. The treatment is resuscitation
and, depending on the stability of the patient, either
investigations or immediate laparotomy. Cardiovas-
cularly unstable profoundly acidotic patients may be
taken to theatre. Massive intestinal ischaemia can
only be treated with extensive bowel resection, which
has a high mortality and morbidity and, if successful,
often necessitates lifelong total parenteral nutrition.
Palliative care could be an alternative in patients for
whom this outcome is unacceptable or impractical, or
in those with radiological pan-enteric ischaemia. In
segmental infarction, resection of non-viable segments
followed by embolectomy or revascularisation may be
attempted.
Ischaemic large bowel does not often present as
an acutely painful abdomen. This condition usually
Imaging, Volume 21 (2009) Number 1
Imaging in the management of non-traumatic acute abdominal pain

Figure 16. Ischaemic small bowel secondary to superior mesenteric vein thrombosis. Note the abnormal dilated loops of small
bowel with quite dense thickened walls and intramural gas indicative of ischaemia.

presents with a change in bowel habit or rectal bleeding, imaging findings should be discussed directly and
and, for this reason, is not dealt with specifically in this clearly with the clinical team in order for the team to
paper. make a surgical decision.

The role of imaging in the management of acute Challenges for the radiologist in diagnosing
mesenteric ischaemia ischaemic bowel
If the diagnosis is clear clinically, and the patient is Patients with suspected ischaemic bowel often have
unstable, immediate surgery is indicated. However, renal impairment, and giving iv contrast will contribute
many of these patients have an acute abdomen of to further renal impairment. A risk–benefit analysis and
unknown cause and have a CT scan in order to make a direct discussion with the clinical consultant responsible
diagnosis. for the patient’s immediate care has to be made in each
case. One approach by the radiologist is to complete a
quick non-iv contrast spiral through the abdomen and
CT diagnosis of ischaemic bowel: top tips pelvis first. If, for example, a pyonephrosis or pneumo-
peritoneum is detected, then no further imaging is
Most cases occur in chronically unwell patients, who required. If the diagnosis is unclear and iv contrast is
are often medically or surgically institutionalised and to be administered, then an iso-osmolar contrast agent
have a plethora of possible aetiologies. Acute superior should be administered in the presence of prompt
mesenteric artery occlusion is responsible for 60–70% of
cases, non-occlusive conditions are responsed in 20–30%
of cases and mesenteric venous occlusion accounts for
5–10% (Figures 15 and 16) [33]. If the diagnosis is being
clinically questioned, the radiologist must consider
completing both arterial and portal venous imaging to
ensure that major arteries and veins are healthy.
Ischaemic bowel has a variety of appearances. Gener-
ally, the bowel looks unhealthy; its calibre can vary from
dilated thin-walled to collapsed thick-walled. Wall
enhancement may be poor in arterial causes and may
show increased delayed enhancement in venous causes
(Figures 15, 16 and 17). Interloop ascites, small bowel
faeces or inflamed mesentery might be present. The
presence of bubbles of gas in the bowel wall circumfer-
ence (i.e. in both the dependent and non-dependent
portions) is highly specific of ischaemically injured
bowel. Gas may be seen in the draining venous and
Figure 17. Ischaemic small bowel obstruction secondary to a
portal venous system, giving rise to the characteristic
tight obstructing band adhesion. The band adhesion
‘‘crow’s feet’’ appearance in the peripheral portal venous extended from the midline into the right iliac fossa.
radicals within the liver. If the reporting radiologist Compare and contrast the dilated fluid-filled enhancing
is unsure whether the bowel gas is within the wall or proximal jejunum with the featureless fluid-filled ischaemic
in the non-dependent anterior intraluminal compart- mid-jejenum in the right abdomen, which has reduced wall
ment, prone imaging can help resolve this question. The enhancement.

Imaging, Volume 21 (2009) Number 1 15


resuscitation, and any non-essential but nephrotoxic
medication should be discontinued.
The commonest pitfall is to mistake dilated, thin-
walled small bowel that may or may not contain air–
fluid levels for an ileus (Figure 15). This is a common
finding in acute arterial infarction. Although gas within
the wall is thought to be highly specific for ischaemic
bowel, it is important that the reader realises that no one
sign is 100% specific and pneumatosis coli is seen in non-
ischaemic pathologies secondary to infections (e.g.
necrotising enterocolitis in the neonate), inflammation,
neoplastic, pneumatosis cystoides coli, iatrogenic injury
or increased intraluminal pressure (e.g. asthma). In the
dilated colon in a patient with concern for ischaemia, a
‘‘normal wall thickness’’ of between 3 and 5 mm must be
considered abnormal and thickened. In segmental
ischaemia of the colon, the ischaemic segment may be
spastic and collapsed, therefore making it impossible to
differentiate from normal collapsed bowel. Some authors
advocate rectal water or positive preparation to try and
determine whether the segment is in a physiological
collapsed state or pathologically ischaemic. Colonoscopy
would be an alternative approach.
Other conditions causing acute severe
abdominal pain
The authors have addressed in detail the common
surgical diagnoses that present with acute severe abdom-
inal pain. Below, for completeness, we outline some
conditions that also present in this way, but which might
not need surgery or might need surgery by another
specialist, such as a gynaecologist or vascular surgeon.
Acute cholecystitis
The inflamed gallbladder is commonly treated with
antibiotics, although some surgeons prefer to operate on
symptomatic gallbladders during the same admission.
Figure 18. Acute ovarian torsion. Non-contrast CT completed to exclude left renal colic. The left ovary is enlarged with
haemorrhagic enlarged peripheral cortical cysts.
16
J T Smith and C Parchment-Smith
The obstructed infected biliary tree (cholangitis) presents
with rigors, fever and jaundice and needs urgent
intervention. It is usually treated with endoscopic retro-
grade cholangiopancreatography (ERCP) or percuta-
neous transhepatic cholangiography (PTC) with
stenting. Gallbladder empyema can be treated radio-
logically. Patients are typically elderly and acutely
unwell. The gallbladder is painful, thick-walled and
distended full of pus. The culprit is usually a calculus
impacted in the gallbladder neck. Urgent resuscitation
and work-up for percutaneous cholecystostomy is one
treatment option available; surgery is another.
Radiological findings which would indicate that emer-
gency surgery may be necessary include evidence of a
gangrenous gallbladder, air in the gallbladder wall or
evidence of a biliary leak.
Acute pancreatitis
Presenting in exactly the same way as generalised
peritonitis with a rigid, tender abdomen and systemic
upset, imaging in these patients may serve to avoid an
unnecessary laparotomy. Hyperamylasaemia strongly
indicates pancreatitis as a diagnosis, but can also be
present in perforated viscus or bowel ischaemia. For
this reason, a CT scan is sometimes needed to exclude a
surgical cause for the symptoms. The radiological
findings of acute pancreatitis include a swollen pan-
creas, peripancreatic oedema/inflammation, ascites,
inflammatory change extending into the retroperito-
neum and around the transverse colon, and reduced
enhancement indicative of necrosis and haemorrhage.
A detailed discussion of complicated pancreatitis is
outside the scope of this review, but complications
include necrosis, haemorrhage, abscess formation and
pseudocyst formation. These conditions may need
radiological intervention (e.g. aspiration, drainage,
gastrocystostomy) or surgery by a specialist pancreati-
cobiliary surgeon.
Imaging, Volume 21 (2009) Number 1
Imaging in the management of non-traumatic acute abdominal pain
Figure 19. Acute splenic rupture secondary to splenic vein
thrombosis requiring emergency splenectomy. Note the
classical appearance of a mixed high density sub-capsular
haematoma, splenic capsule rupture and large volume
haemoperitoneum.
The renal tract
Renal colic, lower urinary tract infection, pyelonephri-
tis and pyonephrosis can all present as an acutely painful
abdomen. Radiological findings include calculi, hydro-
ureter/hydronephrosis, urothelial enhancement, swollen
kidneys, perinephric fluid and asymmetrical kidney
enhancement. The obstructed infected system needs
prompt radiological drainage, and there is rarely an
indication for surgery.
Gynaecological causes of the acute abdomen
Pelvic inflammatory disease (PID) must always be
considered in a female of reproductive age presenting
with lower abdominal pain. Speculum examination
correlation is advised. If pus is present at the cervical
Figure 20. Fournier’s gas gangrene in a diabetic elderly patient. Note the vulval subcutaneous gas extending into the anterior
abdominal wall. There is an incidental right inguinal hernia. The patient was transferred from the CT scanner straight to theatre
for emergency debridement.
Imaging, Volume 21 (2009) Number 1
os then a swab should be taken and clinical diagnosis of
PID made. Transvaginal ultrasound is often normal but
may detect cervical pain, pyosalpinx or ovarian
abscesses. CT is rarely indicated in young women. As
discussed in the section on appendicitis, women with
lower abdominal peritonism are often investigated by
laparoscopy to exclude appendicitis, and the diagnosis of
PID can be made easily by the presence of inflamed
pelvic organs and pus in the pelvis.
Ovarian torsion can occur at any age and in pregnancy.
It presents with lower abdominal pain, tenderness and
occasionally tachycardia and leucocytosis or fever.
Radiologically, on pelvic ultrasound the ovary is typically
enlarged and has multiple peripherally positioned
enlarged follicles (Figure 18). A cystic or complex ovarian
mass is found in a minority [34]. The ovary may have
absent or abnormal Doppler flow and there is often ascites.
Ectopic pregnancy is a gynaecological emergency that
can lead to sudden life-threatening bleeding at any time.
Clinical hallmarks of an ectopic pregnancy include early
positive pregnancy test and lower abdominal pain.
Radiological signs on ultrasound include a uterine cavity
devoid of foetal pole or presence of pseudogestional sac,
extra-uterine embryo, ovarian mass, haemoperitoneum
or ascites. The presence of lower abdominal pain in a
patient with a positive pregnancy test, with or without
ultrasound signs, is an indication for urgent senior
gynaecological input.
Occult bleeding
All clinicians are aware of the urgency to diagnose a
possible ruptured abdominal aortic aneurysm. There are
many other less common and, therefore, less well-known
diagnoses that can present with life-threatening haemor-
rhage. Any patient with initial tachycardia and hypoten-
sion that has responded to fluid and has abdominal pain
should be a ‘‘red flag’’ the radiologist recognises. In a
minority of cases this may represent life-threatening
haemorrhage. Possible causes are endless and include
17

ruptured non-aortic aneurysms (e.g. common iliac artery
aneurysm), post-biopsy or surgical bleeding, ruptured
hepatocellular carcinoma, ruptured liver adenoma in
women on the oral contraceptive pill, angiomyolipoma
of the kidney either sporadic or associated with tuberous
sclerosis, non-traumatic splenic rupture secondary to
venous infarction caused by haematological malignancy
or life-threatening infection, spontaneous haemoperito-
neum, and retroperitoneal haemorrhage or abdominal
wall haematoma either idiopathic or secondary to over-
anticoagulation. Haematomas are high density and
heterogenous in appearance (Figure 19). If bleeding is
clinically suspected, immediate CT without oral pre-
paration is required. Triple-phase imaging with non-
contrast, arterial and portal venous imaging +/2
delayed imaging is advised.
Occult life-threatening infection
Gas gangrene, necrotising fasciitis (including Fournier’s)
or soft tissue abscesses require prompt diagnosis, but can be
overlooked clinically. Although uncommon in the immu-
nocompetent patient, they may be seen in the elderly patient,
the diabetic or the drug abuser (Figure 20). Obviously, if the
features of necrotising fasciitis are identified radiologically
the surgical team must be contacted by the radiologist
immediately.
Conclusion
Imaging patients with acute abdominal pain requires
great skill and understanding, not only of the disease
processes and imaging findings themselves but also of
the impact of the imaging on medical and surgical
management. The radiologist has a pivotal role in
deciding what imaging technique to utilise and when.
Clear communication with teams responsible for patient
management and intervention are essential in ensuring
high-quality patient care.
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2. Malone AJ, Wolf CR, Malmed BF. Diagnosis of acute
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3. Rao P, Rhea J, Novelline R, McCabe C, Lawrason J, Berger
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4. Lane MJ, Katz DS, Ross BA, Clautice-Engle TL, Mindelzun
RE, Jeffrey RB. Unenhanced helical CT for suspected acute
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