Acute abdomen is a term used to

encompass a spectrum of surgical, medical

and
gynecological
conditions
(intraabdominal process), ranging from the trivial
to the life threatening, which require hospital
admission, investigation and treatment

Assesing the patient with an acute abdomen

need
many
investigation
including
laboratory test and imaging studiesplain
photo, US, CT and contrast study .

Plain abdominal films: erect chest film,

supine, and upright (optional:left lateral
decubitus)
Abdominal US
Abdominal CT

Plain abdominal film

Table 1 Plain abdominal film

Looking for
Gas pattern
Calcifications
Soft tissue masses

Substitute none

Looking for
Free air
Air-fluid levels

Substitute left
lateral decubitus

Hemorrhage
GI perforation
Bowel obstruction
Inflammatory disorder
Circulatory impairment

Intraperitoneal hemorrhage
Rupture:
hepatoma
aortic anuerysm
ectopic pregnancy
ovarian bleeding

Gastrointestinal hemorrhage
Upper GI hemorrhage
Duodenal ulcer
Gastric ulcer
Hemorrhagic gastritis
Esophageal or gastric varices ect.
Lower GI hemorrhage
Bleeding of colon cancer
Ischemic colitis ect.

US finding
Free peritoneal fluid accumulation on the

Morisons pouch, the rectovesical pouch, the

pouch of Douglas, and the bilateral subphrenic
space

Abdominal CT
CTgold standars for specific intraabdominal

pathology

Gastrointestinal perforation are serious

disorder requiring rapid diagnosis and
treatment
Since they may be severe enough to
produce septic or hypovolemic shockrapid
decision-making for urgent laparotomy is
crucially important

Radiological appearances:
Plain abdominal film:
- Oval/linear collection of gas:
Subhepatic space
Morisons pouch
Beneath the diaphragm (the cupola sign)
In the centre of the abdomen over a fluid
collection (the football sign)
Fissure for ligamentum teres

15

16

Fissure for ligamentum

teres

Riglers sign

18

The first investigation when bowel

obstruction is suspected is the supine plain
abdominal X-ray, together with an erect
chest film if perforation is a possibility
Occasionally, all the dilated bowel may be
fluid fill and not visible on a plain X-ray and
further imaging with contrast studies, CT or
US may be needed to demonstrate dilated
bowel

Imaging aims: to confirm the presence of

bowel obstruction, define the level
obstruction, identify the cause and detect
complications such as perforation

Extrinsic

Bowel wall

Intraluminal

Adhesions

Neoplasia

Intussusception

Hernia

Strictures:inflamma Foreign body

tory,
radiation,chemical

Volvulus

Intestinal
ischaemia

Inflammation/abscess
Malignant infiltration
(e.g. peritoenal
deposits)

Gallstone ileus

Etiology:
- Adhesions due to previous
surgery
- Strangulated hernias
- Volvulus
- Gallstone ileus
- Intussusception
- Neoplastic, etc.

Plain filmprimary investigation of choice

Plain film of SBO:
Dilated small bowel loops:

Tend to the central

Numerous
2.5-5.0 cm diameter
Have a small radius of curvature
Valvulae conniventes: thin, numerous, and
extend right across the bowel
Do not contain solid faeces

Multiple fluid levels on the erect film

String of beads sign on the erect film
Absent or little air in the large bowel

28

29

US:SBO

CT sign of SBO
Small

bowel loops measuring>2.5 cm in

diameter
Identifiable focal transition zone from prestenotic
dilated bowel to post-stenotic collapsed bowel
loops

Fluid-filled loops

Bowel calibre change

Etiology:
- Neoplastic (benign & malignant)
- Volvulus (caecal & sigmoid), etc.

Radiological appearances:
Depends on the state of competence
of the ileocaecal valve:

33

Plain-film signs of LBO:

Dilated large bowel loops which:
Tend to be peripheral
Few in number
Large: above 5.0 cm diameter
Wide radius of curvature
Haustra: thick and widely separated and may or
may not extend right across the bowel (compare
these features with the valvulae conniventes found
in the small bowel
Contain solid faeces

 Caecum maybe dilated

Small bowel may be dilated

Contrast enema maybe helpful:

To differentiate pseudo-obstruction and may be

indistinguishable on plain film from mechanical

of obstruction
To localized the point of obstruction
To diagnose the cause of obstruction e.g.
tumour, inflamatory mass

Plain film:Sigmoid
volvulus

coffee bean sign

Generalised paralytic ileus:

Etiology:
- Peritonitis
- Post-operative
- Hypokalaemia
- General debility or infection
- Drugs: morphine
- Congestive cardiac failure, renal colic, etc.

Radiological appearances:
- Both small & large-bowel dilatation
- Horizontal-ray films: multiple fluid levels
39

40

Acute appendicitis
Acute pancreatitis
Acute cholecystitis
Abdominal absces
Peritonitis

Abdominal x-ray (AXR)

Non-specific finding
Approximately 10%a calcified appendicolith

US

Generally, the normal cannot be defined with US,

clear visualization of the appendix is suggestif of

inflammation
Swollen, non compressible appendix greater than
7 mm in diameter with a target or bulls-eye
configuration is produced by the hypoechoic
dilated appendiceal lumen
Assymetrical wall thickening due to phlegmonous
infiltration, an appendicolith with acoustic
shadowing

US finding
Echogenic hallo form by omental tissues draped

over the appendix

Free fluid in the culdesac
Atony in the terminal ileum with compression US

CT finding
90% diagnostic accuracy to detect acute appendicitis
With the good contrastfilling of the terminal ileum

and the cecum (oral contrast given 1 hour before

examination)
Tubular structure 4 mm to 20 mm in diameter with a
thickened wall that enhance after administration IV
contrast medium
Pericecal fluid collection and calcified appendicolith

Plain film:apendicolith

Severity of acute
pancreatitis
rangesmild edema
with minimal
symptoms to a
severe necrotizing
process that
culminates in
multiple organ failure
US and CT most
precisely define the
anatomic extent of
the lesions and the
detect local
complications

Plain filmsno significant plain film

findings in up to two-thirds of patients
wih acute pancreatitis
Plain-film signs may include:
Paralytic ileus in the left upper quadrant
Generalized ileus
Loss of left psoas outline
Separation of greater curve of stomach

from tranverse colon

CXR signs that may be seen include:

Left pleura effusion
Atelectasis of left lower lobe
Elevated left hemidiaphragm

US finding:
The acutely inflamed pancreasenlarged with

decreased echogenicity and blurred irregular

margin
Fluid collection are seen as hypoechoic areas
US can be used to guide aspiration and the
drainage procedures, and for follow up

CTimaging investigation of choice for

acute pancreatitis, and is particularly
useful for the following:

Confirmation of the diagnosis

Identification of necrotic gland tissue
Diagnosis of complication
Guidance of interventional procedures

CT signs of acute pancreatitis include:

Diffuse or focal pancreatic enlargement with

decreased density and indistinct gland margins
Thickening of surrounding fascial planes e.g. left
paranephric fascia

 Acute fluid collections, most commonly related to

pancreas though also in the lesser sac and in the left

pararenal space
Phlegmon appears as an irregular mass spreading along
fascial planes and can be quite extensive
Abscess
Pseudocyst

Approximately 85%-90%
of cases with acute
cholecystitis (AC) develop
as a complication of
cholelithiasis
Conversely, approximately
10%-20% of patients with
gallstone will require
surgery for complication,
usually cholecystitis,
within 15 years after their
stone disease is
diagnosed
Acalculous cholecystitis
account for 5%-15% of
cases of acute
cholecystitis
(immunocompromize,
critically ill,iatrogenic,
congenital etc)

Plain filmsinsensitive for acute

cholecystitis
Plain films signnonspesific and
include:
Gallstone (only seen in 10%)
Soft tissue mass in the right upper

quadrant due to distended gallbladeer

Paralytic ileus in the right upper quadrant

USinvestigation of choice for suspected

acute cholecystitis
US signs of acute cholecystitis include:
Gallstones:hyperechoic lesions with acoustic

shadowing which are mobile

Thickening of gallbladder wall to greater than
4 mm
Hypoechoic gallblader wall due to oedema
Surrounding fluid or localized fluid collection
Distended gallbladder
Localized tenderness to direct probe pressure

CTscanning contribute little to

diagnosis of cholecystitis
CTinvestigation of
complicatiosbiliary or
pericholecystic abscess

Peritonitisan inflammatory or
suppurative reaction of the peritoneum
to direct irritation
Cause:
Inflammatory
Infectious
Ischemic

Exudation,
Hematogenous,
Contiguous extension,
Iatrogenic manipulation

Plain abdominal radiograph: cannot

provide specific
Air-fluid Levels
Stones
Ascites
Eggshell calcification
Air in Biliary tree.
Obliteration of psoas-shadow in retroperitoneal disease
Right lower quadrant sentinel loops in acute
appendicitis

USnonspecific
Abdominal CT
CT signs
Ascites (free or encapsulated)
Infiltration of the omentum and/or mesentery
Thickening of the parietal peritoneum

Angiography for ischaemia, hemorrhage

Acute inflammatory colitis

Toxic megacolon
Pseudomembranous colitis
Ischaemic colitis

66

Plain film can assess :

the extent of the colitis
the state of mucosa:
It can be assessed from :
- the faecal residue:
In left-sided disease, the proximal limit of
faecal residue will indicate the extent of
active mucosal lesion.
- the width of the bowel lumen
- the mucosal edge
- the haustral pattern

67

A fulminating form of colitis with transmural

inflammation, extensive & deep ulceration &
neuromuscular degeneration.
Involve the transverse colon
Ro. Findings:
Mucosal islands (=pseudopolyps) & dilatation (8
cm)
Common complication:
Perforation in the sigmoid & peritonitis

68

69

Etiology:
Vascular insufficiency & bleeding into the wall
of the colon.
Sudden onset of severe abd.pain in the early
hours of the morning, followed by bloody
diarrhoea.
In middle-aged & elderly patients.
The wall of splenic flexure & descending colon is
greatly thickened thumb printing (plain films).
The right side of colon is frequently distended.

70

thumb printing

72