Dr.raju sharma 1
- 1. Clinical & Imaging Inputs in Acute Abdominal Inflammatory Conditions Prof. Raju Sharma All India Institute of Medical Sciences, New Delhi
- 2. Clinical Inputs History Pain: location, type, duration, Fever Vomiting Diarrhoea Distension Examination Tachycardia Guarding Rigidity Lump
- 3. Lab Parameters CBC Leucocytosis with shift to right C Reactive Protein: inflammatory marker Procalcitonin: biomarker of sepsis Pancreatic amylase, lipase: ↑ in acute pancreatitis LFTs Fecal Calprotectin: marker of bowel inflammation
- 4. Spectrum Acute hepatitis Liver abscess Acute cholecystitis Cholangitis Acute pancreatitis Acute pyelonephritis Acute gynae disease: PID, TO abscess Acute gastroenteritis Appendicitis Bowel obstruction Inflammatory Bowel Disease Enterocolitis: Infectious Diverticulitis
- 5. IMAGING MODALITIES Plain radiograph (supine/erect) Ultrasonography- screening tool Computed Tomography- modality of choice Magnetic Resonance Imaging – seldom used Angiography Image guided intervention
- 6. Computed Tomography Modality of choice for abdominal emergencies Global perspective of entire abdomen Uninhibited by bowel gas & fat MDCT: thin collimation, MPRs Oral contrast: not useful in emergent situation I.V contrast mandatory unless CI CT Angiography: bowel ischemia, GI bleed Radiation concern: ASIR, low dose protocols
- 7. Bowel Obstruction Small bowel obstruction is more common than large Common causes: adhesions, hernia, volvulus, inflammatory strictures, intussusception, ischemic Accounts for 20% of acute abdominal surgical conditions Simple/Strangulated Complete/Incomplete Open/Closed loop
- 8. Acute Abdomen: Quadrant Approach Helps choose modality Narrows differential diagnosis ACR appropriateness criteria RUQ: USG (9) MRI & CT (6) LUQ RLQ: CT (8) USG (6) LLQ: CT (9) USG (4) Non-localized pain – CT (8) USG (4) Beta HCG testing should be done in women of reproductive age group
- 9. Acute Abdomen Bowel Obstruction Perforation Right Upper Quadrant Pain Biliary pathology Lower Quadrant Pain Plain Radiographs CT USG Bowel Ischemia GI Bleed CT Angiography MRCP/CT DSA/Intervention USG CT
- 10. Right Upper Quadrant Pain Among the commonest reasons for ED visit USG is the modality of choice, occ CT or MRI are required Liver: Ac hepatitis, abscess, hydatid Gall Bladder: calculi, ac. cholecystitis & its complications, Mirrizi syndrome Acute pancreatitis Peptic ulcer disease
- 11. Complications of Cholelithiasis Acute cholecystitis Perforation, peri-cholecystic abscess Pancreatitis Gall stone ileus Biliary fistula Mirrizi’s syndrome
- 12. Acute Cholecystitis Commonest cause: gall stones Sonography: modality of choice Hallmarks: thickened GB wall (>3mm), distended GB, pericholecystic edema, sonographic Murphy’s sign (92% sensitivity) Acalculus cholecystitis – seen in sick ICU patients Gangrenous, Emphysematous, Xanthogranulomatous cholecystitis
- 14. Gangrenous Cholecystitis Striated thickening of wall, irregularity, intraluminal membrane, Murphy’s sign may be absent
- 15. Emphysematous Cholecystitis • More common in males & diabetics • Stones seen only in 50% • Small vessel disease may be responsible • Murphy’s sign is often absent • Organism: Cl. welchii, E coli • Mortality 15%
- 16. Ruptured GB
- 17. Gall stone eroding & causing Pseudoaneurysm
- 18. Gall Stone Ileus Accounts for 1-5% of non-malignant small bowel obstruction GB perforation with fistula formation with duodenum Gall stone impaction occurs in ileum(54-65%), jejunum (27%) and rarely duodenum (1-3%) Bouveret syndrome Riggler triad: bowel obstruction, pneumobilia, obstr. Gall stone – seen in 30-40% patients
- 19. Mirrizi’s Syndrome • CHD/ CBD obstruction due to impacted calculus in GB neck/ cystic duct • May be associated with cholecystocholedocal fistula • Uncommon, 2% of pts operated for symptomatic gall stones • Preop diagnosis is important: USG, MRI • Standard technique of Sx: increased risk of injury to CBD due to dense adhesions in hepato- duodenal ligament
- 20. Liver Abscess
- 21. Amoebic Liver Abscess with Typhlitis
- 24. 32yr old: pain, jaundice fever
- 25. Oriental Cholangiohepatitits (OCH) • Common in south east Asia • Rec episodes of RUQ pain, fever, jaundice • Multiple intra and extrahepatic strictures • Intraductal calculi specially in absence of gall stones • Segmental atrophy specially of lateral segment of left lobe
- 26. Acute Pancreatitis Causes: gall stones, alcohol, abdominal surgery CT is the modality of choice Balthazar grading system and CT scoring system Ideal for detecting pancreatic necrosis Can diagnose complications of acute pancreatitis
- 27. Types Interstitial Pancreatitis (80-90%) Necrotizing Pancreatitis (5-10%)
- 30. Infected Walled off Necrosis
- 31. Complications Of Acute Pancreatitis Pseudocyst Infected walled off necrosis Pseudoaneurysms Vascular thrombosis
- 32. Left Upper Quadrant Pain Less common than other sites Splenic pathology: infarct, abscess, spontaneous rupture Gastritis Pancreatitis & its complications Left pyelonephritis Splenic flexure colitis, ischemia Sub-phrenic abscess
- 33. Splenic Infarction Causes: pancreatitis, portal hypertension, sickle cell anemia, splenomegaly Presents with left upper quadrant pain Peripherally located wedge shaped hypodense, non-enhancing lesion
- 34. Splenic Abscess with Rupture
- 36. Right Lower Quadrant Pain Common presenting symptom Ac appendicitis, IC Tb, IBD, amoebic typhlitis, mesenteric adenitis, adnexal pathology Omental infarction, epiploic appendagitis, neutropenic enterocolitis Central abdominal pain which shifts to RIF, leucocytosis USG followed by CT is the way to go Reported sensitivity & specificity of CT for appendicitis: 90-99%
- 38. Retrocecal Appendicitis Perforated Appendicitis
- 39. Crohn’s Disease
- 40. Epiploic Appendagitis • Oval fat density mass with a central dot & an inflamed peripheral hyperdense rim • D/D: omental infarct which is usually larger • Tt: conservative
- 41. Omental Infarct Sudden onset of right lower quadrant pain Fat density with stranding Usually > 5cm Primary/ secondary Usually self limiting Conservative Tt
- 42. Neutropenic Enterocolitis • Oedema & inflammation of cecum, asc colon & occ small bowel • Combination of chemoRx induced mucosal injury - facilitating infection, altered immune response • Should be considered in any neutropenic patient (<500 cells/cumm) presenting with fever, pain RIF, GI bleed &/or diarrhoea
- 43. Left Lower Quadrant Pain Causes: colitis, diverticulitis, urolithiasis, epiploic appendagitis, gynae causes CT is considered the modality of choice Colitis: ischemic, infective, pseudomembranous, UC, Crohn’s An empty colon sign favours infective colitis over ischemic & inflammatory etiology Crohn’s & pseudomembranous colitis: greater wall thickening than in ischemic & UC Adnexal pathology
- 44. Crohn’s Colitis
- 45. Ischemic Colitis
- 46. Diverticulitis • Bowel wall thickening, peri-colonic inflammation, diverticulosis • Inflamed diverticuli may be hyperdense on CT • Sigmoid colon: most often involved • Hinchey’s classification • Perforated malignancy may mimic perforated diverticulitis
- 48. Intra-Abdominal Abscess Post-operative patient Complication of appendicitis, bowel perforation Inflammatory Bowel Disease Diverticulitis On USG: fluid with debris Fluid attenuating lesion with thick rim enhancement On MRI: fluid signal with restricted diffusion
- 50. Post-Op Patient
- 51. Acute Abdomen in Pregnancy & Women in Reproductive Age Group As far as possible avoid ionizing radiation Sonography first line MRI (no Gadolinium) is very useful CT only if benefit outweighs the risk Non-pregnancy related: biliary, acute appendicitis Pregnancy related: ectopic, abruption, HELLP Gynae causes: PID, TO abscess, ovarian hgic cyst, torsion
- 52. Conclusion Wide spectrum of diseases Clinical findings: often non-specific & frequently overlap Judicious use of imaging modalities: narrow D/d & triage patients Diagnostic laparotomy: thing of the past USG & CT: mainstay of imaging Niche indications for MRI Quality of imaging & interpretation must be high
- 53. Thank you for your attention!