Abdomen radiography
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Abdomen Radiography. Abdomen Module. Sean Duguay and Justin North, MD. Directions. View in presentation mode This module is meant for independent study Highlighted words in yellow have actions Clicking on them once will identify certain areas

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Abdomen radiography

Abdomen Radiography

Abdomen Module

Sean Duguay and Justin North, MD


Directions

Directions

  • View in presentation mode

  • This module is meant for independent study

  • Highlighted words in yellow have actions

    • Clicking on them once will identify certain areas

    • Clicking on them again will remove identifiers

  • This icon is present when there is additional information in the note section


Objectives

Objectives

  • Recognize normal anatomic structures

  • Systematic search pattern

  • Recognize pathology: obstruction, free air, mass, infection/inflammation, stones

  • Ordering abdomen imaging - Algorithms

  • Adult vs. Pediatric imaging


Normal anatomy

Normal Anatomy

Upright Abdomen

Heart

CT Coronal

Lungs

Diaphragm

Stomach

Liver

Gallbladder

Pancreas

Small Intestine

Ascending Colon

Transverse Colon

Descending Colon


Normal anatomy1

Normal Anatomy

Upright Abdomen

CT Coronal

Spleen

Psoas Muscles

Vertebral Column

Aorta

Inferior Vena Cava

Abdomen Wall

Ribs – Anterior

Ribs – Posterior

Kidneys


Search pattern

1

Search Pattern

Common Groupings

  • Bones

  • Stones

  • Gas

  • Mass

Midline

LUQ

RUQ

LLQ

RLQ

Quadrants

  • RUQ

  • RLQ

  • LUQ

  • LLQ

  • Midline

Midline


Search pattern1

Search Pattern

Bones

  • Evaluate ribs, spine, pelvis and femurs for fracture, dislocation, subluxation, osteoarthritic changes, and lesions

  • Evaluate soft tissues for subcutaneous air, foreign bodies, and surgical clips


Search pattern2

Search Pattern

Stones

  • Evaluate kidneys, ureters, bladder, and urethra for opacities

  • Evaluate deposition of calcium in…

    • Arteries: aorta, iliac, renal

    • Organs: GB, appendix

    • General regions: Pelvis

      *Phlebolith = calcified pelvic veins commonly mistaken for urinary tract stones


Search pattern3

Search Pattern

Gas

  • Evaluate intraluminal air within stomach, GB, small intestine, large intestine, and rectum for dilatation, air-fluid levels, and bowel orientation

  • Evaluate extraluminal airunder diaphragm or between bowel for perforation

  • Evaluate periphery for subcutaneous air


Search pattern4

Search Pattern

Mass

  • Evaluate for organomegaly

    • Bladder

    • Spleen

    • Liver

    • Kidneys

  • Mass effect

  • Shadows

    • Psoas

    • Abdomen Wall


Search pattern5

Search Pattern

RUQ: Liver, GB, hepatic flexure, kidney, ureter

RLQ: Appendix, cecum, ureter, ovary, psoas m.

LUQ: Pancreas, spleen, splenic flexure, kidney, ureter, stomach, diverticulum

LLQ: Diverticulum, ureter, ovary, psoas m.

Midline: Spine, aorta, IVC, uterus

All: Small intestine

Midline

LUQ

RUQ

LLQ

RLQ

Midline


Case 1

Case 1

  • 78 yo female with h/o fall c/o bilateral hip pain

  • Findings:

  • Diagnosis:

    - Bilateral femur fractures

  • Bilateral femoral cortical

  • defects


Case 2

1

Case 2

  • 39 yo male with h/o left colicky pain radiating towards groin and gross hematuria

  • Findings:

  • Diagnosis:

    - Nephrocalcinosis

  • Opacification in left kidney

  • region


Case 3

1

Case 3

  • 58 yo male with h/o alcoholism complains of chronic epigastric pain, occasionally radiating to back

  • Findings:

  • Diagnosis:

    - Chronic Pancreatitis

  • Punctate calcifications along

  • distribution of pancreas


Case 4

Case 4

  • 49 yo overweight female with h/o chronic colicky RUQ pain after meals

  • Findings:

  • Diagnosis:

    • - Porcelain GB likely secondary to chronic cholecystitis

  • - Calcification of GB wall


Case 5

1

Case 5

  • 67 yo with h/o diffuse abdomen pain suddenly c/o right shoulder pain

  • Findings:

  • Diagnosis:

    - Ruptured abdominal viscus

  • - Air under right diaphragm

  • (pneumoperitoneum)

Rigler’s Sign

(Double Wall Sign)

  • - Rigler’s sign

  • - Safety pin likely on gown

Upright Plain Film


Case 5 cont

1

Case 5 (Cont…)

  • Which air is the free air?

  • - Free Air

  • - Not Free Air


Case 6

1

Case 6

  • 54 yo with h/o laparotomy at age 37 for acute appendicitis develops increasingly severe abdomen pain

  • Findings:

  • Diagnosis:

    - Small bowel obstruction likely secondary to adhesions

  • Should see air in this distribution

  • Plicae circulares

  • Dilated small bowel

  • - Dilated loops of small bowel with visible plicae circulares

  • - Lack of large bowel dilation

  • 3,6,9 Rule (Normals)

  • Small Bowel < 3 cm

  • Large Bowel < 6 cm

  • Cecum < 9 cm


Case 7

1

Case 7

  • 78 yo with h/o sudden left lower quadrant pain

  • Findings:

  • Diagnosis:

    - Sigmoid Volvulus

  • “Bent inner tube”

  • Or

  • “Coffee Bean Sign”

  • - Loop of dilated bowel pointing cranially

  • - Lack of air in rectum


Case 8

1

Case 8

  • 64 yo male c/o hemochezia, constipation, and weight loss for 6 mo

  • Findings:

  • Diagnosis:

    - Colon Cancer

  • - Descending colon filling defect

“Apple core” lesion

Double Contrast Barium Enema


Case 9

1

Case 9

  • 59 yo male with h/o alcoholism, weight loss, nausea and vomiting develops abdomen distension over last two years

  • Findings:

  • Diagnosis:

    • - Alcoholic hepatitis (from biopsy)

  • - Hepatomegaly

  • - Stool due to constipation

  • (enhanced 2o oral contrast)


Case 10

1

Case 10

  • 51 yo female with h/o IV drug use develops abdomen distension and spider angiomata

  • Findings:

  • Diagnosis:

    - Viral Hepatitis (from biopsy)

  • - Ascites


Case 11

1

Case 11

  • 17 yo female with h/o elevated bhcg and left flank pain

  • Findings:

  • Diagnosis:

    • Pregnancy

    • Post-renal failure 2o obstruction w/ stent placement

  • - Fetus

  • - Ureter stent

Head

Spine


Case 12

Case 12

  • 22 yo male with h/o RLQ pain for last twelve hours and fever

  • Findings:

  • Diagnosis:

    - Appendicitis

  • - Inflammatory changes around appendix

  • (fat stranding)


Case 13

Case 13

  • 69 yo with h/o constipation and occasional hematochezia c/o severe LLQ pain

  • Findings:

  • Diagnosis:

    - Diverticulitis

  • - Diverticula

  • - Inflammatory changes around colon diverticulum

  • (fat stranding)


Case 14

Case 14

  • 45 yo female with h/o recurrent kidney stones and urinary tract infections

  • Findings:

  • Diagnosis:

  • - Kidneys joined at midline

  • - Horseshoe kidney


Case 15

Case 15

  • 35 yo male with h/o cerebral aneurysm

  • Findings:

  • Diagnosis:

  • - Bilateral enlarged kidneys with multiple cysts

  • - Multiple hepatic cysts

  • - Polycystic Kidney Disease


Case 16

Case 16

  • 45 yo female with history of generalized abdomen pain

  • Findings:

  • Diagnosis:

  • Normal Adrenal Gland

  • Mass

  • Bilateral adrenal mass

  • Normal adrenal gland

  • No other acute findings

  • Adrenal adenoma

  • (most commonly identified incidentally and not clinically significant)


Case 17

Case 17

  • 18 month child with h/o painless rectal bleeding and intussusception

  • Findings:

  • Diagnosis:

  • Increased uptake right lower

  • quadrant (likely ileum)

  • Increased uptake in

  • stomach

and

bladder

  • - Meckel’s diverticulum

Technetium-99m (99mTc) pertechnetate scan


Case 18

Case 18

  • Newborn male with failure to pass meconium w/in 48 hrs

  • Findings:

  • Diagnosis:

  • Dilated colon

  • No air in rectum or distal colon

  • - Hirschsprung’s Disease


Case 19

Case 19

  • Newborn female with h/o polyhydramnios and bilious vomiting

  • Findings:

  • Diagnosis:

  • Dilated stomach and proximal duodenum

  • - Absence of air beyond proximal duodenum

  • - Duodenal atresia

  • “Double bubble” sign


Case 20

Case 20

  • 33 yo female with h/o ulcerative colitis, jaundice, and fatigue

  • Findings:

  • Diagnosis:

  • Multiple intrahepatic

  • biliary strictures

  • Multiple space-occupying

  • defects (likely air or stones)

  • Primary sclerosing

  • cholangitis

ERCP of biliary tree


Case 21

Case 21

  • 49 yo male with h/o right costophrenic tenderness and dysuria

  • Findings:

  • Diagnosis:

  • - Irregular hyperdensity in distribution of right kidney

  • - Staghorn calculus


Case 22

Case 22

  • 35 yo female with h/o smoking and oral contraceptive use

  • Findings:

  • Diagnosis:

  • Wedge-shaped perfusion

  • defect reaching periphery

  • - Splenic infarction


Intrauterine device iud

Intrauterine Device (IUD)

  • Fundus of uterine cavity

  • in T configuration

  • Indications

    • Contraception, emergency contraception, reduce heavy bleeding

  • Positioning

  • Malposition

    • Partially expelled

    • Malrotation

    • Migration


Ureter stent

Ureter Stent

  • Stent positioned from renal

  • pelvis to bladder (coil seen in

  • both locations)

  • Indications

    • Ureteral obstruction, prophylactic, newly created ureteral anastamoses

  • Positioning

  • Complications seen on x-ray

    • Migration out of kidney or bladder

    • Stent calcification


Ivc filter

IVC Filter

  • Inferior Vena Cava (above or

  • below renal veins depending on

  • VTE origin)

  • Indications

    • Contraindications to anticoagulation, VTE (venous thromboembolism) refractory to anticoagulation

  • Positioning

  • Complications seen on x-ray

    • Migration

    • Fragmentation


Endograft

Endograft

  • Abdominal aorta +/- common

  • iliac arteries

  • Indications

    • Abdominal aortic or aorto-iliac aneurysms

  • Positioning

  • Complications seen on x-ray

    • Migration

    • Kinking

    • Fragmentation


Abdomen radiography

References

Lewis, Petra, Kitt Shaffer, Joshua Becker, Holly Gil, Mark Mullins, and Beverly Wood. "AMSER-ID Download Page." AMSER. N.p., n.d. Web. 17 Jan. 2013. <www.dartmouth.edu/~amserimages/imagedb/index.html>.

Hodin, Richard. "Sigmoid volvulus." Evidence-Based Clinical Decision Support at the Point of Care | UpToDate. N.p., n.d. Web. 17 Jan. 2013. <http://www.uptodate.com/contents/sigmoid-volvulus>.

Wesson, David. "Intestinal atresia." Evidence-Based Clinical Decision Support at the Point of Care | UpToDate. N.p., n.d. Web. 17 Jan. 2013. <http://www.uptodate.com/contents/intestinal-atresia>.

Radswiki. "Horseshoe kidney | Image | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/images/570782>.

Gaillard, Frank, and Maxime St-Amant. "Primary sclerosing cholangitis | Radiology Reference Article | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/articles/primary-sclerosing-cholangitis>.

Gaillard, Frank. "Hirschsprung disease | Image | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/images/148189

Gaillard, Frank, and Yuranga Weerakkody. "Meckel's diverticulum | Radiology Reference Article | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/articles/meckels-diverticulum>.

Bashir, Omar. "Endovascular aneurysm repair graft | Radiology Case | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/cases/endovascular-aneurysm-repair-graft>.

Khan, Ali N. "Pneumoperitoneum Imaging ." Pneumoperitoneum Imaging. Medscape, 18 May 2011. Web. 27 Jan. 2013.


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