28-y-o female with RLQ pain, nausea, low-grade fever,   WBC  Zissin R, Head of CT  Meir Medical center

28-y-o female with RLQ pain, nausea, low-grade fever, WBC Zissin R, Head of CT Meir Medical center PowerPoint PPT Presentation


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Ac abd. pain - a diagnostic challenge . RLQ - DDAcute appendicitis (AA)Epiploic appendagiitis / Omental infarction - non-surgical mimicker of AAGI related: Crohn's disease (CD), Rt-sided diverticulitis, Inf. enteritis (Yersinia), Perforated cecal caMesenteric lymphadenitis Acute GUT pathol

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28-y-o female with RLQ pain, nausea, low-grade fever, WBC Zissin R, Head of CT Meir Medical center

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1. ????? ?? ???? ?? ???? ??? ????? ?????? ???? ????? ????? ???? ???? ?? ???? ??? ????? ??????, ??????? ???????. ???? ????? ??? ????? ????? ???.????? ?? ???? ?? ???? ??? ????? ?????? ???? ????? ????? ???? ???? ?? ???? ??? ????? ??????, ??????? ???????. ???? ????? ??? ????? ????? ???.

2. Ac abd. pain - a diagnostic challenge RLQ - DD Acute appendicitis (AA) Epiploic appendagiitis / Omental infarction - non-surgical mimicker of AA GI related: Crohn’s disease (CD), Rt-sided diverticulitis, Inf. enteritis (Yersinia), Perforated cecal ca Mesenteric lymphadenitis Acute GUT pathology: Ac Pyelonephritis Renal colic Gynecologic etiology Right lower quadrant – ???? ????? ???? ????? ???????? ?????? ?????? ??: ???, ??????, ?????? ????????, ????? ???' ???????? ?????. ?-DD ????? ??????? ?? ?????????: acute appendicitis (AA) - ????? ?????. epiploic appendagitis - ????? ????? torsion ???? ???? ????? ????????? ??? ????, ???? ???? acute diverticulitis. ??? ???? ??? Omental infraction – ?????? ??? ???? ??????. ???? GI – ???? ???? ?????, diverticulitis ??? ????, ???????? ?? ??? ?? yersinia, ????????? ?? cecal CA. ????? ????? ?? ?????? ?????? ?????????. ????? ??????. ????? ??????????? ??????.Right lower quadrant – ???? ????? ???? ????? ???????? ?????? ?????? ??: ???, ??????, ?????? ????????, ????? ???' ???????? ?????. ?-DD ????? ??????? ?? ?????????: acute appendicitis (AA) - ????? ?????. epiploic appendagitis - ????? ????? torsion ???? ???? ????? ????????? ??? ????, ???? ???? acute diverticulitis. ??? ???? ??? Omental infraction – ?????? ??? ???? ??????. ???? GI – ???? ???? ?????, diverticulitis ??? ????, ???????? ?? ??? ?? yersinia, ????????? ?? cecal CA. ????? ????? ?? ?????? ?????? ?????????. ????? ??????. ????? ??????????? ??????.

3. The most common cause of RLQ pain and 28% of ac. abdominal pain Treated surgically !!! Perforation rate ~ 20%, (more common <9y and >60y) The most common emergency in children and pregnant women. 6% chance during lifetime for each person Classic history: periumbilical pain migrating to RLQ only in 50%, atypical presentation mainly children, women 20-40y, elderly (1)Acute appendicitis ?????? ?? ???? ???? ?????? ?? ???? ??? ?????, ?? ??? 6% ????? ???? ???? ????? ?????. ??? ???-????????????? ????? ?? ?????? ?????? ????? ????????? ???? ???????, ?????? ??????, ???? ???? ??????? (????? ?????????) ?????????. ??? ?????? ?-DD, ???? ????? ???? ???? ??????, ?? ?????? ?? ??? ??? – ??????. ????? ????? ???? ?????? ????? ???? ????? ????????? ?-20% ???????, ??? ???? ???? ?????? ???????, ?? ???????? ??????? ????.(1)Acute appendicitis ?????? ?? ???? ???? ?????? ?? ???? ??? ?????, ?? ??? 6% ????? ???? ???? ????? ?????. ??? ???-????????????? ????? ?? ?????? ?????? ????? ????????? ???? ???????, ?????? ??????, ???? ???? ??????? (????? ?????????) ?????????. ??? ?????? ?-DD, ???? ????? ???? ???? ??????, ?? ?????? ?? ??? ??? – ??????. ????? ????? ???? ?????? ????? ???? ????? ????????? ?-20% ???????, ??? ???? ???? ?????? ???????, ?? ???????? ??????? ????.

4. Imaging modalities in acute abdomen Plain abdominal films: supine & erect – LIMITED INDICATIONS US – non invasive, no radiation CT – semi invasive, radiation ! Contrast media studies: imaging of bowel only (barium, gastrografin) – radiation ????? ??????, ????? ?????????, ?????? ????? (?????? ???, ????? ?? ??? ???????, ????? ?? – ????? ????????????). ?????? ??????? – ???? ????? ?? ??' ????? ?????? ???????: ?????? ???-????? – ??? ???? ??????. ?????? ?? ????? ??????? ?? ????? ?? ????. ???????? ?????? ???????. ?????: ?? ?????????? ???????? ????????. US – ????????? (???????) ?? ????-??????????. ?? ??????, ??? ?????. CT – ????? ???-?????????, ?? ??????? ????? ???? ????? ?? ???, ????? ????? ??????? ???????, ??? ?? ?? ?? ????? ?? ?????. ?????? ?? ???? ????? ????? ?? ??? ?????? – ?????? ?????? ?? gastrografin. ?????? ????? ?? ?? ???? ????? ???? ?????' ??? ????? ?-CT.????? ??????, ????? ?????????, ?????? ????? (?????? ???, ????? ?? ??? ???????, ????? ?? – ????? ????????????).

5. Plain abdominal films - Indications: 1. Detection of free air: Common causes: perforation of hollow viscus, post-operation, peritoneal dialysis 2. Gas (air) distribution: intestinal obstruction – dilated loops, air/fluid levels displaced loops – a secondary sign of mass effect 3. Detection of pathological calcifications Most common: calculi (20% of gallstones; 80% urolithiasis), vascular, intra-abdominal radiopaque foreign bodies Usually insensitive in AA but can suggest an alternative diagnosis ????? ???-????? ?? ??? ???? ?? ?????? ????-????? ?????? ??????? (??? ???? ????? ??????). ???? ?????: ????? ????? ????? ??? ???? ??' ??????. ????? ?? ?????? (???, ????), ?? ?? ???? ???? ???? ?? ????? ????. ?????? – ?? ?? ????? ?? ?????. ????? ????? (???, ???"?, ?????). ???? ??? ?? haustra?? ????? ??? ?? valvule coliventes (???? ???? ??????). ????? ?? (?? ???) ?? ?-haustra?? ???????? ??????? (????) ??-transverse (????). ????? ????? ????? ????: ???????? ?? ?? ???? ???? – ??? ???????? ??? ????. ????? ????? ???? ?? ????? – ???? ???? ?????, ????? ????????? (?????? ?????), ?????? ????? ?????? ???? ????? ??????, ???? ???? ???? ?????? ?? ?????. ????? ??????? ???? ??? ?????? ??? ???? ????? ??????? ??????????. ????? ????? ?? ????? ?????? ???? ????: ????? ?? ??????? ??? ?? ????? ?? ?????-???? – ???? ?? ?????. ???????? ?????? ?? ?? ??????? – ???? ???? ???? ?? ????? ?????????. ???? ?? ???? ?-CT ?? ?????? ??????? ?????? ?????? ????? ????. ??????????? ??????: ???? ????. ?????????: ????? ????? ???? (80% - ?? ???? ???? ?? ??????) ?? ???? (20% ??????? – ???? ???? ??? ???? ??? ?-US ??? ??????), ?????????? ???? ??, ????? ????. ????? ???? ????? ?-acute apendicitis – ??? ??? ????? ????? ??? ????? ??, ?? ???? ???? ????? ???? ???? ?????? ?????? ??? ??? ??????. ????? ??????: ????? ?? ??? ???????. ??? ??????? ?? ????? ???? ????? ?? ????? ?? ????? ?????? ?? ?????? (?? ???, ????, ??????? ?? ???? ????). ???? ????? ???? ????? ?? ????? ????? ???? ??????? – ?????? ???? ?????? ?? ??? (decubitus). ?? ???? ????? ????? ?????, ???? ?????? ?? ?? ???? (?????? ?? ?? ????), ??? ???? ?? ?? ????? ??? ???? ????? ????. ????? ?? ??????, ???? ???? – ????? ????? ?????. ????? ?? ???? ???? ??? ???? ??? ???? ????? ?? ????? ??? ???? ???? ???? ?????. Mechanical SBO – ???? ??????? ???????. ?????? ????? ???? ?????-????. ?????? (?? ????) ?? ???? ????? ??????? ???????? ?? ???? ??? – valvule coliventes. ?????? ??? ?????? ????? ???? ????? ??? ????? ?????? ?????? – endovascular stent ?????? ?????????? ?? ???????. ?? ????? ?????, ???? ?????????? ??????? ?? ???????. ???? ????? ????? ?? ????, ??????? ??? ??? ?? ??????? ????? ????? ???? ??? ????? ???? ??? ???. Ureteral calculus - ????? ?? ??? ??? – ???? ???"? ??????? ?? ?? ??????. ????? ?? ????? IVP (intra venous pielopathy) – ????? ?? ??' ???? ?????? ??? ???? ?? ????, ???? ???? ?????? ???? ?????? ??? ?????. ????? ???? ?????? - ???? ????? ????? ????? ???? (?? ??? ??? ??). "?? ?? ????? ????? ????? ??????? ????? ????" "?? ?? ?????".????? ???-????? ?? ??? ???? ?? ?????? ????-????? ?????? ??????? (??? ???? ????? ??????). ???? ?????: ????? ????? ????? ??? ???? ??' ??????. ????? ?? ?????? (???, ????), ?? ?? ???? ???? ???? ?? ????? ????. ?????? – ?? ?? ????? ?? ?????. ????? ????? (???, ???"?, ?????). ???? ??? ?? haustra?? ????? ??? ?? valvule coliventes (???? ???? ??????). ????? ?? (?? ???) ?? ?-haustra?? ???????? ??????? (????) ??-transverse (????). ????? ????? ????? ????: ???????? ?? ?? ???? ???? – ??? ???????? ??? ????. ????? ????? ???? ?? ????? – ???? ???? ?????, ????? ????????? (?????? ?????), ?????? ????? ?????? ???? ????? ??????, ???? ???? ???? ?????? ?? ?????. ????? ??????? ???? ??? ?????? ??? ???? ????? ??????? ??????????. ????? ????? ?? ????? ?????? ???? ????: ????? ?? ??????? ??? ?? ????? ?? ?????-???? – ???? ?? ?????. ???????? ?????? ?? ?? ??????? – ???? ???? ???? ?? ????? ?????????. ???? ?? ???? ?-CT ?? ?????? ??????? ?????? ?????? ????? ????. ??????????? ??????: ???? ????. ?????????: ????? ????? ???? (80% - ?? ???? ???? ?? ??????) ?? ???? (20% ??????? – ???? ???? ??? ???? ??? ?-US ??? ??????), ?????????? ???? ??, ????? ????. ????? ???? ????? ?-acute apendicitis – ??? ??? ????? ????? ??? ????? ??, ?? ???? ???? ????? ???? ???? ?????? ?????? ??? ??? ??????. ????? ??????: ????? ?? ??? ???????. ??? ??????? ?? ????? ???? ????? ?? ????? ?? ????? ?????? ?? ?????? (?? ???, ????, ??????? ?? ???? ????). ???? ????? ???? ????? ?? ????? ????? ???? ??????? – ?????? ???? ?????? ?? ??? (decubitus). ?? ???? ????? ????? ?????, ???? ?????? ?? ?? ???? (?????? ?? ?? ????), ??? ???? ?? ?? ????? ??? ???? ????? ????. ????? ?? ??????, ???? ???? – ????? ????? ?????. ????? ?? ???? ???? ??? ???? ??? ???? ????? ?? ????? ??? ???? ???? ???? ?????. Mechanical SBO – ???? ??????? ???????. ?????? ????? ???? ?????-????. ?????? (?? ????) ?? ???? ????? ??????? ???????? ?? ???? ??? – valvule coliventes. ?????? ??? ?????? ????? ???? ????? ??? ????? ?????? ?????? – endovascular stent ?????? ?????????? ?? ???????. ?? ????? ?????, ???? ?????????? ??????? ?? ???????. ???? ????? ????? ?? ????, ??????? ??? ??? ?? ??????? ????? ????? ???? ??? ????? ???? ??? ???. Ureteral calculus - ????? ?? ??? ??? – ???? ???"? ??????? ?? ?? ??????. ????? ?? ????? IVP (intra venous pielopathy) – ????? ?? ??' ???? ?????? ??? ???? ?? ????, ???? ???? ?????? ???? ?????? ??? ?????. ????? ???? ?????? - ???? ????? ????? ????? ???? (?? ??? ??? ??). "?? ?? ????? ????? ????? ??????? ????? ????" "?? ?? ?????".

6. Ultrasound Advantages: - Lack of radiation, non-expensive and availability - Aids in diagnosing alternative causes Disadvantages : - Operator dependent !! - Sen 85-90%, Spec 92-96%, As NPP is too low CT Mainly in children & childbearing age women US ???????? ?? ??????: ??? ?????, ?????? ?? ???? ??????. ???? ???? ?????? ??????????? ???? ??????. ????????: ?????? ????? ????? – ?? ?????? ?? ?? ???????. ?-CT ??????? – ???? ???? ?? ????? ???? ?????? ??? ???? ???, ????? ?-US ?? ?????? ??????, ?? ?? ??. ??????? ?????? ?????????? ??? 90%, ??-NPV ??? ????? ????, ???? ??? ???? ?? ??? ??????????? ????? ??-US ?????, ????? ????? ?????? ?????? ?"? CT. ????? US ?????? ?? ????? ???? ???????, ??? ????? ?????? ??????.US ???????? ?? ??????: ??? ?????, ?????? ?? ???? ??????. ???? ???? ?????? ??????????? ???? ??????. ????????: ?????? ????? ????? – ?? ?????? ?? ?? ???????. ?-CT ??????? – ???? ???? ?? ????? ???? ?????? ??? ???? ???, ????? ?-US ?? ?????? ??????, ?? ?? ??. ??????? ?????? ?????????? ??? 90%, ??-NPV ??? ????? ????, ???? ??? ???? ?? ??? ??????????? ????? ??-US ?????, ????? ????? ?????? ?????? ?"? CT. ????? US ?????? ?? ????? ???? ???????, ??? ????? ?????? ??????.

7. Aperistaltic, noncompressible, blind-ended, fluid-filled, tubular structure with distinct wall layers arising from the cecal base Outer diameter > 6 mm Appendicolith Periappendiceal fluid collection ??????? ??? ????? ?? blind end (????). ?-US ???? ???? ???????? ??? ???? ????? ??? ???, ????? ?????? ?? ???? ??? 6 ?"?, ?????? ???? ?? ??? ???? ??????? ???? ???-????????????. ????? ?????? ??????? ???? ?? ???? ??? 6 ?"?, ??? ?? ?????? ?????.??????? ??? ????? ?? blind end (????). ?-US ???? ???? ???????? ??? ???? ????? ??? ???, ????? ?????? ?? ???? ??? 6 ?"?, ?????? ???? ?? ??? ???? ??????? ???? ???-????????????. ????? ?????? ??????? ???? ?? ???? ??? 6 ?"?, ??? ?? ?????? ?????.

8. Computed Tomography - CT Radiation! (excludes pregnancy, consider benefit versus radiation risk) Semi invasive exam. – IV injection of CM CT ???? ?? US ????? – ?? ?????? ?-CT. ???? ???? ?????, ???? ?? ???? CT-??? ????? ??????? (??????? ????? CT-??? ??????? ?? ???-??? ?-PE ?????? ?? ????). ??????? ???? ?????.CT ???? ?? US ????? – ?? ?????? ?-CT. ???? ???? ?????, ???? ?? ???? CT-??? ????? ??????? (??????? ????? CT-??? ??????? ?? ???-??? ?-PE ?????? ?? ????). ??????? ???? ?????.

9. ?-CT ?????? ????? ?-72' – ?????? ????? ?? CT ???, ??? ??? ??? 5 ????. ?????? ???? ?????? ??????? ?? ???????? ???? ?????.?-CT ?????? ????? ?-72' – ?????? ????? ?? CT ???, ??? ??? ??? 5 ????. ?????? ???? ?????? ??????? ?? ???????? ???? ?????.

10. ???? ?? ????? ?????? ?? ????? ??????? ?? ?????. ?????? ?????? ??? ??' ????? ????????? ?????.???? ?? ????? ?????? ?? ????? ??????? ?? ?????. ?????? ?????? ??? ??' ????? ????????? ?????.

11. Type of CT examinations Diagnostic study Interventional procedure: - F. N. A (fine needle aspiration) - Diagnostic puncture (bacteriological evaluation) - Drainage of abscess, fluid collections Screening - Virtual colonoscopy - Cardiac CT - Low dose chest CT ???? CT ?????? ??????????? (????? ????? ??????) - ??????? ??? ??????. ?????? ???????? – ???? ????? ????? ?????? ?? ???????? ?? ?????? ???? ????? ??? ??????? ?? CT, ??? ??? ?????, ??????? ???? ?????, ?????? ???????. ????? ?? ?? ?????? ??? ?? ??? (?????) ?????? ??????. ????? FNA ?? ????? ?? ?????. ?????? ??? – ??????????? ?????????, ????? ???????? ??????? ?????? ????? ?????? ????? ?? ???? ????? (????).???? CT ?????? ??????????? (????? ????? ??????) - ??????? ??? ??????. ?????? ???????? – ???? ????? ????? ?????? ?? ???????? ?? ?????? ???? ????? ??? ??????? ?? CT, ??? ??? ?????, ??????? ???? ?????, ?????? ???????. ????? ?? ?? ?????? ??? ?? ??? (?????) ?????? ??????. ????? FNA ?? ????? ?? ?????. ?????? ??? – ??????????? ?????????, ????? ???????? ??????? ?????? ????? ?????? ????? ?? ???? ????? (????).

12. Radiation on CT Abd CT (~ 500 CXR) (BE-350 CXR, Upper GIT-150 CXR) Typical effective dose 10mSv (time provide for equivalent effective dose from background radiation – 3.3y) Malignancy risk: 5%/1Sv 1 to 2000 ?????? ??? ??? 500 ?????? ???, ?? ????? ??????? ??????? ???? ???? (1:2,000).?????? ??? ??? 500 ?????? ???, ?? ????? ??????? ??????? ???? ???? (1:2,000).

13. Technical notes – Abdominal CT Optimal technique: Oral+IV Contrast Media - Oral (for maximum GIT opacification) -IV (semi-invasive) ~120cc 2,5-4cc/sec Optional: - Rectal - Cysto CT Delayed scan as necessary ?????? ?????? ?-CT-??? ????? ?? ?????? ????? – ????? ???? ????? ????, ???? ?????, ???-??? ??????? ????? ???? ??????. ?-CT ??? ???? ???? ?? ??' ?????? (??? ?? ???) ????? ?????: ????? ???? 1-2 ???? ???? ??????. ????? ???? ????? ??? ??????. ????? ??? ??????. cysto-CT - ????? ??? ?????? ???? ????????. ??"? ????? ???? ?? ?????. ?? ?????? ????? ???? ?????: ???????? ????? ????? ???? – ?? ???? ????? ?? ?? ????? ????, ?? ?????? ??????????. Angio-CT – ????? ?????? ?? ???' ??????????, ????? ?????? ???? ??????.?????? ?????? ?-CT-??? ????? ?? ?????? ????? – ????? ???? ????? ????, ???? ?????, ???-??? ??????? ????? ???? ??????. ?-CT ??? ???? ???? ?? ??' ?????? (??? ?? ???) ????? ?????: ????? ???? 1-2 ???? ???? ??????. ????? ???? ????? ??? ??????. ????? ??? ??????. cysto-CT - ????? ??? ?????? ???? ????????. ??"? ????? ???? ?? ?????. ?? ?????? ????? ???? ?????: ???????? ????? ????? ???? – ?? ???? ????? ?? ?? ????? ????, ?? ?????? ??????????. Angio-CT – ????? ?????? ?? ???' ??????????, ????? ?????? ???? ??????.

14. ??????? ????? ?? ??? ?-hounsfield units ??????? – ?? ??? ?? ?????? ??? ???? ?????? ??????. ?? 5 ????? ???????: ??? ??? – ???, ???? ????? ???' ?????? ?? ????, ????, ??????????. ????? ???? – ????, ????, ????, ???. ???? (???) – ???, ??????? ?-CSF, ?????, ????? ??????? ????? – ??? ????. ????. ??? ???? – ????? ?????? ?-GI.??????? ????? ?? ??? ?-hounsfield units ??????? – ?? ??? ?? ?????? ??? ???? ?????? ??????. ?? 5 ????? ???????: ??? ??? – ???, ???? ????? ???' ?????? ?? ????, ????, ??????????. ????? ???? – ????, ????, ????, ???. ???? (???) – ???, ??????? ?-CSF, ?????, ????? ??????? ????? – ??? ????. ????. ??? ???? – ????? ?????? ?-GI.

15. Acute Appendicitis CT diagnosis depends on combined appendicular and periappendicular signs CT sens. 94-97%; spec. 97-99%; accuracy 93-98%; NPV & PPV 94-98% Appendicular signs: distended (>6mm), unopacified thickened wall (>2mm) app. appendicolith Periappendicular signs: pericecal fat strandings cecal mural thickening- “arrowhead” ????? CT ??????? ????? ????? ????, ???? ???? ??????? ?????? (???? ???? ??? ???? ???). ?????? ????? ??? ??? (?? ???), ??? ?????. ?????? ??? ???? ??-????, ???? ??? ??? ??????? ????? ????? ????? ?????? (????? ????? ????? ????? ?? ??? ???? ?????, ???? ???? ??? ?????). ?? ????? ?? ????? ???? ????, ????, ?????, ????. ?????? ??????? (???? ???) ????? ??? ?? ????? ??????? ?? ????? (??????? ?-haustra??) – ?? ?-hepatic flexure. ????? ?? ??????? ??-VC ????? ?????? ?-renal veins. ?????????? ?????? ???? ????? ???? ?????? ???? ???? ??? ?????? ???? ????. ????? ?? ??? ???? ?? ??? ????? (????). ?????? ????? ????, ?????? ???? ??? ????? ?????? ???? – ???? ?????? ?? blind end, ???? ????? ????, ????? ?? ???? ????? ????? ???, ????? ?? 6 ?"?. ?????? ???? ??? ?????. ????? ?????? ??? ?? ????? ?????? ???? ????? ????? ?????. ????? ????? ???. ?????? ??? ??? ????? ????, ???? ?????, ???? ??? ?????? 6 ?"?. ????? ?? ??? ????? ?-psoas. ????? ???? CSF, ????? ?? ?????? ????? ????? ????? (rectus abdominis). ?-CT ???? ????? ?????, ?? ????? ??? ???? ????? ??????, ?????? ??? ????????. ????? ??? ?-US ???? ????? ???? (??? ?????), ?? ???? ?? ????? ????? ????? (?? ????? ??? US). ??????????? ?? ??????: ??????? – ????? ?-6 ?"? ?? ???? ?????, ????? ???? ??? (?? ????? ????), ????? ????? ???? ?????? ??? (appendiculith – ??? ??????). ???? ??????? - ?? ????? ???? ????? (?????????? – ????? ?????? ????? ???-???????????), ????? ??? ????. ???? ?? ???? ??? ?? ???? ???? ?? ???? ??? ??????? Epiploic appendigitis (?-DD) ???? ?? ????? ????????, ???? ?? ???? ????? ??? ?? ???????? ?? ???????????. ????? ????? ?? ???? ??? ????? ?????? ???? ?? ???? ?-CT ???? ????? ?????? (????? ??????????) ?????? ???.????? CT ??????? ????? ????? ????, ???? ???? ??????? ?????? (???? ???? ??? ???? ???). ?????? ????? ??? ??? (?? ???), ??? ?????. ?????? ??? ???? ??-????, ???? ??? ??? ??????? ????? ????? ????? ?????? (????? ????? ????? ????? ?? ??? ???? ?????, ???? ???? ??? ?????). ?? ????? ?? ????? ???? ????, ????, ?????, ????. ?????? ??????? (???? ???) ????? ??? ?? ????? ??????? ?? ????? (??????? ?-haustra??) – ?? ?-hepatic flexure. ????? ?? ??????? ??-VC ????? ?????? ?-renal veins. ?????????? ?????? ???? ????? ???? ?????? ???? ???? ??? ?????? ???? ????. ????? ?? ??? ???? ?? ??? ????? (????). ?????? ????? ????, ?????? ???? ??? ????? ?????? ???? – ???? ?????? ?? blind end, ???? ????? ????, ????? ?? ???? ????? ????? ???, ????? ?? 6 ?"?. ?????? ???? ??? ?????. ????? ?????? ??? ?? ????? ?????? ???? ????? ????? ?????. ????? ????? ???. ?????? ??? ??? ????? ????, ???? ?????, ???? ??? ?????? 6 ?"?. ????? ?? ??? ????? ?-psoas. ????? ???? CSF, ????? ?? ?????? ????? ????? ????? (rectus abdominis). ?-CT ???? ????? ?????, ?? ????? ??? ???? ????? ??????, ?????? ??? ????????. ????? ??? ?-US ???? ????? ???? (??? ?????), ?? ???? ?? ????? ????? ????? (?? ????? ??? US). ??????????? ?? ??????: ??????? – ????? ?-6 ?"? ?? ???? ?????, ????? ???? ??? (?? ????? ????), ????? ????? ???? ?????? ??? (appendiculith – ??? ??????). ???? ??????? - ?? ????? ???? ????? (?????????? – ????? ?????? ????? ???-???????????), ????? ??? ????. ???? ?? ???? ??? ?? ???? ???? ?? ???? ??? ??????? Epiploic appendigitis (?-DD) ???? ?? ????? ????????, ???? ?? ???? ????? ??? ?? ???????? ?? ???????????. ????? ????? ?? ???? ??? ????? ?????? ???? ?? ???? ?-CT ???? ????? ?????? (????? ??????????) ?????? ???.

16. ??? ???? ??? ??????? ???? ???? ????????, ?? ???? ????? ??? ???? ??? ??????. ??????? ????? ?? ?????? ?????? ??? ???? ?? ???? ???, ????? ??? ???? ???? (???? ??? ????? ????? ????? ???). ????? ???? ???????? ????? ?????? ????? ???? ?????? ?-U (???), ???????? ??? ?? ????. ?? ?? endometrial cavity, ???? ??????? ????? ????? (???? + ?????). ??? ?????? ???? ?? douglas pouch ????? ???? – ?? ?? ??? ?????. ???????? ???? ?????, ?????? ?? ???? ????? ??????. ?? ????? ????? ???? ???? ???? ???????????, ??? ???? ????? ?? ??????? ?? ???, ????? ?????????????. ?????????? ??? ???? ??? ????? ?????: ???????? ?????? ?????? ???? ???-???????????. ????? ?????? ??????? ?? ??????? ???? ??????? ?? ???? (????? ?????? ?? ????) – ???? ???-???????????. ???? ?? ???????? ?? ????? – ???? ????????. ?? ?? ?? ???? ??????, ?? ????? ???? ????? ?? ????? ?????. ??? ?????? ????? ????????? ???, ???????? ???? ??????? ??? ????? ??-????? (per-cutanius). ?????? ??????? ????? ?? ???? ???? ??????? CT (???? ?? ?-US), ?????? ?? ?????? ??? ????? ??????? ?????. ???????? ??????? ?? ??? ????? ?????????? (?????? ?? ????? ?????). ??? ???? ??? ??????? ???? ???? ????????, ?? ???? ????? ??? ???? ??? ??????. ??????? ????? ?? ?????? ?????? ??? ???? ?? ???? ???, ????? ??? ???? ???? (???? ??? ????? ????? ????? ???). ????? ???? ???????? ????? ?????? ????? ???? ?????? ?-U (???), ???????? ??? ?? ????. ?? ?? endometrial cavity, ???? ??????? ????? ????? (???? + ?????). ??? ?????? ???? ?? douglas pouch ????? ???? – ?? ?? ??? ?????. ???????? ???? ?????, ?????? ?? ???? ????? ??????. ?? ????? ????? ???? ???? ???? ???????????, ??? ???? ????? ?? ??????? ?? ???, ????? ?????????????. ?????????? ??? ???? ??? ????? ?????: ???????? ?????? ?????? ???? ???-???????????. ????? ?????? ??????? ?? ??????? ???? ??????? ?? ???? (????? ?????? ?? ????) – ???? ???-???????????. ???? ?? ???????? ?? ????? – ???? ????????. ?? ?? ?? ???? ??????, ?? ????? ???? ????? ?? ????? ?????. ??? ?????? ????? ????????? ???, ???????? ???? ??????? ??? ????? ??-????? (per-cutanius). ?????? ??????? ????? ?? ???? ???? ??????? CT (???? ?? ?-US), ?????? ?? ?????? ??? ????? ??????? ?????. ???????? ??????? ?? ??? ????? ?????????? (?????? ?? ????? ?????).

17. Epiploic appendagitis (2) Epiploic appendagitis ?????? ???????? ?????? ????? torsion ??????? ????? ?????? ????? ????? ?????????? ?? ?????????????.(2) Epiploic appendagitis ?????? ???????? ?????? ????? torsion ??????? ????? ?????? ????? ????? ?????????? ?? ?????????????.

18. ?-CT ???? ????? ????? ?? ?????????: ????? ???? ????? (?????) – ????? ???? ??????? ?? ????, ??? ????? ?? epiploic appendigitis – ?? ??????, ??? ?????? ??????. ?????? ?? ??????? ?? ???? ????? ???????.?-CT ???? ????? ????? ?? ?????????: ????? ???? ????? (?????) – ????? ???? ??????? ?? ????, ??? ????? ?? epiploic appendigitis – ?? ??????, ??? ?????? ??????. ?????? ?? ??????? ?? ???? ????? ???????.

19. Crohn’s Disease (CD) - terminal ileitis Diarrhea- most common presentation Gradual, progressive RLQ pain - 45-95% Role of CT: In known cases - for detection of: - complications (abscess, enterovesical fistula, perianal disease) - alternative diagnosis (look for the appendix) * CD may be first diagnosed on CT in pts. presented with acute abdomen – RLQ pain (3) ????? ?? ?-terminal ileitis – crohn's ?-CT ?? ??? ??????????: ?? ????? ???? ????? ?-crohn ??? ?? ??????? ?????, ?-CT ?????? ??????? ?? ????? ??? ??????, ????????, ???? ???-??????. ???? crohn ????? ????????? ?????: ????????????, renal colic. ???? ????? ???? ????? CT ?????? ?? ??? ?????, ????? ????? crohn ????? ?? ?? ????, ??? ????? ????: ?????? ????? ?????? ????? ??? ?????????? ???? ???? ?????? ???? (????? ??????? ??? ????? ????).(3) ????? ?? ?-terminal ileitis – crohn's ?-CT ?? ??? ??????????: ?? ????? ???? ????? ?-crohn ??? ?? ??????? ?????, ?-CT ?????? ??????? ?? ????? ??? ??????, ????????, ???? ???-??????. ???? crohn ????? ????????? ?????: ????????????, renal colic. ???? ????? ???? ????? CT ?????? ?? ??? ?????, ????? ????? crohn ????? ?? ?? ????, ??? ????? ????: ?????? ????? ?????? ????? ??? ?????????? ???? ???? ?????? ???? (????? ??????? ??? ????? ????).

20. CT in CD Direct imaging of the bowel wall (normal <3mm) Secondary signs in surrounding mesentery: -mesenteric vascular engorgement -fluid within the mesenteric root -peri-bowel fat stranding, ”creeping fat” -mesenteric adenopathy To guide P.C. interventional procedures ?-CT ????? ?? ???? ???, ????? ??? ??????? ?????. CT ??? ?? ?????? ????? ??-????. ???? ?????: ?? ????? ?? ???? ???? ???, ???????? ????? ????? ?????. ???? ???????: ????? ????? - ????? ????? ?? ?????? ???????? ?? ????? ???? ?? ???? ??? - ???? ?????. ???? ??????? ??? 3 ?"?. ???? ???? – ???? ?????? ???? ?????? ?? ????. ????? ???? ????????? ????? ????????? ??? – ????? ??????? ?????? ?????? ??????. ???? ????? ???????, mesenteric adenopathy, ???? ???? ?? ???????? ??????: crohn + ????.?-CT ????? ?? ???? ???, ????? ??? ??????? ?????. CT ??? ?? ?????? ????? ??-????. ???? ?????: ?? ????? ?? ???? ???? ???, ???????? ????? ????? ?????. ???? ???????: ????? ????? - ????? ????? ?? ?????? ???????? ?? ????? ???? ?? ???? ??? - ???? ?????. ???? ??????? ??? 3 ?"?. ???? ???? – ???? ?????? ???? ?????? ?? ????. ????? ???? ????????? ????? ????????? ??? – ????? ??????? ?????? ?????? ??????. ???? ????? ???????, mesenteric adenopathy, ???? ???? ?? ???????? ??????: crohn + ????.

21. Stones and Obstruction Non contrast scan Determine the level of obstruction: calculi, and associated parenchymal changes (4) ???????????? ????? ???? ????? ????? - ???? ????? ???? ?????, ?????? ??? ??"? ?????? (??? ??? CT): ?????? ?????? ??????, ??? ???????. ????? CT ?? ????? ???? ?????? (?????? ???????) ?? ?????? ????? ?? ????? ????? ????? ?? ?????????? ?? renal colic ?????? ?????? ????????????. ???? ???????? ????? ????? ????? ????? ??????? ???????? ????? ?????? – ?? ????? ?? ????? ?????? ??????. ?????? ????? ?? ???? ????? ??? (IV) ?????? ???' ??????. ????? ????? ????? ???? ?????, ?? ?????? ?????????? (?????? ????? ??????). ????? ????? ????? ??? ???? ???? ?? ??????? – ???? (?????). (5) ????? ??????? ??? ????? - ???? ????? ?????? ????? ?????. ???? ??? ??? ?????. ?????? ??? ??? ????? ???? ?????. ????? ????? ?????: ????? ????? ????? – ????? ?"? ??????????. ????????. ????? ?? ??? ?????. ????? ?????? ????? ?? ???????? ???? (??? ?? ?????).(4) ???????????? ????? ???? ????? ????? - ???? ????? ???? ?????, ?????? ??? ??"? ?????? (??? ??? CT): ?????? ?????? ??????, ??? ???????. ????? CT ?? ????? ???? ?????? (?????? ???????) ?? ?????? ????? ?? ????? ????? ????? ?? ?????????? ?? renal colic ?????? ?????? ????????????. ???? ???????? ????? ????? ????? ????? ??????? ???????? ????? ?????? – ?? ????? ?? ????? ?????? ??????. ?????? ????? ?? ???? ????? ??? (IV) ?????? ???' ??????. ????? ????? ????? ???? ?????, ?? ?????? ?????????? (?????? ????? ??????). ????? ????? ????? ??? ???? ???? ?? ??????? – ???? (?????). (5) ????? ??????? ??? ????? - ???? ????? ?????? ????? ?????. ???? ??? ??? ?????. ?????? ??? ??? ????? ???? ?????. ????? ????? ?????: ????? ????? ????? – ????? ?"? ??????????. ????????. ????? ?? ??? ?????. ????? ?????? ????? ?? ???????? ???? (??? ?? ?????).

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