Acute appendicitis on US is seen as a noncompressible, thick-walled, dilated, blind-ending tubular structure in the right lower quadrant measuring 7 mm or more in diameter with graded compression, with or without a visible appendicolith. Although a strict size limit for normal appendices, similar to ultrasonographic imaging, is not applicable to CT given the lack of compression, acutely inflamed appendices are typically dilated and approach or exceed 1 cm in diameter. It is the result of migration of a gallstone into the small bowel with subsequent impaction, most often at the ileocecal valve. The fundus is the most dependent portion of the stomach and is subsequently the most common site for layering intraluminal contents, notably blood products. Colonoscopy can be performed to reduce the volvulus, but surgical intervention, including cecopexy or resection, is indicated in complicated cases. Author information: (1)Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore. Spanning 25 to 30 cm in length, the esophagus deviates to the left in the neck, to the right in most of the thorax, and then back to the left as it joins the gastroesophageal junction. It is typically located in the distal ileum approximately 2 feet from the ileocecal valve. As previously discussed, attention to the degree of gastric distention helps discern true gastric wall thickening from artificial thickening resulting from collapsed lumen. Herpes esophagitis typically presents with multiple small ulcers represented by pooled barium. The treatment of patients with typhlitis typically includes high doses of antibiotics and intravenous fluids to prevent transmural necrosis and perforation. In 15% to 20% of patients with UC a fulminant form of the disease may develop that is characterized by extensive inflammation with severe symptoms and colonic dilatation. Epiploic appendagitis represents acute inflammation or infarction of an epiploic appendage. Weight loss, malabsorption, and perianal fistulas and fissures are also frequently observed. The focal inflammation in the duodenal wall may result in benign-appearing common bile duct strictures and duodenal obstruction. Role of radiology in Abdominal Emergencies. The second (descending) portion of the duodenum contains the ampulla of Vater and abuts the pancreas, forming the pancreaticoduodenal groove. Appendectomy is the treatment of choice in simple acute appendicitis, and laparoscopic appendectomy is increasingly common. Clinical presentation. Acute colonic obstructions are emergencies requiring early detection to prevent complications such as perforation or ischemia. In cases of suspected ischemic colitis the mesenteric vessels should be closely scrutinized for obstructing arterial or venous thrombi. Patients with decreased gastric motility, such as those who have undergone gastric surgery, are predisposed to formation of phytobezoars, which may also pass into the small bowel and cause obstruction more distally as well. Peptic ulcer disease, trauma, and iatrogenic causes lead the list of potential causes of duodenal perforation. Viral organisms known to cause colitis include herpes, cytomegalovirus, Norwalk virus, and Rotavirus , and associated fungal organisms include Histoplasma and Mucor . Hernias are the most common cause of SBO in developing countries. Special Section on Celiac Disease. Larger ulcers are seen with cytomegalovirus and human immunodeficiency virus (HIV) esophagitis. Although early changes, such as aphtoid ulceration, are beyond the resolution of MR, it can be useful in the evaluation of fixed stenoses and segmental dilatation and to detect adhesions. Typhlitis, also known as neutropenic colitis , is seen in profoundly neutropenic and severely immunocompromised patients. It results from incomplete absorption of the omphalomesenteric duct and is frequently associated with heterotopic gastric or pancreatic mucosa in up to 50% of cases, with gastric heterotopia being most common. 13-53 ). A high degree of clinical suspicion is needed, particularly in patients using angiotensin-converting enzyme inhibitors and a variety of other medications, in the setting of typical imaging findings. The duodenum is the most common site for aortoenteric fistulas, owing to the proximity of these two structures in the retroperitoneum. Seeing AXRs have their limitations, some doctors tend to opt for abdominal CT as first choice. Primary small bowel neoplasms are rare. In older adults, left-sided ischemic colitis is more typical secondary to hypoperfusion, whereas right-sided ischemic colitis due to hemorrhagic shock is more common in younger patients. Multiplanar reformations (MPRs) and postprocessing techniques aid in a confident diagnosis and can be helpful to depicting findings. Dr Vikas Shah (@DrVikasShah) is a consultant radiologist at University Hospitals of Leicester NHS Trust in Leicester, UK, and an honorary fellow of the University of Leicester. In the setting of severe stenosis or occlusion of the mesenteric arterial or venous supply, bowel ischemia can lead to significant bowel wall thickening, resulting in SBO. English subtitles and a certificate are provided. Mucosal hyperenhancement reflects inflammation, and the degree of enhancement correlates with the degree of inflammation. The supine abdominal view demonstrates the bowel pattern to better extent, whereas air-fluid levels within the bowel are evident on the upright view. The cause and pathophysiologic process of intussusception are not well understood, particularly intussusception without a lead point. 13-6 ). When found in older children and adults, it should trigger a search for a lead point, such as an underlying neoplasm, inciting adhesion or foreign body. Similar to CD, UC is more common in white and Jewish populations and in northern Europe and North America. Thumbprinting, nodules, inflammatory polyps, and ulcers are additional findings that may be identified in cases of infectious colitis on barium enema. These fistulas can result from primary duodenal perforation, such as from malignancy, ulcer disease, or trauma, or from an extrinsic source, as is often the case with aortoduodenal fistulas. A “beak” sign is seen at the site of the torsion as a fusiform tapering. High-grade obstruction should be suggested when there is a substantive caliber difference between proximal and distal loops of bowel (and absent passage of contrast material through the transition point if delayed imaging is performed). Small bowel obstruction occurs in the late phase of radiation enteritis, most often in the distal small bowel as a result of adhesive and fibrotic changes that develop several months after therapy. The nitrous oxide created from the inflammation is believed to inhibit smooth muscle tone, resulting in bowel distention. On CT, abnormally increased mucosal and serosal enhancement of affected colonic segments, bowel wall thickening, and ascites are suggestive of infectious colitis ( Fig. Radiology has a role in differential diagnosis. C. difficile overgrowth is normally suppressed by colonic bacteria; however, antibiotic use suppresses normal bowel flora, enabling the overgrowth of C. difficile . Image quality on the PC version is much better than the Web version. There are important collateral pathways providing connection between these arteries, including between the celiac trunk and the SMA via the gastroduodenal artery and between the SMA and IMA via the marginal artery of Drummond and the arcade of Riolan. Complications of CD include abscesses, fistula formation, anal fissures, and colon cancer. The less common internal hernia occurs when there is protrusion of the viscera through a defect in the peritoneum or mesentery into another compartment within the abdominal cavity. 13-32 ). Common predisposing factors for ileus include sepsis, electrolyte disturbances, GI infection, and recent surgery. Imaging findings of aortoesophageal fistulas include a focal outpouching of the aorta toward the esophagus, adjacent esophageal wall thickening, and extraluminal gas within or abutting the aortic wall ( Fig. Perforation of peptic ulcers within the duodenal bulb and stomach remains one of the most common causes of GI perforation, warranting close examination of the stomach and proximal duodenum for ulcers when free intraperitoneal gas is identified on CT ( Fig. Surgical resection may be indicated when complications such as transmural necrosis, intramural necrosis, abscess, uncontrolled sepsis, and/or GI hemorrhage are present. Computed tomography findings of duodenal diverticulitis resemble those seen in inflamed diverticula elsewhere in the GI tract: a focal, round outpouching from the duodenal lumen with wall thickening and adjacent fat stranding and fluid ( Fig. A potential advantage over CT that has been proposed is the characterization of malignant versus benign strictures. Patients with UC usually present with bloody diarrhea, passage of mucus, abdominal pain, tenesmus, and urgency of defecation. There is often a skin opening with erythema and focal granulation tissue with purulent or serosanguineous discharge. Characteristic imaging features include reversible bowel and mesenteric edema, characterized by multiple dilated small-bowel loops with regular thickened mucosal folds, a stacked-coin appearance with bowel wall thickening, and thumbprinting. Acute disorders of vascular origin, such as acute hemorrhage, ischemia/infarction, and vasculitis are discussed in the nontraumatic vascular emergencies section. 13-3 ). In abdominal emergencies there is no indication of an immediate abdominal CT scan. Although the pathogenesis of colonic pseudo-obstruction is not fully understood, abnormal parasympathetic autonomic regulation of the colon and intramural ganglion damage are among proposed mechanisms. Because the mucosa receives a majority of the vascular supply to the colonic wall, it is most susceptible to ischemia. Emergency Radiology presents a comprehensive review of emergency pathologies commonly encountered by practicing radiologists and residents in training. 6 hours of video content for $24 & … Shimpi TR(1), Shikhare SN(2), Chung R(2), Wu P(2), Peh WCG(2). Conservative management is preferred when possible, and surgery is performed much more selectively than in the past. On unenhanced CT examinations, a thickened appendix with surrounding inflammatory changes, with or without a calcified appendicolith (see Fig. Complications of esophageal perforation include mediastinitis, pneumonia (from direct spread of infection or from aspiration), and empyema/abscess formation. The degree of bowel wall involvement ranges from isolated mucosal to transmural pathologic process depending on the severity and duration of ischemia. Although subjective, features favoring high-grade obstruction include (1) the presence of multiple air-fluid levels, particularly when discrepant levels are seen within the same loop, (2) dilated loops averaging more than 2.5 cm in diameter and/or exceeding 50% of the caliber of the largest visible colonic loop, and (3) a large number of distended loops of bowel. Although small bowel follow-through studies can provide spatial resolution in the evaluation of the mucosa that is superior to that of cross-sectional studies, and these studies have been performed in the past to triage patients with suspected SBO into surgical versus nonsurgical management, the widespread use of abdominal CT has largely replaced this practice. A fistula results from an abscess derived from an infection originating in the anal canal glands at the dentate line. Urgent surgery may be necessary when these complications develop. Although the incidence of peptic ulcers has decreased since the advent of H. pylori treatment and proton pump inhibitors, they remain a potential cause for presentation to the ED. In some instances the diverticulum will extend toward the umbilicus. Many of these complications are first diagnosed in the ED setting. Emergency Radiology. This type of gastric volvulus is more commonly associated with diaphragmatic defects and vascular compromise. A false diagnosis of colonic obstruction, particularly in patients with obstructive symptoms, may lead to inappropriate surgical exploration. With disease progression the bowel wall thickens and becomes featureless due to the loss of haustral folds. The patient was given neutral oral contrast to distend the bowel loops and to better depict the bowel wall and enhancement. Presenting signs and symptoms in patients with acute ischemic colitis include the acute onset of mild to severe crampy abdominal pain, nausea, and vomiting; bloody diarrhea and rectal bleeding may also occur several hours after the onset of abdominal pain. The esophageal wall has an adventitial layer, but no serosa, which permits esophageal diseases to more readily extend into the nearby neck, mediastinum, or upper abdomen. Abdominal pain is one of the most frequent reasons that elderly people visit the emergency department (ED). HIV, chronic steroid treatment, renal failure, transplant patients and cancer patients on chemotherapy) Multiple comorbidities Previous abdominal surgery Cardiac disease (AF, IHD) Alcoholism Pregnancy A very common cause of abdominal pain in emergency department patients is constipation, which may be of varying degrees of severity, usually without an associated focal obstructing lesion. Computed tomography may be employed to confirm a suspected diagnosis of typhlitis, to monitor disease progression based on the mural thickness, and to detect complications such as pneumoperitoneum in cases of silent perforation or necrosis. The duodenum is the shortest segment, with retroperitoneal location and lacking a mesentery. In this article, we review the deadliest causes of abdominal pain in this population, including mesenteric ischemia, abdominal aortic aneurysm, and appendicitis and potentially lethal non-abdominal causes. The gastric antrum demonstrates a thicker wall on CT and can normally demonstrate mural stratification, owing to its greater muscular composition and increased peristalsis in this segment. In addition, imaging findings of septic thrombophlebitis may be visualized on CT, including thrombus in mesenteric and portal veins. Cytomegalovirus can be reactivated in the setting of immunosuppression and can result in hemorrhagic enteritis. In such cases of equivocal findings for duodenal perforation, oral contrast, either for fluoroscopy or repeat CT, may be a useful adjunct because a delay in diagnosis may portend a poor outcome. The SMA supplies the jejunum and ileum. Iatrogenic SBO can occur as a result of endoscopic capsule retention because they have been used more often in the evaluation of the small bowel, particularly in patients with CD. Other reported causes of epiploic appendagitis include incarcerated hernia or bowel obstruction. In patients who have undergone gastric surgery, particularly Billroth and Roux-en-Y gastric bypass procedures, marginal gastric ulcers may appear at the gastrojejunal anastomosis. Aphthous ulcers with a target appearance, deep fissuring ulcers, and lymphoid hyperplasia are characteristic findings on colonoscopy. Small bowel obstruction can occur during the acute phase of CD when the intense acute transmural inflammation causes narrowing of the bowel lumen, during the chronic phase due to fibrotic stenosis, postoperative adhesions, incisional hernias, and exacerbation of the inflammatory condition (acute flare). Occasionally a “whirl” sign of the mesenteric vessels can be seen, reflecting the rotation of the bowel loops around the fixed point of obstruction. In the setting of SBO, it can be performed without oral contrast administration, because the retained intraluminal fluid serves as a natural negative contrast agent (and delays transit of any ingested contrast). The degree of distention within the gastric segment in question determines normal wall thickness on CT. The use of oral contrast for the diagnosis of SBO is controversial. Intussusception is a benign and common condition in children younger than 3 years old, but a rare cause of bowel obstruction in adults. After gastric adenocarcinoma the second most common tumor to obstruct the stomach and/or duodenum is pancreatic head adenocarcinoma, which can cause gastric outlet obstruction in 15% to 25% of cases. This conglomerate of findings should prompt a search for an adjacent hyperenhancing nodule representing a gastrinoma, although these may be difficult to identify on routine portal venous phase CT and may require multiphase phase CT, endoscopic ultrasonography (EUS), or octreotide scan to aid in detection. 13-45 ). Computed tomography findings include the pathognomonic bowel-within-bowel configuration, with or without mesenteric fat and mesenteric vessels. Spectrum of acute complications in Crohn disease (CD). Mesenteric fibrofatty proliferation, comb sign (engorgement of the vasa recta), and mesenteric lymphadenopathy are additional findings (see Fig. An uncommon cause of gastric obstruction, gastric volvulus presents clinically with Borchardt triad: sudden epigastric pain, intractable retching, and inability to pass a nasogastric tube. Computed tomography findings include long segment thickening of the esophageal wall (greater than 5 mm), as well as a “target” sign caused by mucosal hyperemia and submucosal edema ( Fig. Ingested foreign bodies may be a cause of gastric or small bowel obstruction and often fall into two major categories: trichobezoars and phytobezoars. Infectious colitis refers to colonic inflammation caused by a variety of bacterial, viral, fungal, or protozoan infections. Most patients require a delay of at least 40 to 60 minutes from contrast material ingestion to imaging. Patients who have undergone organ transplantation also have an increased risk for developing bezoars, which is hypothesized to be secondary to decreased gastric motility, either due to vagus nerve injury or a side effect of cyclosporine. A Meckel scan can confirm the presence of gastric mucosa within the diverticulum in equivocal cases ( Fig. In cases of fulminant UC severe colonic dilatation or toxic megacolon may be seen. The diverticulum can be associated with mural thickening and hyperenhancement, with focal calcifications at the base (enteroliths), and adjacent mesenteric fat stranding and fluid collections. Malaise, and abscesses are identified as loculated low-attenuation fluid collections, possibly containing foci of air an. Detect complications of sigmoid volvulus may be complicated abdominal emergencies radiology by obstruction, such as appendiceal perforation periappendiceal! 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