Site Specific Abd Pain-SS

Site Specific Approach toAbdominal Pain

Susan L Summerton, M.D.

Objectives

•Upon completion of this session, theparticipant should be able to:

•Identify which diagnoses are most likely giventhe site of the patient’s presenting abdominalpain

•Order appropriate radiographic studies basedon the location of presenting symptoms

•Describe and recognize radiographic signs ofcommon causes of abdominal pain

ACR Appropriateness Criteria®

•American College of Radiology

•180 topics in Diagnostic Imaging

•Continuously updated

•Evidence based guidelines

•Assist physicians

•Enhance quality of care

•Efficacious use of radiology

$H:\RSmith\AMS 2013\2013-02-13_104355.png$

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

Abdominal Pain

1.Right Upper Quadrant

2.Left Upper Quadrant

3.Right Lower Quadrant

4.Left Lower Quadrant

5.Midepigastric and Back Pain

Right Upper Quadrant Pain

•Differential Considerations

•Cholelithiasis/Cholecystitis

•Acute hepatitis

•Cholangitis

•Peptic ulcer disease

•Right lower lobe pneumonia

•Renal causes

Reprinted with permission of the American College of Radiology. No otherrepresentation of this material is authorized without expressed, written permission fromthe American College of Radiology. Refer to the ACR website at www.acr.org/ac for themost current and complete version of the ACR Appropriateness Criteria®.

Which of the following three patients has gallstones?

Audience Question

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$H:\RSmith\Teaching Files\Gallbladder\Cholelithiasis - seen on US but not on CT\trv GB CT.tif$

A.A

B.B

C.C

D.A and C

E.B and C

F.All the above

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$H:\RSmith\Teaching Files\Gallbladder\Cholelithiasis - seen on US but not on CT\trv GB CT.tif$

Audience QuestionWhich of the following three patients has gallstones?

A.A

B.B

C.C

D.A

E.B

F.A

$H:\RSmith\Teaching Files\Gallbladder\Cholelithiasis - seen on US but not on CT\sag GB CT.tif$

$H:\RSmith\Teaching Files\Gallbladder\Cholelithiasis - seen on US but not on CT\Sag GB US.tif$

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$H:\RSmith\Teaching Files\Gallbladder\Cholelithiasis - seen on US but not on CT\Trv GB US.tif$

Acute Calculous Cholecystitis:Ultrasound Findings

•Gallstones

•Hyperechoic foci withposterior shadowing

•GB wall thickening

•Normal wall ≤ 3 mm

•Distended gallbladder

•Pericholecystic fluid

•Positive sonographicMurphy’s sign

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$H:\RSmith\Teaching Files\Gallbladder\Pericholecystic Fluid\sag 3.tif$

1.6 cm

Acute Calculous Cholecystitisand

Choledocholithiasis

$H:\RSmith\Teaching Files\Gallbladder\Acute calculus cholecystitis 3\sag neck stone.tif$

$H:\RSmith\Teaching Files\Gallbladder\Acute calculus cholecystitis 3\sag.tif$

Supine

Left Lateral Decubitus

Gallstone lodged

in gallbladder neck

Gallstones

Acute Calculous Cholecystitis

Biliary Sludge

•Calcium bilirubinate granules and cholesterolcrystals often in thick, viscous bile

•Clinical significance?

•May represent early stages of gallstone formation

•Can cause pancreatitis

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Acute Calculous Cholecystitis - CT

•Calculi

•Fluid/inflammation

•Wall thickening/ enhancement

•GB Distension

•Bile duct calculi

•high density structure in CBD

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\Multiple Case Conference\Acute Non GI Cases\2. Acute calculous cholecystitis - ct\acute calculous cholecystitis on ct.03.jpg$

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MRI

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MRCP

Cholelithiasis &

Choledocholithiasis

Complications of Cholecystitis

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75 year old male withabdominal pain

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Emphysematous Cholecystitis

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$C:\Users\Ryan\Desktop\Desktop Data\Radiology\Multiple Case Conference\Acute Non GI Cases\4. GB perforation\1.jpg$

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Perforated Gallbladder

Discontinuity inGB wall

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\Multiple Case Conference\Acute Non GI Cases\3. Emphysematous chole on 2 studies ct\CT axial first study 1.jpg$

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Perforated and GangrenousCholecystitis

Left Upper Quadrant Pain

•Differential Considerations

•Spleen

•Splenomegaly

•Infarct

•Infection

•Trauma

•Peptic Ulcer Disease

•Diverticulitis

•Left Lower Lobe Pneumonia

•Renal Causes

Splenomegaly

Common

Less common

•Lymphoma/Leukemia

•Portal hypertension

•Mononucleosis (EBV)

•Viral: HSV, CMV, HIV

•Gaucher’s disease

•Glycogen storagedisease

•Sickle Cell – acutesplenic sequestrationcrisis

•Sarcoid/Amyloid

•Still’s disease

•Lupus

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Spleen\Splenomegaly with splenic contusion or infarct, mono\Splenomegaly with splenic contusion or infarct.02.jpg$

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Contusion in an enlarged spleen

secondary to Mononucleosis

18 yo male with fever, lethargy andLUQ pain after football practice

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Normal

20 cm

Splenic Trauma Imaging

•Used to demonstrate initial injury

•Document progression, stability orresolution of injuries

•Decision for surgery :

•hemodynamic variables

•lab studies

•serial bedside clinical assessments

Splenic Trauma CT

•Four Appearances:

•Intrasplenic hematoma/Contusion

•Laceration

•Subcapsular hematoma

•Infarcts

•Active bleeding - focal extravascularenhancement similar in intensity to the aorta

•Hemoperitoneum – high density free fluid

•associated with clinically significant injuries

$H:\RSmith\Teaching Files\Spleen\Intrasplenic hematoma\axial ct 2.tif$

Spleen Injuries

$H:\RSmith\Teaching Files\Spleen\Shattered Spleen\axial ct 3.tif$

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$H:\RSmith\Teaching Files\Spleen\Lac and active extravasation\lac and bleed coronal.tif$

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Ruptured Spleen withHemoperitoneum

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85 yo male with LUQ pain

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Malignant melanoma

Right Lower Quadrant Pain

•Differential Considerations

•Appendicitis

•Diverticulitis

•Inflammatory bowel disease

•Pelvic/Ovarian etiologies - Ultrasound

CT of theabdomen andpelvis withcontrast

Exceptions to using CT forappendicitis

•Children

•Ultrasound first, then CT if needed

•Pregnant Women

•Ultrasound first, then MRI if needed

Appendicitis: Role of Imaging

•Negative appendectomy rate

•Based on clinical findings = 15-20%

•Based on CT = 4%

•Use of CT has resulted in a decrease inthe negative appendectomy and adecrease in the perforation rate

*Balthazar EJ, et al. Appendicitis: the impact of computed tomography imagingon negative appendectomy and perforation rates. Am J Gastroenterol 1998;93:768-771

Acute Appendicitis: CT Signs

•Thickened appendix

•Appendiceal wall hyperenhancement

•Focal cecal thickening

•Periappendiceal inflammation

•Appendicolith

Acute Appendicitis: CT

•Thickness

•< 6 mm: generally excludes appendicitis

•6-10 mm: indeterminate

•>10 mm: surgery if symptomatic

Leite NP, et al. CT Evaluation of Appendicitis and its Complications:Imaging Techniques and Key Diagnostic Findings. AJR 2005; 185:406-417.

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Bowel\acute appy 3\CT\ser003img00067.jpg$

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Bowel\acute appy 3\CT\ser003img00070.jpg$

Dilated, Fluid Filled Appendix

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Bowel\acute appy 3\CT\ser300img00073.jpg$

11 mm

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\Penn Cases\GI\acute appy\CT\ser003img00051.jpg$

Acute UncomplicatedAppendicitis

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Bowel\acute appy\CT\ser003img00049.jpg$

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\Penn Cases\GI\acute appy\CT\ser300img00089.jpg$

Ultrasound: Normal Appendix

$H:\RSmith\Teaching Files\Appendix\Normal Appendix Ultrasound\app sag measurement.tif$

$H:\RSmith\Teaching Files\Appendix\Normal Appendix Ultrasound\sag 2.tif$

$H:\RSmith\Teaching Files\Appendix\Normal Appendix Ultrasound\transverse.tif$

5 mm

Appendicitis

•US findings

•Diameter > 6 mm

•Non-compressible

•Thickened wall

•Appendicolith

•Abscess

•Hyperechoic/Hypervascularperiappendiceal fat

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MRI

Normal

Appendicitis

Complications of Appendicitis

•Perforation

•Abscess

•Peritonitis

•Bowel obstruction

•Thrombophlebitis

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Bowel\acute appy 2\_smithry__0416045213\ser002img00073.jpg$

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Bowel\acute appy 2\_smithry__0416045213\ser002img00075.jpg$

Mesenteric Adenitis

•Clinical presentation mimics appendicitis

•Self-limited benign inflammation of ilealmesenteric lymph nodes

•Children > adults

•Most common alternative condition identifiedat surgery after removal of normal appendix

Mesenteric Adenitis

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Normal

Appendix

Mesenteric Adenitis - Ultrasound

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67 year old female with RLQpain

$H:\RSmith\Teaching Files\Colon\Perforated cecum from chicken bone\axial 1 hazy mesentery.tif$

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Perforated Cecum – Chicken Bone

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Left Lower Quadrant Pain

•Differential Considerations

•Diverticulitis

•Inflammatory Bowel Diseases

•Epiploic Appendagitis

•Pelvic/ovarian etiologies - Ultrasound

CT abdomenand pelvis withcontrast

Diverticulitis

•CT Findings

•Diverticula

•Colonic wall thickening

•Pericolic fat stranding

•Abscess

•Extraluminal air

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Bowel\Diverticulitis\Axial 1.jpg$

True or False. The treatment for epiploicappendagitis is surgery.

Audience Question

a.True

b.False

c.I am not sure whatepiploic appendagitisis.

Audience Response

True or False. The treatment for epiploic appendagitisis surgery.

a.True

b.False

c.I am not sure whatepiploic appendagitis is.

Epiploic Appendagitis

•Epiploic Appendages

•2-5 cm long small pouches of fat

•Serosal surface of the colon

Epiploic Appendagitis

•Torsion, infarction, ischemia of an epiploicappendage

•Symptoms: Mild pain, fever, leukocytosis

•Clinical course:

•self limited

•spontaneous resolution

Epiploic Appendagitis:Imaging Features

•Pericolonic low density(fatty) mass

•Hyperdense rim

•Peripheral inflammatorychanges

•Central high density focusfrom vascular thrombosis

Midepigastric/Back Pain

•Differential Considerations:

•Pancreatitis

•Bowel Obstruction

•Abdominal Aortic Aneurysm

•Aortic Dissection

•Peptic Ulcer Disease

•Nephrolithiasis

•Best imaging modality

•CT abdomen andpelvis with contrast

•Except

•PUD

–Endoscopy

•Nephrolithiasis

–Noncontrast CT

The Revised Atlanta Classificationof Acute Pancreatitis

The Acute Pancreatitis ClassificationWorking Group – 2008

Standardize reports

Improve communication

Pancreatitis: Clinical Definition

1.Abdominal pain suggestive of pancreatitis

2.Serum amylase and lipase levels > 3x normal

•Imaging may be used if < 3x normal

3.Characteristic findings on CT, MRI, or US

Causes

Common

•Alcohol Abuse

•Gallstones

Less Common

•Metabolic disorders

•Congenital/Structural

•Trauma

•Drugs

•Infection

•Malignancy

•Pregnancy

•Idiopathic – 20%

Role of Imaging

•Diagnose severity

•Identify local and systemic complications

•Guide for therapeutic intervention

•Follow response to therapy

The diagnosis of pancreatic necrosis on CTrequires intravenous contrast.

Audience Question

a.True

b.False

Audience Response Question

The diagnosis of pancreatic necrosis on CTrequires intravenous contrast.

a.T

b.F

Acute PancreatitisDiagnostic imaging

•CT of abdomen and pelvis with intravenouscontrast imaging modality of choice

•Imaging findings on CT correlate with clinicaloutcome

•Two Morphologic Types:

•Acute interstitial edematous pancreatitis

•Acute necrotizing pancreatitis- Requires IV contrast

Contrast Enhanced CT

•Pancreatic/Peripancreatic Necrosis

•Fluid Collections

•Location

•Fluid characteristics

•Wall

•Presence of gas

Terminology: Fluid Collections

1.Acute peripancreatic fluid collection

2.Pseudocyst

3.Acute necrotic collection/Post necroticpancreatic fluid collection

4.Walled-off pancreatic necrosis

•Pancreatic abscess and phlegmon are nolonger acceptable terms

Pancreatitis - CT

•Pancreatic changes

•Focal or diffuse enlargement

•Decrease in density due toedema

•Blurring of the margins of thegland due to inflammation

•Peripancreatic changes

•Stranding densities in fat andblurring of fat planes

•Thickening of the retroperitonealfascial planes

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Pancreas\Pancreatitis\CT axial 1.jpg$

$C:\Users\Ryan\Desktop\Desktop Data\Radiology\TEACHING FILES\Pancreas\Pancreatitis\CT axial 3.jpg$

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Acute Interstitial Pancreatitis

Normal Pancreas

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Ultrasound

•Mainly used to evaluate for gallstonesand/or to follow the size of pseudocysts

•Findings:

•Pancreatic enlargement

•Decreased pancreatic echogenicity

•Heterogeneous echogenicity

•Peripancreatic fluid collections

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Acute Interstitial Pancreatitis

Normal Pancreas

Complications of Pancreatitis

•Necrosis

•Fluid collections

•Vascular

•Pseudoaneurysm

•Thrombosis of peripancreatic vessels

•Superimposed Infection

Necrosis

•Requires IV contrast to diagnose

•Amount of necrotic tissue is strongestpredictor of mortality

•greater or less than 30%

•Increased mortality with superimposedinfection

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Pancreatic Necrosis

Normal

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Acute Pancreatitis

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? Focal Necrosis

Pancreatic Pseudocyst

•Fluid collection encapsulated by a fibrouswall > 4 weeks after onset of symptoms(Surgical definition=6 weeks)

•No associated tissue necrosis within thefluid collection

Pseudocyst

•50% resolve spontaneously

•20% are stable

•30% cause complications

•< 4 cm - will likely resolve

•> 10 cm - majority require drainage

•Size and duration have not been shownto be predictors of morbidity/mortality

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$C:\DOCUME~1\SmithRy\LOCALS~1\Temp\1.2.840.113619.2.55.3.1510605370.76.1339676483.652.381.bmp$

$C:\DOCUME~1\SmithRy\LOCALS~1\Temp\1.2.840.113619.2.55.3.1510606170.947.1350906028.170.271.bmp$

$C:\DOCUME~1\SmithRy\LOCALS~1\Temp\1.2.840.113619.2.55.3.1510605370.535.1351078214.451.311.bmp$

$C:\DOCUME~1\SmithRy\LOCALS~1\Temp\1.2.392.200036.9116.2.2.2.1762675955.1352251983.5610821.bmp$

6/6/12

6/9/12

6/14/12

10/22/12

10/26/12

11/7/12

Hx: recurrent pancreatitis

CBD

Posterior

Main PD

MRCP

Pancreas Divisum

CBD

Minor Papilla

Major Papilla

Accessory Pancreatic Duct (Santorini)

Main Pancreatic Duct (Wirsung)

Ventral Duct of Wirsung

Normal

CBD

Minor Papilla

Major Papilla

Accessory Pancreatic Duct (Santorini)

Main Pancreatic Duct (Wirsung)

Ventral Duct of Wirsung

Pancreas Divisum

OTHER CAUSES OFMIDEPIGASTRIC/BACK PAIN

Abd Pain and Pulsatile massSuspected AAA

•Ultrasound

•Limited by body habitus and bowel gas

•CT abdomen and pelvis without

•Preferred for symptomatic patients

•CT angio of abdomen and pelvis

•Enables pre interventional planning

•MRI

$C:\DOCUME~1\SmithRy\Local Settings\Temp\1.2.840.113619.2.55.3.1510605370.767.1251373846.248.424.bmp$

Ruptured Aortic Aneurysm

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$C:\DOCUME~1\SmithRy\Local Settings\Temp\1.2.840.113619.2.80.40129220.19030.1251924432.361.bmp$

Ruptured Aortic Aneurysm

•2/3rd die before reaching hospital

•Risk of AAA rupture within 5 years:

•3-3.9 cm: 2%

•4-4.9 cm: 3-12%

•5-5.9 cm: 25%

•6-6.9 cm: 35%

•7+ cm: 75%