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A site specific approach to radiologic diagnosis A site specific approach to radiologic diagnosis Dr. Ahmed Refaey Abdominal pain.

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Presentation on theme: "A site specific approach to radiologic diagnosis A site specific approach to radiologic diagnosis Dr. Ahmed Refaey Abdominal pain."— Presentation transcript:

1 A site specific approach to radiologic diagnosis A site specific approach to radiologic diagnosis Dr. Ahmed Refaey Abdominal pain

2 Locations of abdominal pain Right upper quadrant RUQ Right upper quadrant RUQ Left upper quadrant LUQ Left upper quadrant LUQ Right Lower quadrant RLQ Right Lower quadrant RLQ Left lower quadrant LLQ Left lower quadrant LLQ Midepigastric Midepigastric

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4 Acute RUQ pain Acute cholecystitis – most common Acute cholecystitis – most common DD DD - PUD - PUD - acute hepatitis - acute hepatitis - liver abscess - liver abscess - RLL pneumonia - RLL pneumonia

5 RUQ pain imaging evaluation Ultrasound Ultrasound Acute cholecystitis – most common Acute cholecystitis – most common DD DD - PUD - PUD - acute hepatitis - acute hepatitis - liver abscess - liver abscess - RLL pneumonia - RLL pneumonia

6 US in acute cholecystitis Gall stones with ….. Gall stones with ….. …. ( sonographic Murphys sign ) …. ( sonographic Murphys sign ) distended gall bladder distended gall bladder Pericholecystic fluid collection Pericholecystic fluid collection Obstructing stone in GB neck or in cystic duct Obstructing stone in GB neck or in cystic duct gall bladder wall thickening (> 3 mm ) gall bladder wall thickening (> 3 mm )

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8 LUQ pain

9 Peptic ulcer disease Peptic ulcer disease Splenic infarct Splenic infarct LLL pneumonia LLL pneumonia

10 Diagnostic tests Plain X-ray chest -- pneumonia Plain X-ray chest -- pneumonia US - splenic infarct US - splenic infarct UGI - peptic ulcer disease UGI - peptic ulcer disease

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13 RLQ pain

14 Acute appendicitis Acute appendicitis Mesenteric adenitis Mesenteric adenitis Diverticulitis Diverticulitis Urinary tract calculi Urinary tract calculi Gynacologic disease Gynacologic disease

15 Diagnostic imaging US US CT CT Exceptions for CT Exceptions for CT * children * children * pregnant women * pregnant women Acute appendicitis Acute appendicitis Mesenteric adenitis Mesenteric adenitis Diverticulitis Diverticulitis Urinary tract calculi Urinary tract calculi Gynacologic disease Gynacologic disease

16 CT findings in acute appendicitis Dilated appendix ( > 6 mm ) Dilated appendix ( > 6 mm ) Non filling of the appendix with contrast Non filling of the appendix with contrast Peri-appendiceal inflammatory changes Peri-appendiceal inflammatory changes Increased enhancement of the wall Increased enhancement of the wall Appendicolith Appendicolith Accuracy of CT is % Accuracy of CT is %

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21 US findings in acute appendicitis Non-compressible Non-compressible Dilated appendix ( > 6 mm ) Dilated appendix ( > 6 mm ) Hyperemic thick wall Hyperemic thick wall Appendicolith Appendicolith Surrounded by omentum Surrounded by omentum Peri-appendiceal fluid collection Peri-appendiceal fluid collection

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27 Mesenteric adenitis Clinical presentation similar to appendicitis Clinical presentation similar to appendicitis inflammatory / infectious process inflammatory / infectious process Children > adults Children > adults Most common alternative condition identified at surgery with removal of normal appendix Most common alternative condition identified at surgery with removal of normal appendix

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30 Mesenteric adenitis vs appendicitis Both may have lymphadenopathy and ileal wall thickening. Both may have lymphadenopathy and ileal wall thickening. Appendix is normal in mesenteric adenitis. Appendix is normal in mesenteric adenitis.

31 Rt side diverticulitis

32 Uretric stone

33 LLQ pain

34 Divericulitis Divericulitis Epiploic appendagitis Epiploic appendagitis Perforated colon cancer Perforated colon cancer Urinary tract calculi Urinary tract calculi Gynacologic disease Gynacologic disease

35 Diagnostic imaging CT: best overall examination CT: best overall examination US : better for females US : better for females

36 CT in diverticulitis Diverticulosis Diverticulosis Wall thickening Wall thickening Inflammatory changes in pericolonic fat Inflammatory changes in pericolonic fat Extraluminal air or abscess Extraluminal air or abscess Soft tissue inflammatory mass ( phlegmon) Soft tissue inflammatory mass ( phlegmon) Evidence of colovesical fistula Evidence of colovesical fistula

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40 Epiploic appendagitis Epiploic appendages Epiploic appendages * small fatty protrusions * small fatty protrusions * 2-5 cm long * 2-5 cm long * serosal surface of colon * serosal surface of colon

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42 Epiploic appendagitis Torsion of epiploic appendages Torsion of epiploic appendages Clinical presentation similar to diverticulitis Clinical presentation similar to diverticulitis * localized abdominal pain, fever and elevated WBCs * localized abdominal pain, fever and elevated WBCs * typically no nausea and vomiting * typically no nausea and vomiting

43 CT in epiploic appendagitis Low density mass ( fat ). Low density mass ( fat ). Surrounding hyperdense rim Surrounding hyperdense rim May have central dot May have central dot ( thrombosed vessel) ( thrombosed vessel)

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47 Left uretric stone

48 Qynacologic causes of LQ/pelvic pain PID PID Ruptured ovarian cyst Ruptured ovarian cyst Hemorrhagic ovarian cyst Hemorrhagic ovarian cyst Adenexal torsion Adenexal torsion Ectopic pregnancy Ectopic pregnancy

49 Diagnostic imaging US is the primary imaging modality US is the primary imaging modality

50 Midepigastric pain

51 PUD PUD Acute pancreatitis Acute pancreatitis Aortic dissection Aortic dissection Aortic aneurysm rupture Aortic aneurysm rupture

52 Diagnostic imaging CT the best for all except PUD CT the best for all except PUD PUD Acute pancreatitis Aortic dissection Aortic aneurysm rupture

53 Acute pancreatitis diagnostic imaging CT is the modality of choice CT is the modality of choice US may be useful screening tool US may be useful screening tool

54 CT in acute pancreatitis Focal or diffuse enlargement Focal or diffuse enlargement Peripancreatic inflammation Peripancreatic inflammation Areas of necrosis Areas of necrosis Peripancreatic collection Peripancreatic collection

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56 Abdominal aortic aneurysm Without rupture, may present with pulsatile abdominal mass without pain Without rupture, may present with pulsatile abdominal mass without pain With rupture, presents with midabdominal and back pain With rupture, presents with midabdominal and back pain

57 CT diagnosis of AAA rupture Retroperitoneal hematoma Retroperitoneal hematoma Contrast extravasation Contrast extravasation

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59 Abdominal aortic dissection CT is the modality of choice CT is the modality of choice

60 Abdominal aortic dissection CT diagnosis Contrast in 2 channels Contrast in 2 channels Intervening intimal flap Intervening intimal flap

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62 Summary RUQ pain acute cholecystitis US RUQ pain acute cholecystitis US LUQ pain splenic/gastric UGI/US LUQ pain splenic/gastric UGI/US RLQ pain A.appendicitis CT/US RLQ pain A.appendicitis CT/US LLQ pain diverticulitis CT LLQ pain diverticulitis CT Midepigastric pancreas/aorta CT Midepigastric pancreas/aorta CT Young female pelvic pain US Young female pelvic pain US Children use US whenever possible Children use US whenever possible

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