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ACUTE ABDOMEN ABNORMAL GAS COLLECTIONS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY.

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Presentation on theme: "ACUTE ABDOMEN ABNORMAL GAS COLLECTIONS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY."— Presentation transcript:

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2 ACUTE ABDOMEN ABNORMAL GAS COLLECTIONS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY

3 OR GAZ

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5 RADIOGRAPHS –LEFT LATERAL DECUBITUS ABDOMEN –UPRIGHT ABDOMENT –UPRIGHT CHEST –SUPINE ABDOMEN ACUTE ABDOMEN EXAMINATION

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7 PNEUMOPERITONEUM

8 FREE AIR SENSITIVITY OF IMAGING STUDIES COMPUTED TOMOGRAPHY 99% LATERAL UPRIGHT CHEST RADIOGRAPH 98% AP UPRIGHT CHEST RADIOGRAPH 80 - 90% LEFT DECUBITUS ABDOMEN RADIOGRAPH 80- 90% SUPINE ABDOMEN RADIOGRAPH ?

9 PNEUMOPERITONEUM SENSITIVITY OF IMAGING STUDIES RADIOLOGIC DEMONSTRATION DEPENDS ON: –VOLUME OF FREE AIR –TIME INTERVAL BEFORE IMAGING –TYPE OF IMAGING –CONDUCT OF IMAGING EXAMINATION AS LITTLE AS ONE CC CAN BE DEMONSTRATED 10% OF PATIENTS WITH PERFORATED ULCERS DO NOT DEMONSTRATE PNEUMOPERITONEUM

10 UPRIGHT CHEST

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12 PNEUMOPERITONEUM UPRIGHT RADIOGRAPHS UNDER RIGHT HEMIDIAPHRAGM UPRIGHT ABD CENTRAL TENDON AND HEMIDIAPHRAGM

13 FREE AIR…….DECUBITUS VIEW GAS BETWEEN LIVER AND BODY WALL BUT MAY ALSO BE IN OR ONLY IN THE PELVIS

14 ACUTE ABDOMINAL PAIN UPRIGHT AP CHEST & LEFT LATERAL DECUB NEGATIVE

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16 PNEUMOPERITONEUM SUPINE RADIOGRAPHS

17 GAS BUBBLE ON LIVER SURFACE

18 FREE AIR CENTRAL TENDON

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20 RIGLER’S SIGN BOTH SIDES OF BOWEL WALL VISIBLE DOUBLE WALL SIGN

21 MASSIVE PNEUMOPERITONEUM FOOTBALL SIGN

22 FALCIFORM LIGAMENT GAS BUBBLE OVER LIVER

23 FALCIFORM LIGAMENT

24 PNEUMOPERITONEUM SUBHEPATIC GAS BUBBLE

25 DIVERTICULITIS PNEUMOPERITONEUM

26 ANTERIOR ABDOMINAL WALL ANATOMIC FOLDS

27 FREE AIR INFERIOR EPIGASTRIC VESSELS (LATERAL UMBILICAL LIGAMENTS)

28 FREE AIR 2 DAYS AFTER OHT CT 3 DAYS LATER: DIVERTICULITIS

29 PNEUMOPERITONEUM WITH PERITONITIS PERFORATED VISCUS –ULCER –NEOPLASM –BOWEL OBSTRUCTION –ISCHEMIC BOWEL –TRAUMA TRAUMA PERITONITIS –GAS FORMING ORGANISM

30 PSEUDO-PNEUMOPERITONEUM

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32 CENTRAL TENDON GAS YES, BUT JUST THE STOMACH

33 GAS UNDER THE RIGHT HEMIDIAPHRAGM HEPATIC FLEXURE ANTERIOR-SUPERIOR TO LIVER

34 SUBDIAPHRAGMATIC FAT SIMULATING FREE AIR

35 FREE AIR OR NOT FREE AIR? THAT IS THE QUESTION PNEUMOTHORAX SIMULATES FREE AIR

36 GAS IN SUBPHRENIC ABSCESS SIMULATES FREE AIR

37 RETROPERITONEAL GAS SIMULATES FREE AIR

38 RETROPERITONEAL GAS

39 LITTLE CHANGE IN POSITION OR SHAPE WHEN COMPARING SUPINE, UPRIGHT, DECUB RADIOGRAPHS BUT FREE INTRAPERITONEAL GAS IS FREELY MOBILE TENDS TO STAY IN ONE RETROPERITONEAL COMPARTMENT DUODENAL PERFORATION…..RUQ ANTERIOR PARARENAL SPACE SIGMOID DIVERTICULITIS….. LLQ PERIRENAL ABSCESS…………. PERINEPHRIC SPACE OFTEN FORMS LINEAR, CURVILINEAR GAS COLLECTIONS RETROPERITONEAL GAS IMAGING

40 49-YEAR-OLD MAN WITH FEVER AND DIARRHEA FOR 2 WEEKS. HE HAS INFECTED URINE

41 BENEATH DIAPHRAGM CAN SIMULATE PNEUMOTHORAX BUT MEDIAL, LATERAL, LOW NOT DIRECTLY UNDER APEX AS FREE AIR –DIFFERENTIATE BY OBTAINING UPRIGHT OR DECUBITUS VIEWS LARGE VOLUME OF GAS CAN OUTLINE RETROPERITONEAL STRUCTURES KIDNEY, LIVER MARGIN, PSOAS, FLANK STRIPE RETROPERITONEAL GAS CAN EXTEND CEPHALAD TO MEDIASTINUM FASCIAL PLANES OF BODY WALL AND EXTREMITIES INTO PERITONEAL CAVITY RETROPERITONEAL GAS IMAGING

42 RETROPERITONEAL GAS

43 13-YEAR-OLD GIRL WITH CROHN’S DISEASE HAS SUBACUTE FEVER AND ABD PAIN

44 RETROPERITONEAL GAS EXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT

45 ABDOMINAL PAIN 4 HOURS AFTER COLONOSCOPY AND BIOPSY EXTENSIVE RETROPERITONEAL GAS

46 BAROTRAUMA MEDIASTINUM – RETROPERITONEUM – FREE AIR

47 IATROGENIC –SURGERY –DIAGNOSTIC PROCEDURE TRAUMA –PENETRATING –RUPTURED VISCUS RETROPERITONEAL DUODENUM, COLON, RECTUM PERFORATED BOWEL SECONDARY TO TUMOR, INFECTION, OBSTRUCTION, NECROSIS CAUDAL EXTENSION OF PNEUMOMEDIASTINUM GAS WITHIN ABSCESS RETROPERITONEAL GAS CAUSES

48 BOWEL WALL GAS

49 PNEUMATOSIS OF COLON INFANT ADULT NECROTIZING ENTEROCOLITIS ISCHEMIC COLITIS

50 WHAT IS THE ABNORMALITY HERE? USE LUNG WINDOWS TO LOOK FOR GAS

51 72-YEAR-OLD WOMAN WITH DIARREHA FOR 2 DAYS NORMAL PHYSICAL EXAMINATION

52 58-YEAR-OLD WOMAN MILD ABDOMINAL PAIN FOR 2 DAYS DIFFERENTIAL DIAGNOSIS? SCLERODERMA, GAS IN COLON WALL

53 PNEUMATOSIS 2 DAYS AFTER SEGMENTAL SB RESECTION RESOLVED SPONTANEOUSLY, DISCHARGED AFTER 1 WEEK BOWEL WALL GAS MAY BE INNOCUOUS

54 ASYMPTOMATIC 40-YEAR-OLD MAN BENIGN STEADY STATE PNEUMATOSIS

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56 ISCHEMIC BOWEL

57 ISCHEMIC BOWEL IMAGING SIGNS –DILATION PSEUDOOBSTRUCTION –BOWEL WALL THICKENED PNEUMATOSIS UNENHANCING –GAS IN VESSELS MESENTERIC, SMV, PORTAL VEINS –OBSTRUCTED VESSELS SMA, SMV –HIGH DENSITY CLOT ON UNENHANCED CT –FILLING DEFECTS ON CT WITH IV CONTRAST –ASCITES, FREE AIR AFTER PERFORATION

58 ACUTE ONSET OF ABDOMINAL PAIN SMA EMBOLIS

59 ISCHEMIC COLITIS IN TWO PATIENTS

60 ISCHEMIC SB AND COLON THICKENED MUCOSAL FOLDS

61 SBO ISCHEMIC BOWEL AT SURGERY: SB TWISTED UNDER ADHESION WITH OBSTRUCTI0N & SEGMENT OF DEAD BOWEL

62 61-YEAR-OLD MAN WITH PROSTHETIC AORTIC VALVE HAS ACUTE GI BLEEDING

63 ISCHEMIC COLITIS

64 ISCHEMIC SMALL BOWEL ETIOLOGY ? SMV CLOT

65 47-YEAR-OLD WOMAN 2 WEEKS AFTER MI ACUTE ABDOMINAL PAIN OCCULT BLOOD + STOOL SMA EMBOLIS FROM MURAL THROMBUS

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67 BILE DUCT GAS

68 IATROGENIC –BILE DUCT SURGERY –SPHINCTEROTOMY BILIARY FISTULA –GALLSTONE ERODING INTO BOWEL –DUODENAL ULCER –UPPER ABDOMINAL MALIGNANCY –TRAUMA CHOLANGITIS –GAS FORMING ORGANISM

69 BILE DUCT GAS CHUNKY AND CENTRAL

70 59-YEAR-OLD MAN HISTORY OF DUODENAL ULCER

71 BILE DUCT GAS AND SBO

72 SBO GALLSTONE ILEUS

73 GALLSTONE ILEUS

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76 GALLSTONE ILEUS BILE DUCT GAS, SBO, STONE

77 GALLSTONE ILEUS

78 86-YEAR-OLD MAN ABD PAIN, VOMITING X 2 DAYS NO HISTORY OF PRIOR SURGERY AND NO HERNIAS

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80 82-YEAR-OLD MAN COMES TO ER ABDOMINAL PAIN AFEBRILE, NORMAL WBC ABD 1 DAY LATER

81 THE 82-YEAR-OLD MAN NOW HAS THE DIAGNOSIS OF SBO AND A CT STUDY IS DONE

82 73-YEAR OLD MAN SIGNED OUT AMA AFTER UGI ONE YEAR LATER ADMITTED WITH ABD PAIN, VOMITING

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84 75-YEAR-OLD WOMAN NAUSEA AND VOMITING X 1 DAY

85 GALLBLADDER COLON FISTULA

86 49-YEAR-OLD MAN WITH INTRACTABLE DIARRHEA RADIOGRAPH 2YEARS EARLIER

87 GALLBLADDER GAS

88 GALLBLADDER LUMEN –GALLBLADDER-BOWEL FISTULA –GALLSTONE ILEUS –EMPHYSEMATOUS CHOLECYSTITIS GALLBLADDER WALL GAS –EMPHYSEMATOUS CHOLECYSTITIS

89 EMPHYSEMATOUS CHOLECYSTITIS

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92 38 Emph Chole

93 53-YEAR-OLD WOMAN RUQ PAIN AND FEVER SUPINE UPRIGHT LEFT LAT. DECUBITUS

94 2 WEEKS POST HEART TRANSPLANT FEVER AND ABDOMINAL PAIN PREOPERATIVE RADIOGRAPH

95 PORTAL VEIN GAS

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97 SMALL BOWEL ISCHEMIA GAS IN MESENTERIC AND PORTAL VEINS 48 SubPhrenic Abs CT

98 65-YEAR-OLD MAN ABDOMINAL PAIN, NORMAL PX PORTAL VEIN GAS DELICATE AND PERIPHERAL

99 36-YEAR-OLD MAN MULTIPLE CONGENITAL ANOMALIES FEVER, WBC 17.8, 15 BANDS ISCHEMIA OF SB AND STOMACH

100 ISCHEMIC BOWEL MESENTERIC VEIN GAS

101 ABSCESS

102 SUSPECT AN ABSCESS WHEN RADIOGRAPHS SHOW A GAS COLLECTION THAT IS ABNORMAL BECAUSE OF PERSISTENCE ON MULTIPLE VIEWS GET HISTORY, PX, LAB DATA BY CONSULTATION WITH ORDERING MD AND BY LOOKING IN EMR CONFIRM WITH CROSS-SECTIONAL IMAGING

103 APPENDICEAL ABSCESS RETROCECAL APPENDIX ABNORMAL GAS… UNCHANGED ON MULTIPLE VIEWS

104 SIGMOID DIVERTICULITIS GAS FILLED “DIVERTICULUM

105 GIANT ABSCESS 2 WEEKS AFTER ANEURYSM SURGERY

106 8 DAYS POST LEFT HEMICOLECTOMY TEMP 39.1, WBC 16,OOO 15 BANDS PERIHEPATIC ABSCESS. CONNECTION TO BOWEL SHOWN BY UGI

107 SUBPHRENIC ABSCESS

108 FEVER 10 DAYS AFTER ABDOMINAL SURGERY

109 CROHN’S DISEASE WITH ABSCESS

110 54-YEAR-OLD WOMAN TRANSFERRED WITH PERSISTENT FEVER AND ELEVATED WBC POST DIVERTICULAR ABSCESS DRAINAGE

111 47-YEAR-OLD WOMAN HAS FEVER, WBC 29.6 7 DAYS POST HEMICOLECTOMY

112 PERCUTANEOUS DRAINAGE OF ABSCESS ABSCESS WITH FISTULA TO SMALL BOWEL SHOWN BY DELAYED SCANNING

113 PERITONITIS THICKENED, ENHANCING PERITONEUM

114 PANCREATIC ABSCESS

115 PANCREATIC GAS GAS IN PANCREATIC BED –ABSCESS –POST PANCREATIC DRAINAGE PROCEDURE PERCUTANEOUS OR SURGICAL –PUESTOW PROCEDURE –PSEUDOCYST –PANCREATIC FISTULA

116 PANCREATITIS WITH ABSCESS LESSER SAC ABSCESS GAS IN PANCREATIC ABSCESS

117 PANCREAS-COLON FISTULA POST PUESTOW PROCEDURE PANCREAS-GAS BUT NO ABSCESS

118 LESSER SAC

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120 GASTRIC ULCER PERFORATION INTO LESSER SAC

121 GALLBLADDER IN LESSER SAC

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123 GAS IN LESSER SAC PERFORATED GASTRIC ULCER

124 CULTURE HISTORY OF RADIOLOGY

125 INTERMITTENT ABDOMINAL PAIN FOR 3 WEEKS TAKING NSAIDS FOR 2 MONTHS

126 68-YEAR –OLD MAN SUDDEN ONSET OF SEVERE ABDOMINAL PAIN

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