Imaging the Abdomen

Question 1

For what 3 reasons may the abdomen be imaged?

Answer 1

• to confirm a clinical diagnosis / suspicion
• to rule out important diagnoses / pathologies
• to guide or evaluate management / treatment

Question 2

What are the following structures on AXR?

What do the pink lines represent?

Answer 2

• the pink lines represent the lateral margin of the psoas muscle
  
  • this can be seen as there is a change in density - soft tissue with fat next to it
  • if this lateral border cannot be seen, there may be an abnormality (e.g. collection of fluid)
• the faeces appear speckled in appearance as they contain air

Question 3

What are the limited number of indications for when an AXR might be performed?

Answer 3

• suspected perforation (of a hollow organ / viscus i.e. bowel, gallbladder, bladder)
  
  • an erect CXR would be performed for suspected pneumoperitoneum
• small or large bowel obstruction
• toxic megacolon (in ulcerative colitis exacerbations and C-diff infection)
• foreign body ingestion
• renal calculus (but AXR has been superseded by other imaging modalities)

Question 4

What is Rigler’s sign?

When might this be seen?

Answer 4

• it is the “double-wall sign” as gas is outlining both sides of the bowel wall
• there is gas present within the bowel lumen and within the peritoneal cavity
• this is present in pneumoperitoneum where there is >1000ml gas

Question 5

What is shown in this AXR?

Answer 5

small bowel obstruction

• the small bowel is dilated as diameter >3cm
• it is small bowel as valvulae connvientes are visible across the full width of the bowel and it is positioned more centrally within the abdomen
• the prominent valvulae conniventes produce a “coiled spring” appearance

Question 6

What are 3 possible causes of small bowel obstruction?

What symptoms would this present with?

Answer 6

Causes:

• adhesions following previous abdominal surgery
• IBD can cause strictures than narrow the lumen of the bowel
  
  • this does not cause obstruction, but the narrower lumen means obstruction is more likely
• direct and indirect abdominal hernias

Symptoms:

• colicky abdominal pain
• vomiting

Question 7

What is shown in this AXR?

Answer 7

large bowel obstruction

• the large bowel is dilated (>6cm for colon and >9cm for caecum)
• haustra are visible that do not completely traverse the bowel and faeces can be seen within it (speckled appearance)

Question 8

What are the 2 main causes of large bowel obstruction?

What is the main symptom and why is it an emergency?

Answer 8

Causes:

• it can be caused by cancerous tumours (rectal carcinoma)
• it can be caused by twisting of the bowel (volvulus)

Symptoms:

• there is an inability to pass flatus as the bowel is not opening
• this is an emergency due to the risk of rupture leading to faecal peritonitis

Question 9

What are the 2 most common types of volvulus?

Why can this only happen in certain locations?

Answer 9

• volvulus describes twisting of the bowel, and in order for the bowel to twist, it needs to have a mesentery
• the majority of the large bowel is retroperitoneal and unable to move
• the only parts that can twist are the parts on a mesentery - the sigmoid colon and caecum

Question 10

How does sigmoid volvulus present?

In what age group is this more common and why?

Answer 10

• twisting of the sigmoid colon presents with the “coffee bean sign” that tends to point towards the upper abdomen
• the sigmoid colon stretches with age and becomes redundant, and so the likelihood of volvulus increases with age
• this is an emergency as there is a high risk of bowel perforation and/or ischaemia secondary to vascular compromise

Question 11

What is meant by “thumb-printing” on AXR?

Answer 11

• this describes thumb-shaped, nodular, indentations at regular intervals in the bowel wall
• it occurs when there is thickening of the large bowel wall
• this is usually caused by oedema (infective / inflammatory process), but can also be a sign of bowel ischaemia
• the haustra become thickened at regular intervals to resemble “thumb-prints”

Question 13

What is shown in this AXR and how can you tell?

Answer 13

pneumoperitoneum

• Rigler’s sign is present as the bowel wall appears nicely delineated
  
  • free air in the abdomen means that both sides of the bowel wall become visible
• there is free air present under the diaphragm
• be aware that there is often air present underneath the left hemidiaphragm due to the presence of the stomach - not pathological

Question 14

What is shown in these images?

What is the drawback of using AXR to identify this pathology?

Answer 14

• most renal calculi are radio-opaque, but some will be missed
• the calculus is visible on AXR, but the AXR reveals nothing about the effect that the stone is having on the kidney
  • i.e. is there any renal impairment or hydronephrosis?

Question 15

What is shown in this image?

Answer 15

medullary sponge kidney

• instead of a stone in the hilum, there is calcification of the medulla producing fuzzy, patchy calcification

Question 16

What is shown in this image?

Answer 16

Double J stents

• these are used for urinary tract obstruction

Question 17

Often AXR can be unremarkable in cases of serious pathology.

When might there be a serious cause of abdominal pain and a normal AXR?

Answer 17

1. appendicitis
2. pancreatitis
3. leaking AAA
4. ruptured ectopic pregnancy
5. mesenteric ischaemia / infarct
6. diverticulitis

Question 18

What are the drawbacks of AXR?

Answer 18

• it is only likely to be beneficial in specifc cases, but can be falsely reassuring when there is underlying serious pathology
• it may not reveal underlying pathology
• no functional information can be obtained
• further imaging will still be required if AXR is inconclusive

Question 19

What abdominal structures can be imaged well on USS?

What structures cannot be imaged well?

Answer 19

• USS is very good for delineating fluid, air and soft tissue

Structures that can be imaged well:

• gallbladder and biliary tree
• liver
• aorta
• kidneys

Structures that CANNOT be imaged well:

• pancreas
• gas-filled structures (if there is overlying bowel containing gas then this obscures structures so they can no longer be seen)

Question 20

What are the advantages of using USS?

Answer 20

• cheap
• portable - can be used in A&E if patient is too unstable for CT
• non-invasive - can be used to guide interventions such as drains and biopsies
• non-ionising radiation

^^ these factors make USS an attractive option for screening when possible

• it allows good visualisation of hollow viscera, stones and fluid-filled structures
• it can be used to demonstrate free fluid in the abdomen

Question 21

What are the disadvantages of using USS?

Answer 21

• interpretation of images requires considerable skill / training
• it is user / operator dependent
• it is difficult in overweight/obese patients or if a patient has abdominal pain
• may not give a definitive diagnosis
• may not show other pathology
• not adequate for detailed surgical planning

Question 22

In what 5 scenarios is CT abdomen indicated?

Answer 22

• when a definitive diagnosis is needed
• to exclude life-threatening pathologies
  
  • e.g. to rule out AAA as the cause of abdominal pain in patients presenting with a history of “renal colic”
• for staging in malignancy as CT can reveal metastatic disease (e.g. in the liver)
• for surgical planning in malignancy, IBD and vascular surgery
• for monitoring disease progression in malignancy and IBD

Question 23

When is CT scanning of the abdomen used in the acute setting?

Answer 23

• suspected ruptured AAA
• trauma patients
  
  • if there is direct / obvious abdominal trauma
  • OR mechanism of injury is severe enough to warrant whole body CT
• suspected mesenteric ischaemia / bowel infarction
• acute pancreatitis
• bowel obstruction - to determine the site and cause

Question 24

What is the most important factor to consider before taking a CT scan of the abdomen?

Answer 24

Timing

• CT scans of the abdomen and pelvis can be performed in many different ways depending on the question being answered

Question 25

What are the advantages of CT scanning the abdomen?

Answer 25

* it provides a **_definitive diagnosis_** * it allows for **excellent visualisation of the anatomy**, which allows for **surgical planning** * **other pathologies** may be demonstrated * *e.g. hepatic metastases in the case of bowel obstruction due to cancer* * it can be used **with contrast** if required * *e.g. CT angiogram for abdominal vessels*

Question 26

What are the disadvantages of CT scanning the abdomen?

Answer 26

* it requires the patient to be **transferred to CT** - they need to be **stable enough** * **image interpretation may take longer** and you need to wait for the radiologists report * it uses **ionising radiation**, which is increased further if contrast is used * the patient needs to **lie still** in the scanner

Question 27

What type of scan is this and what pathology does it demonstrate?

Answer 27

* this is **_fluoroscopy_** (barium studies of the GI tract) * this shows a **_barium swallow_**, as barium has entered the lumen of hollow structures * it demonstrates a **stricture in the cervical oesophagus**

Question 28

What type of scan is this and what pathology does it demonstrate?

Answer 28

* this is a **_barium enema_** * the patient has an **_incompetent ileocaecal valve_** as the contrast has passed through the large bowel and **entered the small bowel**

Question 29

What is fluoroscopy? How is it performed and what type of information can be obtained?

Answer 29

* fluoroscopy uses **X-rays** and **contrast agent** to acquire **_"real time" images_** * static images can also be obtained * it allows for **functional and dynamic information** to be obtained * it can be used to **guide interventional procedures**

Question 30

What types of pathology is fluoroscopy good for investigating?

Answer 30

* **pharyngeal pouches** * **oesophageal strictures** - benign or malignant * **small bowel lesions** - ulceration, inflammation, erosions (Crohn's/UC) * **large bowel pathologies** - diverticulitis, malignancy, polyps

Question 31

What needs to be considered prior to fluoroscopy?

Answer 31

* it has a **high ionising radiation dose** (300x that of a CXR) * the patient must be able to **swallow contrast** * adequate bowel prep is required

Question 32

What interventional procedures may be performed on the abdomen using imaging?

Answer 32

* image guided biopsies * percutaneous drains * stenting - GI tract / biliary tree * percutaneous PEG & JEG

Question 34

What are the benefits of MRI scanning of the abdomen and when may it be performed? When is it not appropriate?

Answer 34

* it provides **excellent visualisation of _all tissues_**, including soft tissues * it can be used if **detailed visualisation of the GI tract** is needed * it is **_not**_ appropriate for the _**acute setting_ / acute abdominal pain** * it is only used for **_targeted problem solving_** (not a "fishing trip")

Question 35

What are the 5 major uses of MRI scanning in abdomino-pelvic imaging?

Answer 35

* **_MRCP_** in **jaundice** / to look for **retained stones** post-op * **MRI adrenal, renal and liver** - to characterise lesions found on CT/US * in **_inflammatory bowel disease_** to assess **wall thickness / enhancement** * for **staging** in **colorectal cancer** * for **diagnosing and staging prostate cancer** (and with US for targeted biopsy)