Radiology: Abdomen Flashcards
(59 cards)
1
Q
what could right upper quadrant pain suggest?
A
- cholecystitis and biliary colic
- congestive hepatomegaly
- hepatitis or hepatic abscess
- perforated duodenal ulcer
- retrocecal appendicitis (rarely)
2
Q
what could right lower quadrant pain suggest?
A
- appendicitis
- cecal diverticulitis
- Meckel’s diverticulitis
- mesenteric adenitis
3
Q
what could right or left upper quadrant pain suggest?
A
- acute pancreatitis
- herpes zoster
- lower lobe pneumonia
- MI
- radiculitis
4
Q
what could left upper quadrant pain suggest?
A
- gastritis
- splenic disorders (abscess or rupture)
5
Q
what could left lower quadrant pain suggest?
A
- sigmoid diverticulitis
6
Q
what could right or left lower quadrant pain suggest?
A
- abdominal or psoas abscess
- abdominal wall herniations
- cystitis
- endometriosis
- incarcerated or strangulated hernia
- IBD
- PID
- renal stone
- ruptured abdominal aneurysm
- ruptured ectopic pregnancy
7
Q
what is a supine AXR good for?
A
- assessing for bowel obstruction
8
Q
what is an erect CXR good for in relation to abdomen?
A
assessing for hollow viscus perforation
9
Q
cons to CT?
A
- radiation exposure
- contrast induced nephropathy - i.e. DM risk
- contrast allergy
10
Q
MRI good for?
A
- good for visualising soft tissue
- used as second line test for hepato-biliary, small bowel and pelvis
11
Q
MRI cons?
A
- long time to acquire images as opposed to CT
12
Q
RIF pain possible diagnoses?
A
- appendicitis
- renal colic
- tubo-ovarian pathology
13
Q
how does acute appendicitis present?
A
- challenging diagnosis
- periumbilical pain, N and V
- localizes RIF
14
Q
appendix imaging?
A
- CT and USS are important tools
- ideally USS first then CT if this is inconclusive
- gen speaking when imaging acute abdomen - give IV contast - 60-80 secs after passed in you scan (portal venous phase)
15
Q
what time do you take an arterial phase scan?
A
- 20 seconds
16
Q
CT findings of acute appendicitis?
A
- periappendiceal inflammation
- fat stranding (black on CT abd becomes white when oedematous (inflammation)
- thickening of fascia or mesoappendix
- extraluminal fluid
- phlegmon
- abscess
focal wall nonenhancement representing necrosis
perforation
17
Q
how does right ureteric calculus present and what test?
A
- loin to groin pain
- unenhanced - non-contrast CT (CT KUB) is gold standard for imaging ureteric stones
- stones >1mm are visualised
- assoc hydronephrosis/inflammatory change
18
Q
LIF pain possible diagnoses?
A
- diverticulitis
- colitis
- colorectal cancer
- tubo-ovarian pathology
- renal colic
19
Q
acute diverticulitis presentation?
A
- left iliac fossa pain
- unremitting pain w assoc tenderness
- possibly, ill-defined mass
- as disease progresses, symptoms become more generalised
- inflammation of outpouchings
20
Q
acute diverticulitis imaging?
A
- no role for AXR or US
- consider CXR for perforation
- CT w IV contrast IX of choice
21
Q
A
- gas filled diverticuli
- thickened hypoenhancing bowel
- hallmark of inflammation: abnormal oedematous fat stranding sitting in adjacent sigmoid mesocolon
22
Q
complications of acute diverticulitis
A
- abscess formation
- fistulation to adjacent structures e.g. bladder
- CT can help explain symptoms
23
Q
some other potential causes of LIF pain?
A
- colorectal carcinoma - less inflam change, usually shorter segment
- epiploic appendagitis - epiploae twists round
- ischaemic colitis - is their central obstructing lesion (thrombus)
- IBD
- tubo-ovarian pathology
- pseudomembranous colitis
24
Q
epigastric and RUQ pain
A
- biliary colic
- cholecysitits
- pancreatitis
- peforation
25
acute cholecysitits presentation?
almost always secondary to gallstones
DX based on
- sign of inflammation RUQ paine tc
- sign of inflammation - fever, WCC, CRP
26
1st line imaging for acute cholecystitis
- US!!! - confirm gallstones, biliary dilatation and inflammation
- CT can be false for calculi, but good for complications
- MRI if biliary tree dilatation
27
gallbladder findings of acute cholecystitis?
- gallbladder wall thickening >3mm
- pericholecystic fluid
28
acute cholecystitis CT findings?
- cholelithiasis - gallstones isodense to bile will be missed on CT
- gallbladder distention
- gallladder wall thickening
- mural or mucosal hyperenhancement
- pericholecystic fluid and inflammatory fat stranding
- enhancement of adjacent liver parenchyma due to reactive hyperaemia
29
MRCP used for?
- shows stone in common bile duct, common hepatic duct or cystic duct
- T2 weighted image - just fluid
30
tx options for biliary stones?
- medical/conservative
- interventional radiology - percutaneous
- ERCP if obstructed biliary tree (risk of pancreatitis)
- surgery
31
pancreatitis presentations?
severe central epigastric pain - over 30-60 min
- amylase v elevated
- radiates through to back in 50% of patients
- poorly localised tenderness and pain
- excaerbated by supine positioning
32
role of imaging in pancreatitis?
- confirm dx - if confused...
- look for reversible causes i.e. biliary dilatation
- avoid it usually - as many pancreatitis patients need A LOT of imaging
US - identify gallstones, biliary dilataton
CT - hallmarks of inflammation
33
CT findings of pancreatitis?
- focal or diffuse parenchymal enlargement
- indistinct pancreatic margins owing to inflammation
- surrounding retroperitoneal fat stranding
- liquefactive necrosis of pancreatic parenchyma
- infected necrosis/abscess formation - parts of pancreas that do not enhance
- vascular complications - portal and splenic vein (thrombosed) and portions of SMA (pseduo-aneurysm - bleeding risk) (as pancreas is retroperitoneal structure)
34
common perforations?
common
- perforated ulcer in upper abdo but decreasing w increased use of PPI's
- diverticular tract (lower GI)
less common
- secondary to cancer
- secondary to ischemia (wall of gut broken down and fallen apart)
35
CT good for for perforation?
- shows free fluid
- clues to site of origin - ie distribution gas, defect in wall, localised inflammatory change
36
see a large area of free gas in ant abdomen more likely to be what?
- more likely to be lower GI perforation as more gas in large bowel than small bowel
37
why does abdomen become distended?
- physiological mass i.e. pregnancy
- full of stuff shouldnt be there i.e. loads of gass, lots of faecal loading
- ascites - lots of fluid in abdomen - i.e. shifting dullness
38
small bowel obstruction signs and symptoms and causes?
symptoms - vomiting, pain and distension
signs - hyperactive bowel sounds, tenderness, palpable bowel loops
common causes for small bowel obstruction - adhesions, cancer, herniae, gallstone illeus
imaging - consider abdo XR
basis of concervative tx or surgery
39
initial imaging for potential small bowel obtruction?
- initial IX is abdo XR
40
what are you looking for to identify small bowel and potentially obstruction
- valvulae conniventes are visible (smooth lines one side of bowel to other)
- loops are central - jejunum and ilium
- dilatation >2.5cm -3cm = obstruction
- paucity of gas distally
41
hallmarks of gallstone ileus on CT?
- large lamellated gallstone impacted in distal small bowel
- fistulated from gallbladder into duodenum
- gas connection between 2 structures
- gas in biliary tree and small bowel obstruction and density that lookslike a stone in RIF
42
large bowel obstruction is ..... until it is proved not?
- colorectal cancer
-> affects patients that get diverticular disease, very common
- other things could be volvulus and diverticulitis
43
large bowel obstruction symptoms
- altered bowel habit, constipation
- full bowel
- impaction
- caecum will perforate and fall apart = faecal peritonitis
44
imaging for large bowel obstruction
- XR
-> peripheral, >5cm, haustra (big bumps) - colonic distension, collapsed distal colon, rectum has little or no air - then too much gas in large bowel = think large bowel obstruction.
- CT
-> confirm dx and localise CT
45
sudden abdominal pain and shock?
- bowel ischaemia
- perforation
- pancreatitis
- leaking AAA
- ruptured ectopic pregnancy
46
causes of bowel ischaemia
- arterial occlusion - 70-80%
- venous occlusion - 5-10%
- non-occlusive hypoperfusion i.e. RTA - 20-30%
- 20% CO goes straight to your gut - straight down abdominal aorta, coeliac axis, SMA and IMA supplies large bowel
- <10% - ischaemia develops
47
signs and symptoms of bowel ischaemia
- often unsuspected
- severe abdominal pain - soft tummy so pain inproportional
- vomiting, diarrhoea, distension inconsistent
- borderline amylase, raised WCC, acidotic
broad diff
patient unwell
48
bowel ischaemia imaging of choice?
- CT - vasculature (site of occlusion), length affected vowel, alternative dx
49
CT findings of bowel ischaemia?
- lack of enhance,ent of lumen of affected vessel
- mucosal/serosal enhancement absent or increased
- altered wall thickness
- ileus/dilated loops of bowel >3cm in dm
- pnematosis intestinalis
other changes: mesenteric oedema, free fluid, intrahepatic portal venous gas: due to pneumatosis intestinalis
- intrahepatic portal venous gas: due to pneumatosis intestinalis (v bad sign - mortality)
- free intra-abdominal gas
50
leaking AAA
- pain
- hypotension
- pulsatile abdominal mass
- MALE
- PREVIOUS CV problems
- PREVIOUS ANEURYSM
51
Ix of choice for leaking AAA
- CT
- will see large distended aorta, two lumens, huge retroperitoneal haematoma
52
46 yr women, acute 48hr period of worsening generalised abdo pain
- absent bowel sounds
- pulse 120
- BP 90/70
- oxygen sats 95%
Ddx?
- shock!!!
- AAA
- perforation
- pancreatitis
- ischaemic bowel
- ruptured ectopic pregnancy ...
53
first steps in case
- ABCDE
- IX -> erect chest XR - free gas for perforation and targeted CT - but chest XR good starting point
54
amylase is v increased what is dx?
- pancreatitis
55
next steps for Acute pancreatitis what ix now?
- ultrasound (fast patient)
- looking for gallstones... then next stop cause idiopathic (alcohol) scorpion bites
56
patient increasingly unwell, tachycardic, inflam markers worse, worseing abdo pain what is going on in scan
- peripancreatic collection
- also want to look for necrosis, (vascular complications (venous thrombosis and arterial aneurysms)
57
CT bones will be?
- white
and gas always black
58
MRI bones will be?
- white or black
- fluid will be white!
59
nasojejunal tube given why?
bypass obstruction in stomach - i.e. pseudocyst
