A site specific approach to radiologic diagnosis Abdominal pain A site specific approach to radiologic diagnosis Dr. Ahmed Refaey MBBCh, MS, FRCR Consultant Radiologist Department of Radiology Riyadh Militry Hospital

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

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

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

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

LUQ pain

LUQ pain Peptic ulcer disease Splenic infarct LLL pneumonia

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

RLQ pain

RLQ pain Acute appendicitis Mesenteric adenitis Diverticulitis Urinary tract calculi Gynacologic disease

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

CT findings in acute appendicitis Dilated appendix ( > 6 mm ) Non filling of the appendix with contrast Peri-appendiceal inflammatory changes Increased enhancement of the wall Appendicolith Accuracy of CT is 94-98 %

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

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

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

Rt side diverticulitis

Uretric stone

LLQ pain

LLQ pain Divericulitis Epiploic appendagitis Perforated colon cancer Urinary tract calculi Gynacologic disease

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

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

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

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

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

Left uretric stone

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

Diagnostic imaging US is the primary imaging modality

Midepigastric pain

Midepigastric pain PUD Acute pancreatitis Aortic dissection Aortic aneurysm rupture

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

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

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

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

CT diagnosis of AAA rupture Retroperitoneal hematoma Contrast extravasation

Abdominal aortic dissection CT is the modality of choice

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

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

Thank you