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