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

OR GAZ

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

PNEUMOPERITONEUM

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 ?

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

UPRIGHT CHEST

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

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

ACUTE ABDOMINAL PAIN UPRIGHT AP CHEST & LEFT LATERAL DECUB NEGATIVE

PNEUMOPERITONEUM SUPINE RADIOGRAPHS

GAS BUBBLE ON LIVER SURFACE

FREE AIR CENTRAL TENDON

FREE AIR CENTRAL TENDON

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

MASSIVE PNEUMOPERITONEUM FOOTBALL SIGN

FALCIFORM LIGAMENT GAS BUBBLE OVER LIVER

FALCIFORM LIGAMENT

PNEUMOPERITONEUM SUBHEPATIC GAS BUBBLE

DIVERTICULITIS PNEUMOPERITONEUM

ANTERIOR ABDOMINAL WALL ANATOMIC FOLDS

FREE AIR INFERIOR EPIGASTRIC VESSELS (LATERAL UMBILICAL LIGAMENTS)

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

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

PSEUDO-PNEUMOPERITONEUM

CENTRAL TENDON GAS YES, BUT JUST THE STOMACH

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

SUBDIAPHRAGMATIC FAT SIMULATING FREE AIR

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

GAS IN SUBPHRENIC ABSCESS SIMULATES FREE AIR

RETROPERITONEAL GAS SIMULATES FREE AIR

RETROPERITONEAL GAS

RETROPERITONEAL GAS IMAGING 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

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

RETROPERITONEAL GAS IMAGING 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

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

RETROPERITONEAL GAS EXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT

ABDOMINAL PAIN 4 HOURS AFTER COLONOSCOPY AND BIOPSY EXTENSIVE RETROPERITONEAL GAS

BAROTRAUMA MEDIASTINUM – RETROPERITONEUM – FREE AIR

RETROPERITONEAL GAS CAUSES 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

BOWEL WALL GAS

PNEUMATOSIS OF COLON INFANT ADULT NECROTIZING ENTEROCOLITIS ISCHEMIC COLITIS

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

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

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

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

ASYMPTOMATIC 40-YEAR-OLD MAN BENIGN STEADY STATE PNEUMATOSIS

ISCHEMIC BOWEL

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

ACUTE ONSET OF ABDOMINAL PAIN SMA EMBOLIS

ISCHEMIC COLITIS IN TWO PATIENTS

ISCHEMIC SB AND COLON THICKENED MUCOSAL FOLDS

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

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

ISCHEMIC COLITIS

ISCHEMIC SMALL BOWEL ETIOLOGY ? SMV CLOT

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

BILE DUCT GAS

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

BILE DUCT GAS BILE DUCT GAS CHUNKY AND CENTRAL

59-YEAR-OLD MAN HISTORY OF DUODENAL ULCER

BILE DUCT GAS AND SBO

SBO GALLSTONE ILEUS

GALLSTONE ILEUS

GALLSTONE ILEUS

GALLSTONE ILEUS BILE DUCT GAS, SBO, STONE

GALLSTONE ILEUS

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

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

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

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

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

GALLBLADDER COLON FISTULA

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

GALLBLADDER GAS

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

EMPHYSEMATOUS CHOLECYSTITIS

EMPHYSEMATOUS CHOLECYSTITIS

EMPHYSEMATOUS CHOLECYSTITIS 38 Emph Chole

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

2 WEEKS POST HEART TRANSPLANT FEVER AND ABDOMINAL PAIN PREOPERATIVE RADIOGRAPH

PORTAL VEIN GAS

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

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

36-YEAR-OLD MAN MULTIPLE CONGENITAL ANOMALIES FEVER , WBC 17 36-YEAR-OLD MAN MULTIPLE CONGENITAL ANOMALIES FEVER , WBC 17.8, 15 BANDS ISCHEMIA OF SB AND STOMACH

ISCHEMIC BOWEL MESENTERIC VEIN GAS

ABSCESS

ABSCESS 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

APPENDICEAL ABSCESS RETROCECAL APPENDIX ABNORMAL GAS… UNCHANGED ON MULTIPLE VIEWS

SIGMOID DIVERTICULITIS GAS FILLED “DIVERTICULUM

GIANT ABSCESS 2 WEEKS AFTER ANEURYSM SURGERY

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

SUBPHRENIC ABSCESS

FEVER 10 DAYS AFTER ABDOMINAL SURGERY

CROHN’S DISEASE WITH ABSCESS

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

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

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

PERITONITIS THICKENED, ENHANCING PERITONEUM

PANCREATIC ABSCESS

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

PANCREATITIS WITH ABSCESS LESSER SAC ABSCESS GAS IN PANCREATIC ABSCESS

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

LESSER SAC

LESSER SAC

GASTRIC ULCER PERFORATION INTO LESSER SAC

GALLBLADDER IN LESSER SAC

GAS IN LESSER SAC PERFORATED GASTRIC ULCER

CULTURE HISTORY OF RADIOLOGY

INTERMITTENT ABDOMINAL PAIN FOR 3 WEEKS TAKING NSAIDS FOR 2 MONTHS

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