1. 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

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

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

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

6. 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 )

8. LUQ pain

9. LUQ pain
Peptic ulcer disease
Splenic infarct
LLL pneumonia

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

13. RLQ pain

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

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

16. 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 %

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

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

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

31. Rt side diverticulitis

32. Uretric stone

33. LLQ pain

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

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

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

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

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

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

47. Left uretric stone

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

49. Diagnostic imaging
US is the primary imaging modality

50. Midepigastric pain

51. Midepigastric pain PUD Acute pancreatitis Aortic dissection
Aortic aneurysm rupture

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

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

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

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

57. CT diagnosis of AAA rupture
Retroperitoneal hematoma
Contrast extravasation

59. Abdominal aortic dissection
CT is the modality of choice

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

62. 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

63. Thank you