CHAPTER 25 ABDOMEN AND PELVIS Peter Harri Reviewer: Nimesh Patel ® wiles | tppncts Willams & Wikins 1Lat auton ca a FX No Ao Panes Uc FIGURE 25.1, Anatomy of the Peritoneal Cavity. A. Diagram of an axial cross section ofthe abdomen illustrates the recesses ofthe greater peritoneal cavity andthe lesser sac. B. CT scan of a patient with a large amount of ascites nicely demonstrates the recesses ofthe greater peritoneal cavity and the lesser sac. The lesser sac is bounded by the stomach (St) anteriorly, the pancreas (P) posteriorly, and the sgastrosplenic ligament (curved arrow) laterally. The falciform ligament (arrowhead) separates the sight and left subphrenic spaces. ld from the greater peritoneal cavity extends into Morison pouch (arrow) between the liver and the right kidney, Fluid in the gastrohepaticreces (asterisk) separates the stomach from the liver (L).S, spleens GB, gallbladder; RK, right kidneys IVC, inferior vena cava; Ao, aorta; LK, Jefe kidney 1 The peritoneal cavity is dived imo greater and lesser pentoncal cavities 18 ‘The upper portion of che greater peritoneal cavity contains the tght and lef subphrenic spaces, which ae divided bythe falevorm ligament 1 The right snbpirenc space connect to Morrison's pouch (right hepatoreal fos), the most dependent portion ofthe abdominal cavity na supine person, Iealso felyconnests with the righ patacolic guter 18 Thelefsubphrenie space can celet Fd huts dived fom the lef paracolic guter bythe phreicosoic ligament @ Wokterskiwer | ippncote Willams & Wikinsi ‘Wangusr Le sutprene } Grenier stomach = | ex. FIGURE 25.2, The Lesser Sac. Sagital plane diagrams of the medial (A) and lateral (B) aspects of the lesser sc illustrate its postion posterior to the stomach and anterior tothe posterior parietal peritoneum covering the pancreas, Note that projections ofthe lesser sac extend tothe diaphragm, resulting in the potential for disease processes in the lesser sae to cause pleural effusions, The coronary ligaments reflect [between the liver and the diaphragm producing a bare area of liver not covered by peritoneum; FLV, fissure ofthe ligamentum venosum, 1H The lesser sac i the bolted peritoneal comparsment baween the tomach and dhe pancreas. Normally iis collapsed bur can become filled with fd 1 Ir isformed bythe gastrohepatie and epatoduodenal iments aneroey which are suspended from the stomach and the duodenal bulb fom the inferior surface ofthe liver and the posterior paveal peritoneum and Fetroperitoncim posteroey 1 Gommanication between the lser sac and the greater sae occur through the foramen of Winslow it Patholosic poceses inthe lesser sac usually occur because of disease in adjacent organs pancreas, stomach) rather than spread from elsewhere inthe abdominal cavity @ Wokterskiwer | ippncote Willams & WikinsPoona! pce TT Prtonea spece TT Pesaran pronin | | Poteet } | jl | Anterior pararenal space: potent ‘aso FIGURE 25.3. Retroperitoncal Compartmental Anatomy. Diagrams illustrate ewo normal variations of the reflections ofthe posterior parietal peritoneum around the descending colon, In (A) the colon is entirely retroperitoneal and in (B) the peritoneum forms a deep pocket lateral to the colon, allowing intraperitoneal fluid to extend far posteriorly. Fluid or disease processes inthe anterior paratenal space from the panereas of colon may also extend posteriorly o the kidney by separating the two layers ofthe posterior renal fascia. 18 "The eropeitoncal space has an anterior pararenal, perirenal, and posterior pararenal space formed bythe antcior and posterior renal fscia Ta) Te enteric pare pecs bctrcs the pots parcel pester wd tetera fascia Te lateral boundary is che aterocoal fascia 18 The pertenal space is formed by the anterior and posterior renal fascia containing the kidney, adrenal land and perineal fat 1 The pomerior renal fascia is made up of rwo layers The anterior layer connects the anterior renal fascia, and the posterior Iyer connects to the lateroconal fascia, Pathologic fli from the anterior pararenal space cam separate these ayes 18 The posterior pararenal space deep to she posterior renal fascia @ Wokterskiwer | ippncote Willams & Wikins‘Oboes FIGURE 25.4, Compartmental Anatomy of the Pelvis. Diagram inthe coronal plane illutraes the omic compartments ofthe pelvis, 1 The pelvis i divided ino these major anatomic compartments: the peritoneal avy, exrapesitoneal pace, and perineum 1 The peritoneal cavity extends ro che level ofthe vagina, forming the pouch of Douglas cul-de-sac) in females or to the level ofthe seminal vesicles, forming the rectovsical pouch in males 12 Theextraperconel space of the pelvis i continuous with the etoperitoneal space ofthe abdomen, extends 0 the pelvic dhaphragm, and inciaes the retropubic space (oF Ress) 12 The perineal Below the pelvic diaphragm @ Wokterskiwer | ippncote Willams & WikinsFIGURE 25.5. Pouch of Douglas. A CT of the pelvis in a woman with abundant ascites demonstrates fluid distension of the pouch of Douglas (PD) (cul-de-sac) posterior tothe uterus (U) and anterior ro the rectum (curved arrow). The broad ligament (long arrows) i outlined by Aud anteriorly and posteriorly. 1B The cade (pouch of Douglas) x the moxt dependent portion ofthe peritoneal cavity and colle Mid, blood, abscess, and intraperitoneal drop metastases 18 Thebroad ligaments reflect over the utero, fallopian tubes, and parameral urine vessels and serve asthe anterior boundary of the ectouteine pouch of Douglas @ Wokterskiwer | ippncote Willams & Wikins 6FIGURE 25.6, Perineal Tumor, A CT scan of a 12-year-old gil witha history of a chabdomyosarcs ‘of the right leg demonstrates a tumor metastasis (7) inthe right ischiorectal fossa. The let ischiorectal fossa (IRF) shows is normal appearance asa triangle of fa bordered by the rectum (R), obturator internus (ON muscle, and the gluteus muscles (GM). The ischioretal fosa is entirely below the levator ani and is par of the perineum. c tip of the eoceyxs IT, ischial ruherosiies, 1B Thesachiorecal fossa is normaly a triangle of fat bordered by the ect, obturator ier, andthe gluteus muscles '= The achiorectal fore is entirely below the levator ani and is pare ofthe perineum @ Wokterskiwer | ippncote Willams & WikinsFIGURE 25.7. Pscudomyxoma Peritonci. A CT scan of a 60-year-old man with intraperitoneal spread of ‘mucinous adenocarcinoma of the colon shows loculations (arrowheads) of Hud indenting the surface of the liver (L}, giving evidence of mas effect. The attenuation of the fluid measured 32H, indicating exudative ascites. 1 Pseadomyxom pertone eles vo gelatinous ascites that occurs as a result of intaperitoneal spread of mucin prodcing cells. This can occur because of rupture of appendiceal macocel, intraperitoneal spread of benign or Iocinows cyt ofthe ovary oF mucinous adenocarcinoma ofthe colon or rectum 1= Conventional adiographs may demonstrate punctate or ring-like calcifications scattered through the peritoneal cavity CCT demonsrates mottled densities, septation, and alcations within the Mid US demonstrate inrapeitonesl nodules that range from hypoechoic to strongly echogenic, The mucinous Buide ‘ypialylculated and causes mass effect onthe liver and bowel @ Wolters kiuwer | ippincote Willams & Wilkins 8K al é = Z | FGURE258, Faeamopeitoncum: Conventional Radiograph. A Supine sbdomina! radiograph of patient witha peforted gastre uler demonstrates visualization of both sides of the bowel wal (Rie Sipe (orowbend) fear outlining the farm ligament aro fe i unig the edge of he Iver (ave aro, and fe ai outing the price gtr arte), Erect ches eaiogaph of & different patient shows a crescent-shaped band of gas (arrow) beeween the liver (L) and the diaphragm. Paeumoperitoneum was caused by a perforated sigmoid colon diverticulitis 18 Free sr within the peritoneal cavity an be due to howel perforation, trauma, resent srger; and infection of he peritoneal caiey with gas-producing organisms 1 Uprieht ches radiographs ate the mos sensive fr fre ait Small amounts of air are slearly demonstrated beneath the domes of the diapheage, 1 Lofeateral dacubius and crosstable lateral views may be used with ver il paints to demonstrate ar outing the liver 18 Signs of pacumopertoncum on supine radiograph include gas om bot sides ofthe bowel wall (Ril sge gas touting te flciorm ligament, gas outining ce peritoneal cavity (the “fovbal sgn”), and ciangularor linear localized extaluminal gas inthe right upper quadrant £@ woters Kluwer | tppincote Wiliams & Wilkins 9FIGURE 25.9. Pneumoperitoneum: CT. A collection of air (arrow) is seen within the peritoneal space ‘between the liver (L) and the diaphragm (arrorohead). Ths isa prime area to search to detect small amounts of fre intraperitoneal air on CT. This patient had a fotn jejunum asa result of trauma from a ‘motor vehicle collision, 1 On Gi, small amounts of extraluminal gas maybe confused with gas within the bowel and ean be serpsingly dltfcule eo recognize 1 Images should be examined a lng windows to detest re intraperitoneal air 18 The peritoneal ress beswcen the liver and the diaphragm s 2 pood place to look for paeumopertonsum on CT @. Wolters kiuwer| Lippincott Williams & Wilkins 10FIGURE 25.10. Abdominal Aortic Aneurysm. Conventional radiograph demonstrates an aneurysm of the abdominal aorta evidenced by wide separation of califications inthe aortic wall (arrowheads) Calcification inthe wall overlying the spine may be difficult co visualize. A radiograph taken with the patient in left posterior oblique postion wil projec the aorta away from the spine and make Visualization of aortic wal calcifications easier 1B Aneurysms ofthe aorta canbe detected on conventional adiograps when the aortic walls ate caleed and the luminal damter exceeds 3cm at measured between cakicatons in the atic wall because the ata lie over the pin. A radiograph inthe lee posterior oblique pesition will allow for easier detection ofthe aortic sleet @ Wokterskiwer | ippncote Willams & Wikins M1FIGURE 25.11. Porcelain Gallbladder. Cone-down radiograph of he right upper quadrant ofthe abdomen demonstrates calcification inthe wall of the gallbladder (arrow). Tis finding is indicative of chronic obstruction ofthe eystc duct, chronic gallbladder inflammation, and an inereased risk of gallbladder carcinoma 1 Porcelain gallbladder is when plagueike and oval calcifications Form nthe gallbladder wall conforming ro the sie asd shape tthe galled 1 Porcelain gallbladder is indicative of chronic obstruction ofthe cystic dct, chronic galllader inflammation, and an incensed risk of gallbladder carcinoma £@ woters Kluwer | tppincote Wiliams & Wilkins 12FIGURE 25.12. Staghorn Calculus. Conventional radiograph reveal a large calculus occupying the collecting system of the left kidney and assuming its shape. Staghoen calculi (S) are usually composed of Struvite and form inthe presence of chronic urinary infection 1 About 85% of urinary calcul ae visible on conventional radogeaphs. They cange i sie fom punctate wp 10 several centimeters 1 Sraphorm cal assume the shape ofthe renal ollecting system 1 They are usally composed of struvite and form in the presence of chronic urinary infection @ Wokterskiwer | ippncote Willams & Wikins 13FIGURE 25.13, Bladder Calcul, Numerous calculi (arrows in the bladder ae evident om this conventional radiograph of the pelvis. The large prostate (R, between arrowheads), responsible For ‘rinary stasis leading €o stone formation, makes & mass impression on the layering stones. Also evident are atherosclerotic cakifications in the iliac arteies (curved arrows) 1 Blader calcul are single or male commonly laminated may be any ss, and usually he nest he midline of the pels 1 aleal within bladder diverticula may be eccentric ro the bladder [lade ale can be formed by urinary stasis, hich can be dae to prose hypertrophy @ Wokterskiwer | ippncote Willams & Wikins 14FIGURE 25.14, Adrenal Calcifications. Conventional radiograph of the abdomen in a 4-year-old demonstrates cakification of both adrenal glands (arrors) resulting from bilateral adrenal hemorrhage a5 an infant. 1 Galatia adrenal glands ae associned with adrenal hemorrhage in the newborn, suberculoss, and Addison dea 18 The calcification is mote and inthe locaton of the adrenal glands on either side ofthe fs umbarvertebea @ Wokterskiwer | ippncote Willams & Wikins 15é ah FIGURE 25.15. Pancreatic Caleifictions. Coarse and punctate eaifications (arrow) extend upward across the left upper quadrant in this patient with chronic alcoholic pancreatitis. Calcifications in the pancreatic head (arrowhead) are obscured by the spine. 1 Pancreatic calication is asocated with chronic alot induced pancreas and hereditary pancreatitis 18 The calcifications are due to pancreatic calcul and are usally coarse and of varying size @ Wokterskiwer | ippncote Willams & Wikins 16FIGURE 25.16, Cakified Renal Cyst, Conventional radiograph shows the rim caeification (arrow) characteristic of wall calcification in a renal est. lid eas may he Fou in she Kids, spleen, lives append wall of ysis curvilinear oe ring-shaped 1B Echinococcus cysts commonly cay and may be found in any intra-abdominal organ aswell as within the peroneal exit {nd the peritoneal avy. Calefsation in he @ Wokterskiwer | ippncote Willams & Wikins 7FIGURE 25.17. Tumoral Caleiiations. Radiograph of the abdomen demonstrates cloudlike caleifications in the distribution of peritoneal recesses. These caleicaions were caused by intraperitoneal spread of a papillary serous eystadenocarcinomas ofthe ovary ‘A wide vary of diferent tumors of abdominal opgans may contain caliations ‘The coarse "popcom” clcfcations of werineIiomyomas ate most characteristic Benign cpt teratoma may form teeth or bone Calcif peritoneal metastases of ovarian or colon mucinous cystadenocarcinoma may outline the peritoneal cavity and may appeae cloud-tke Renal ell arenoma calies np t0 25% of cases @ Wokterskiwer | ippncote Willams & Wikins 18‘COMMON CAUSES OF ACUTE ABDOMEN, Appendicitis Peritonitis Acute cholecystitis Intraperitoneal abscess Acute pancreatitis Retroperitoneal abscess Acute diverticulitis Bowel obstruction Acute uleeratve colitis Urinary eract infection Pseudomembranous colitis Urinary tact obstruction Amebiasis Pelvic inflammatory diseases Acute intestinal ischemia _-Tuboovarian absces There ate many eases for an acute abdomen 18 These include inflammation of GI tract organs. append, gallbladder, pancreas, colonic divriclum), infecionsabscesses, bowel obstruction, bowel ichemia,peritonts, urinary tact infectons andor obstroctions, sd female genta ifotons 18 Routine assessment of the acute abdomen commonly includes she “acute abdomen seis,” which consis of an «rect posterior-anterior cest radiograph and supine and erect or decubitus eadiogaphs ofthe abdomen I Thc chest mcg poids opin tection of cemopsHonsin wad tthe ioasa ta any present with abdominal complains "© The supine abdominal film permits agnosis of many acute abdominal conditions, and the horizontal eam abdominal film add confidence tothe dagnosis 1@ Cor US is routinely obtained ro provide a definitive diagnosis £@ woters Kluwer | tppincote Wiliams & Wilkins 19ae FIGURE 25.18, Normal Bowel Gas Patten. Supine radiograph shows the normal distribution of gas in the stomach (large arrow) and the duodenum (small arrow). The normal mottled pattern of stool is seen in the distribution of the right colon arrowhead). A few gas collections within small bowel curved arrow) are seen in the pelvis. 1 ie-flidlevels are een in normal pants, commonly in the stomach, often in the small bowel, but neve inthe Colon distal othe hepatic Nexuce, Normal acu level inthe small bowel should not exoed 2.5 ein length 1 Small bowel gas usally appears as multiple smal, andom gas collections steed throughout the abomen 1A normal intestinal gas pattern varies rom no intestinal gas to ga within treet our variably shaped small intestinal loops measuring 2.5 ro 3 em in diameter 18 Complete absence of gs inthe smal bowel may be seen in patens with bowel obstruction with Mid rather than sirfling the dilated bowel loops {= The ncemal colon contains some gat and fecal material and varies in diamete fram 3 to em, with the cecum having the largest diameter £@ woters Kluwer | tppincote Wiliams & Wilkins 20COMMON CAUSES OF ADYNAMIC ILEUS. Drugs Atropine, glucagon, morphine, barbiturates, phenothiazines “Metabolic causes Diabetes mellitus, hypothyroidism, hypokalemia, hypercalcemia Inflammation Intraluminal: gastroenteritis Extraluminal: peritonitis, pancreatitis, appendicitis, cholecystitis, abscess Postoperative: resolves in 4-7 days Postrauma Postspinal injury 1B Adynamic ews eypically demonstrates diffe symmetis,predominandy gaseous, distension of bowel. The sal bowel, stomach, and elon are proportionally iste withowt an abrup transition, More bowel lonp are eat than with obstruction '© Occasionally, dynamic ileus may result ina gases abdomen with dilated loops of bowel that ae filled only with fad 1m US is usefl in conieing deceased or absent peristalsis, although examination maybe difculifTarge amounts oF gas are present £@ weterskiuwer | tippincote Wiliams & Wilkins aaFIGURE 25.19. Sentinel Loop. Daily serial radiographs ofthis patient demonstrated a persistent loop of dilated small howel arrow) sn the same location, This sentinel loop was caused by acute pancreatitis, ‘Normal gos pattern is present inthe right colon (arrotwhead). The abdomen is otherwise devoid of inestnal 1 Sentinel loop refers toa segment of intestine that becomes prayed and dilated as ies nex oa inflamed intra-abdominal organ. Issa short segment ofadynamic Hes that appeats san iolted Toop of distended intestine that remains in the same general poston on serial images '= A sentinel lop alerts one tothe presence af an adjacent inflammatory process 2A sein! lop in the sight upper quadrant suggests acute cholecytcs, hepatitis, or pyelonephritis A sein! lop in the lef upper quadrant, pancreatitis, pyelonephritis, or splenic injury may be suspected 1 Inthe lower quadrant, a sentinel loop suggests diverticulitis appendicitis, salpingitis, cystitis or Cohn ease a the cause ofa sentinel lop, @ Wokterskiwe | ippncote Willams & Wikins 22CAUSES OFTOHC NEGACOION Uleerative colts: 75% of eases _Amebie colitis Pseudomembranous cliis Ischemic olitis Crohn colitis Bacterial colitis: cholera, typhoid Tronic megacolon periali i absent andthe large bowel loc all one and conracliy “The paent has progessive abdominal disesion and is toxic, fbi, and obtunded Bowel sounds and bowel movements are absent The bowel yall bears like “wet blatng pap 20% in toxic megacolon and te kof pestorsion i extreme Mortality epprectes £@ weterskiuwer | tippincote Wiliams & Wilkins 23FIGURE 25.20. Toxic Megacolon. A. Supine radiograph of the abdomen demonstrates marked dilation ‘ofthe colon with the cecum measuring 14 em (fed lin) and che descending colon measuring 7 em (white line) in diameter. The mucosal patern of the lower descending colon i strikingly nodular (arrowhead) B, Corresponding CT showed marked thickening of the wall ofthe colon. Toxic megacolon was related to lovrative colitis, The colon perforated just prior to surgery. 1B Toxic megacolon sa manifestation of fulminant colitis characterized hy extreme dilation of allo a portion of the colon with high peoraion risk 18 Conveaionl eadiogrphs demonstrate distesion of che colon without hausta. Dilation ofthe transverse colon lupo 15cm diameters ofen the most striking dng I Tie dengan Suggs wn heres oc tok extents Sextus! te mateo opps beer 1 Peeudopotyp (islands of edematous mucosa surrounded by extensive ulceration) appear as soft sae nodules within the air-dstended clon 1= CT demonserates a distended colon fled wih air and id. The wall of he colon s thin bat hasan iceglae nodular contour si may be sen within dhe colon wall 12 ariam enema is absolutely contraingicaed because of risk of perforation @. Wolters kiuwer| Lippincott Williams & Wilkins 24FIGURE 25.21. Fournier Gangrene. CT shows prominent pockets of gas (arrows) inthe subeutancous tissues ofthe perineum and the scrotum characteristic ofthis condition. 1B Fournier gangrene is necrotizing fasctis f the perineum, perianal nd genial regions 1 Polymirobialonganims exe rapid tse destruction 12 Radiographs and CT show bubbles and steaks of gas in affected soft sues @ Woters ume Lipineot Wiliams & Wns 25BER SEESEESESEEIESEEEESESIEEEEEEEESESISASUEEEIESEEEEEELE SESS UEEEEESESSEEIEE EEL SISieTESESESSEEIE LEA EEE CCAUSES OF SMALL BOWEL OBSTRUCTION Adhesions Postural Postinlsmmacory Incarcerated hernia ‘Malignancy wsualy metastatic Tnxussuseption Volvulus Galltone ites Parasites: Ascaris Foreign body “Tumors ofthe small bowel Crohn disease Radiation enteritis ‘all bowel abstraction account for 80% of linkin] act obsrcton 1 Inthe Western word, poutsurical adhesions account for 75% of small bowel obstruction, whereas in developing nations, 80% of sal bowel obseracion i caused by incarcerated hernia, but only 10% caused by adhesions 1 anents present cimeally with crampy abdominal pain, abdominal dienton, and vomiting £@ weterskiuwer | tippincote Wiliams & Wilkins 26FIGURE 25.22. Small Bowel Obstruction—Conventional Radiograph, Erect radiograph of the abdomen, reveals dilated ainfilled loops of small bowel containing airflid levels at different heights within the same loop (arrows). Note the valvulae conniventes (arrowhead) that extend across the entie diameter of the bowel lamen, The small bowel obstruction was duc to adhesions lings of sll bowel obstroton on conventional radiography ae 1 Dilated loops of smal bosel (23cm) dsproporionae to more distal smal bowel or colon Small howe! ait-iid levels chat exceed 25 rm in wih Aisi levels at fering heights (25 mm) within che same loop (“dynamic ait-Pid evls) (stong evidence of obstuction) Two or more aie-fuidlevels Small bubbles of pa rapped been folds in dilated led loops prodcing the “tring of peal in, a row of sal gas bubbles oreaed horizontally or obliquely across the abdomen 1 Seepladder or haizpin loops of small Bowe are most characteristic @ Wokterskiwer | ippncote Willams & Wikins 27FIGURE 25.23. Small Bowel Obstruction—CT. Coronal plane-reconstructed CT demonstrates abrupt transition (arrow) betvreen dilated and nondilated small bowel in this patient with radiation enteritis causing small bowel obstruction. The small howel feces sign (arrowhead) is als evident. 12 CT diagnosis ofa smal bowel obstruction is based upon demonstration ofa ransicon site between small bowel loops diated with Bud or sr and ollapsed bowel lope distal to the obstroction '= A potential pial sche common finding ofa collapsed descending colon even in patients with adynamic es [Bowel obseiction should not be diagnosed in thi sting unss an obstructing lesion is visualized tthe splenic flere 12 The “small-bowel feces sign ie strong CT evidence of howe obstruction, Particulate fecuent mate mixed with fs bubbles cen within lated smal bowel 1 Abvups beak-likeaaeowing, without othr lesion evident, is indicative of adesions a the cause of obstruction. Other causes, including tumor abscess, inflammation, hernia and intussusception have characteristic dings @ Wokterskiwer | ippncote Willams & Wikins 28FIGURE 25.24. Enteroenteric Intussusception. CT shows small howel obstruction with dilated proximal small howel extending to an area of jejuno-jejunal intussusception (arrows). The lead point proved to be metastatic lesion from malignant melanoma to small bowel 1 Incssusception ia major cause of small bowel abstraction in children burs es common in aul. tn adult, intussusception i often chronic, inzermiten, or subacite, ands usally eased y «polypoid tumor 1 Conventional eadiographs demonstrate sal howel obstruction and a sof tsue mass 18 Barium studies demonstrate barium tapped between the inusssceprum and the receiving bowel forming a coiled pring appearance © CT is usually diagnostic, demonstrating character targe-lke intestinal mass. On tanaverse section, the ier central density ste invaginating loop surrounded by fadensity mesentery that is enveloped by the receiving loop | 1m US exhibits simile “donut” configuration of atenating hyperechoic and hypoechoic ings eepesensing aleemaing mucosa, muscular wall, and mesenteric fat Hssues in cross section @ Wokterskiwer | ippncote Willams & Wikins 29FIGURE 25.25. Transient Intussusception. CT in an asympcomatic patient studied for other reasons shows a short-segment enteroenterc intussusception (ay7ows) without proximal small bowel dilatation. 1B Anympeomatc indents, shore segment (<3. cml jejunal or eal small bowel obstruction sa common and incienral finding on CT ansen intusuecpton without avoid @wokerskuwer| tppincre Willams & Wikins 30CAUSES OF LARGE BOWEL DILATATION Obstruction Colon carcinoma (50%-60%) Metastatic disease, eoeily peli malignancies Diverticulitis ‘Volvulus: cecal, sigmoid, transverse Fecal impaction Amebiasis Ogilvie syndrome Adymamic ileus “Toxic megacolon 1 Lage bowel obstrection s predominantly a condition of older adults asounting for about 20% ofa bowel bbstruction. The cecum dats wo che greatest extent, iespactive ofthe sit of large bowel abstraction. When the cecum exceeds 10 min diameter isa high risk for pesforaton with artendant risk of pertnitis and septic shock 18 Thecommon auss of large bowel dilatation and obstruction ae divide into obstructive and pseudo-obstuctive categories, Most colonic obsractions our inthe ioid colon whee the bowel lumen isnartower and stools tore formed 1 Conventional adiographs ae commonly dignostc in age bowel obstruction, demonstrating dilation of the on from te cecum tothe point of abstraction The colon dial tthe ostaction i devoid of gas 1 When the ieocecal valve x competent, the stall bowel usually contains litle gas; the eolon ie unable to decompress into the small bowel and gaseous distension of the cecum is progressive 1B When the sence vale is incompetent, gassous distension ofthe small howe s presen the colon can decompress into the eu and jejunum, and sk of perforation ofthe eccum i reduced 1B Aili levels distal wo the hepatic lexure are stong evidence of obstruction unes he patent has had an £@ woters Kluwer | tppincote Wiliams & Wilkins aaFIGURE 25.26, Sigmoid Volvulus. Radiograph of the abdomen demonstrates the characteristic massive dilation of the sigmoid colon (S) arising from the pelvis and extending tothe left diaphragm. The three lines representing the walls ofthe twisted loop converging to the left lower quadrant are evident (1, 2,3) '= On conventional radiographs a sigmoid volvulus appears 28 a lege gas filed loop without haustel markings, arising fom the peli and extending high ino the abdomen and often co the diaphragm. The apex ofthe Aistended sigmoid colon may extend cephalad vo che transverse colon ("aoebern exposure sgn) eosimal olonic dilatation s presen in haf ofthe eases 12 Bria enema demonstrates obstruction chat pers to a beak a he point of the swist, usally approximately 15 cm above the anal verge: Mucosal folds spiral into dhe beak a the point of obstruction 18 CT shows an inverted, dilated, U-shaped sigmoid colon, absence of gas inthe rectum, transition zones between tilted and collapsed bowel oscue a the pon of tistng, oblige ies crested bythe orenaton ofthe teansicon zones erate the “maths she Spot sgn” appreciated on sequential images, and a single beak-shaped, teanscon point corresponding to the beak sign sen on bariam enema 12 sigmoid volvulsiclosedloop obsracton; the bow! i prone to ichemia and perforation, ns of which tue be eareflly sought @ Wokterskiwer | ippncote Willams & Wikins 32.FIGURE 25.27. Cecal Volvulus. Supine abdominal radiograph demonstrates displacement ofthe dilated cecim (C) tothe epigastrium, The more distal colon is collapsed. The diagnosis was confirmed at surgery. 1H Gesl volvulus is closed Toop obseaction that may esl ia Schema, necrosis, and perforation. Thee typeof cecal volvuls ae described 1 Cassie radiographic findings are coffee bean-shaped loop of gas-distended bowel having hawstral markings directed toward the lle upper quadrant, apex af the cecum in the lef upper quadeant, cecal distension >10 cm ia ‘lamete, and collapse ofthe distal colon, Proximal small owe dilatation mayor may not be present 18 GT findings inl cecum inthe wpper mid and lef shomen vlvulsin the right lower quadrant seen 3829 area of siting ofthe howel and mesenteric ft ("whi sgn”); appends is displaced othe let upper quadrant ‘wo transition point are presen, one fr the entering oop and one forthe exiting lop, when the loops ae Completely wound around each oer an “s-marks the spot” sign is pesen formed by the crosing configuration ofthe wanstion zones; cecum is distended more than 10cm; and (7 distal large bowel is decompessed 12 A contrat enema demonstrates beaks o°fld-tiketerminacion athe poi of abstraction inthe ascending ‘lon @ Wokterskiwer | ippncote Willams & Wikins 33FIGURE 25.28. PneumatosisIntstinalis. A. Digital radiograph scout san from CT reveals pneumatosis ofthe colon as dar linear sreaks of air arrowheads) in the colon wal. Both small and large bowels are ‘markedly dilated. B. CT image of the same patient viewed with lung windows confirms the presence of air in the colon wal (arrowheads). The small bowel (SB) is dilated, At surgery, both small and large bowels were infracted. The patient expired 1 Preumatois intestinalis refers tothe presence of gas within the bowel wall 1m Ie may occur a a benign ent without clinical sguicance or may be an important Badin of bowel ischemia. Ke ia radiographic sign, nots dvcase 18 Causes of preumatonsnesinals maybe lumped int fur extegris bowel necrosis; macosl disrepion cauted by tlcers, enucosal biopsies, eauma, enteric eubes, oe iflantnatory bowel dieses increased rascosal permeabiliy related co immunosuppression in AIDS, organ transplantation, or chemotherapy: and pulmonary ‘incase resulting in alveolar disrapton and disetion of ai along itera pathways to dhe bowl wal 1m Paeumatosis appears on radiographs or CT a si ir bubbles (ew millimeters to several centimeters) oe line streaks of air within the owel wall especially in its most graviy-dependent aspect. On CT, at bubbles within the lamen may mimic pacumatosis but should always be seen adjacent to the nondependene bowel wall. Ar may tlko be evident within mesenteric vss or within poral ein in the liver @ Wokterskiwer | ippncote Willams & Wikins 34FIGURE 25.29. Hemoperitoncum and Sentinel Clot. CT scan shows high-attenuation fluid in the peritoneal recesses indicating hemoperitoncum (H). A sentinel clot (arrow) stands out as a high- attenuation collection within the lowerattenuation liquid blood. The location of the clot suggests injury tothe liver(L). A laceration ofthe left lobe ofthe liver, nor evident on the CT, was found at surgery. 1B CT findings of taumatic injury include hemopertoneum, which i acute Blood within the peritoneal eviy f= Hemoperitoneu measures 30 to 4S Houndsteld units (2) 1© A sentinel clots a focal collection of clotted blood (measuring >60 H) that may be seen inthe peritoneal cavity adjacent an injured organ fA sensna lor sands out a high attenuation collection within the lowerattenuation liquid blood @ Wokterskiwer | ippncote Willams & Wikins 35FIGURE 25.30. Active Hemorthage—Liver Laceration. CT’ shows a jagged laceration (arrowheads) of the liver (L) filled with Blood. A focus of continuing active hemorrhage (arrow) is sen as an ill defined collection of high-attenuation contrast agent. Hemoperitoneum (H) i evident in the peritoneal recesses. Sp, spleens St, stomach, 1 GT findings of taumatc injury include active Meeding, a evidenced by extavasated contrast (measuring 85 10.370 seen during ater phase of scanning vith MDCT 1 A focus of continuing active hemorrhage is cen san illdcind collection ofhigh-atenation contrast agent @ Wokterskiwer | ippncote Willams & Wikins 36oe A FIGURE 25.31. Renal Infarction. Postcontrast CT reveals a lack of enhancement (arrow) ofthe posterior portion ofthe lft kidney (LK), which occurted asa result ofan intimal rear and thrombosis of a branch renal artery occurring during a motor vehicle collision. Note that the defect in enhancement extends to the capsule of the kidney indicating acute renal vascular injury 1B CT findings of waumatic injury include infarctions, which ate seen as zones of deceased contas enhancement thaceatend wo the capsule ofa solid organ 1 Soli organ infarctions ae dve a inerraption of vascular supply and are typically wedge-shaped with ‘extension the organ capsule @ Wokterskiwer | ippncote Willams & Wikins 37FIGURE 25.32. Hodgkin Lymphoma. CT shows bulky confluent adenopathy (arrows) in the ‘etropertoneum surrounding the aorta (Ao) and displacing the inferior vena cava (IVC) anteriorly ‘Masses of lymphoma (arrowbead) are also present inthe spleen. 1 CT optimized vo detect adenopathy inclads contrast opacification of blood veel and the Gl tract 1 Most pathologicaly enlarged nodes have CT densities slighty ls han skeletal muscle, Low-density nodal imetastaes ae commonly sen ith nonseminomatous textcular carcinoma eubercloss and occasionally Iymphioma 18 On ultrasound, lymphoma typically produces hypoechoic or even anechoic lymphadenopathy. Masses of retroperitoneal nodes may silhoere segment ofthe normally echogenic wall of he aorta (he "sanographi sihovette sgn”) 12 ‘The “sandwich sign” refers o entrapment of mesenteric vessels by masses of enlarged lymph node inthe 1 MR usually provides excellent dflerntaion of Ip nodes from blood vessels because of low void within ‘essls, However, loops of bowel are commonly confused with masses of nodes. On TIWI, lymph nodes show Tew signal intensity compared o surrounding ft. On T2WI, ymph nodes show high signal ineensty compared £0 ‘muscle, Fataturstion technique highlights pathologic adenopathy on T2W1 @ Wokterskiwer | ippncote Willams & Wikins 38ier ‘ABDOMINAL AND PELVIS LYMPHADENOPATHY: UPPER LMITS OF NORMAL NODE SIZE BY tSeation = MAXIMUM SNODELOCATION "DIMENSION (mm) _" COMMENTS Rerrocrural é "May enlarge from dicase above or below the diaphragm Retopertoneal 0 ‘Muliple nodes 810 min in ize are sally abnoemal Gastohepatie 8 ‘Must diferente lymphadenopathy from Tigament coronary varices Porta hepatis 6 ‘May cause biliary obsrvtion Celiac and Superior 0 ‘Also called preaortic nodes mesenteric artery Pancresticoduodenal 0 Comnonly involved by ymphioma and Glearinoma Peraplene 0 Tnvolved by ymphoma and GI Mesenteric it Tn the small bowel mesemery Pelvic 15 ‘Most commonly involved by pelvic tumors 1 None ofthe coerssionl imaging methods can denonsvate amor vabement of ayaph node by aration of intemal agchteture 18 Criteria for pathologic involvement are based primarily on alterations in node size. Short axis measurements of Iymiph node ize are peleeed to determine abaoemal enlargement 1H Morphologic patens of pathologic lymphadenopathy inlade singe enlarged nodes, multiple separate lobulated nlatge nodes, o blk conglomerate mass of lymph nodes 1 Caifcatioa in enlarged nodes may be een with inflammatory adenopathy, mucinous carcinomas, ercomas and tated Iymphoma 1 Normal node are oblong in shape and homogencousin configuration £@ woters Kluwer | tppincote Wiliams & Wilkins 39FIGURE 25.33. Peritoneal Metastases. A CT scan demonstrates intraperitoneal spread of ovarian carcinoma, The rumor i implanted on the omentum (arrows), causing the appearance of "omental cake™ fsthe thickened omentum floats in ascites (A) between howel loops and the abdominal wall. Nodules of tumor (arrowhead) are implanted on the peritoneal surface. 1 Peritoneal metastases are most commonly asocated with ovatian, colon, stomach, or pancreas carcinoma 1 The preferenal tes for tumor implantation ace the pelvic cul-de-sac ight paracolic gute and the greater 18 CT demonstrates tumor nodules on peritoneal surfaces; “omental cake,” which displaces bowel aay fom the nti abdominal wall rumor node inthe mesentery hikening ad nodular ofthe howe wall die 0 Serosal implants; and ascites shat is commonly located 18 US may diecy visualize the peritoneal rumors and demonstrates scondary signs of malignant acts including chovgni debris in thes pation, and mated howel lop @ Wokterskiwer | ippncote Willams & Wikins 40FIGURE 2534. Liposarcoma. CT shows a large liposarcoma (arrows) that arose inthe retroperitoneum asa mottled fatsdesity mass that distorts the inferior vena cava (IVC), surrounds the aorta (Ao) and displaces small and large bowel (8) laterally. oneal metastases can ave mas effet that digo: the inferior vena cava, sarod the aorta and diplace sal and large bowel @ Wokterskiwer | ippncote Willams & Wikins aFIGURE 25.35. Extramedullary Hematopocsis, CT without contrast shows a slightly high-attenaation left paraspinal mass (arrow) and a smaller right paraspinal mass (arrowhead). Cardiomegaly is eviden The patient also had massive hepatosplenomegaly. Extramedullary hematopoesis was induced by sickle call disease 1 Extramedullary hematopoiesis occurs when the pray sites of hematopoiesis in dhe bone mazrow fall as a result of myelobron or when hemolytic anemias overwhelm blood cell production (ey sickle cell discase and thalasemia) 1= The most obvious manifestations are homogeneous well amarginated paraspinal masses that favor the thoracic spine. They are bilterayslaively symmetric and enhance mid, and enhance homogeneously 1 Diffs nelnement of the liver and the spleen may cause masive hepatoxplenemefaly without affecting organ function Wm Icrarely causes apre-saceal mass mimicking achordoma. @ Wokterskiwer | ippncote Willams & Wikins 42FIGURE 25.36, Retroperitoneal Fibrosis. Coronal plane-reconstructed CT performed without IV contrast shows poorly marginated sof tissue (arows) encasing the distal aorta and common iliac vessels The right ureter was enveloped and obstructed by the fibrosing process. A ureteral stent (arrowhead) isin place. The left kidney is absent. 1B Retroperitoneal fibrosis isa rae condition manifs by formation of fibrous plague inthe lower retroperitoneum that encases and compresses the aorta inferior Yena cava, and ureters 1 Causes ate ichopathie, methysergide, small metastatic os, inflammatory aneurysms, tubercsloiy yphils, actinomyjes, and fang 12 ‘Thehallmark of retroperitoneal bros is smooth exerinsc narrowing of one or bh ureters inthe region of LA-L5, Proximal hydronephrosis sults fom impaizment of ureteral peristalsis. The proces may extend int the evs and cause a eardcop configuration tothe bladder and narrowing ofthe sigtoi colon 1G demonserate a lous plague that envelope the vena cava, the aorta, and offen the ureters: The plague may be midline or asymmetric, wall-defined or poly defined, and localized or expansive 18 On MR, the plaques typaly of low signal intensity on both TIWI and T2WI. Plaque that shows high signal intensity on T2WI should be considered suspicious for malignancy a5 cause, lchough early edematous plagues tay have the ue appearance '§ 00 retroperitoneal oss appears as confluent hypocchoic masses encasing the [VC and he aore without nts diplacement ofthe vee unbkelympoms @ Wokterskiwer | ippncote Willams & Wikins 43FIGURE 25.37. Retained Surgical Sponge. A. Digital radiograph ofthe abdomen taken at bedside reveals the characteristic radiopaque tape (arrow) that marks a surgical sponge inadvertently lft within the abdominal cavity. Metalic cutaneous staples identify the patient as having had recent surgery, B. CT seveals the difficulty of identifying the surgical sponge ifthe radiopaque marker (arrow) was not present. The sponge (between arrowheads) contains fluid, blood, and air bubbles producing a pattern very similar to stool inthe colon. The descending colon (curved arrow} is displaced medially. 1 Foreign bodies may be ingested or inserted, ener the abdomen or the pelvis as result of penetrating trauma, or be lef hehind at surgery. Recognition smportan a avoid complications, which incade hemorrhage, abscess formation, septicemia, bowel perforation o obstruction, or embolization '& Many ozlly ingested foreign bodies ae radiopaque. Large or elongated poiated objects may impinge at fexures ‘enarrowed ares ofthe Gi tact sch a the pylori, daojejunaletion, ences valve, or appendix 1 Button batteries contain highly vie substance that can erode or perforate the bowel or cause heavy metal poisoning 18 Wooden foreign bodes are unl nt visualized on conventional radiographs. CT shows high atensation ofthe wooden object US demonstrates high echogenicity with acoustic shadowing '& Retained surgical sponges (gossypiboma) may be asymptomatic cause an abscess, or generate a granalomatous response nding Ronis and calcfeaton. Sponges are usally detestable esate ofan incorporated tape ike forserng like radiopaque marker CT shows mass of sft ese density, fequently containing air bubbles, @ Wokterskiwer | ippncote Willams & Wikins 44FIGURE 25.38, Abscess, CT reveals an abscess arrows) in the retroperitoneum, The abscess contains fluid and gas (arrowhead). Nore the discrete enhancing wall of the abscess. Duodenum (D) containing, intraluminal gas displaced anteriorly and is draped over the collection, In Alsceses eos beats of spillage of contaminated material from perforated howel or as aeomplicaton of surgery trauma, pancreatitis, sepsis, or AIDS. The pelvis isthe most common site for abscess formation '& Radiographic findings inlode sot sue mas, colleton of extaluminal gas, displacement of bowel localized oF sencalived ile, clewation ofthe diaphragm, peurleffosion, and selects or consolation a the ng bases ‘focal collection ofexraluminal gas isthe mos specifi sgn of abscess but x uncomaion '= Cr shows a located ud collection, often with internal debris and fid-Aidleves, The wall ofthe Mud collection are offen thik and ireglar Gas within the tid eollecton is strong evidence of abe. Fascia Adjacent wo the abscess thickened, and fat surrounding the abscess maybe increased in desiy and contain soft tine strand because of inflammation 18 US demonstrates focal uid collection often containing echogenic Hid, oning debris, and sepeations However, completely anechoic uid collections may also be infected. A thickened walls usually evident Gas ‘thin he fi collection i evidenced by echogenic foi proding coma or reverberation arifts @ Woters ume Lipineot Wiliams & Wns 45FIGURE 25.39. Incarcerated Inguinal Hemia. In a patient with acute right pelvic pain, 2 sagittal plane reconstructed CT shows a loop of small bowel (arrow) extending into the inguinal canal (beeween arrowheads). The howel contained within the heria is swollen and edematous with thickened bowel walls, signs of incarceration that were confirmed at surgery 18 hernia ofthe abdominal walls a protrason of bowel omentum, or mesentery through a dees inthe wall of the adomen othe pls A Incarceration refers o hernias that are not redcible Strangulation refers to hernias associated ith bowel bstrcton and bovtl ischemia 12 Ricter hemi entrap only a portion ofthe bowel wal without compromising viability 1 Indirect inguinal hernias extend through the internal inguinal ring ina the inguinal canal aterl to the inferior epinanrc vessel 1 Direct inguinal herias occur media othe infrioe epigastric vessels drscly into the inguinal weakness nits floor 1 Incisonal hemi are complications of sunpey with herniation through the surgical inion 1m Parascomal hernias occur in association with surgically created stomas canal through a @ Wokterskiwer | ippncote Willams & Wikins 46ZBDORINAL AGING FININGS &¥ AS Adeooahy ‘eran cated pada ace yp bye — ll warp dopa oer hn prs ce of MDS tyaphodeo cm same ARI KS, ACT NA ehtome ett ia ens he HC MA one een dut AR Sy ora sce ‘Mace (tem dso Akl Spur cro, meta acne Mc ac a, Cay op iro ‘elas hoi dco CM Capon ‘ibs hla rne sng hand CAN, ‘Crypt ane pee ae oma doce ingnemen rcs fon ese Sten Seneca dc AL, and poral ypeenson al entne>2'om dain PC ATR AL calle to da Coa oom AS, MAL MT ack Gite rns et Gnd icin CM MTB ‘atid ned to CN, Cnptrprden, NT MA (Chl amea "ion bl, rp, Clara 1, MA clit CC "EC peace do CM Tapa pn ypc mor nu Cond dag ay lrg ron wt arin a a dito oe partic EB die cA Copan, pero a Eco ‘eae y KS ARL paypal ne i reac ae MA i Co Vago ID patna re cop oy sles spon Hema inde wal ining do CMY Co “Shooter aes i es Eat ited Sam eameain epi ine one Diep aon nes iy alunos Re aes es a AE No er me FN pe Be HE re ital ten Porapak Bharat 1B AIDS the abdomen is characterized by multiple coexisting diseases with mulicontic involvement, Up 10 90% of patients with AIDS develop com plains related to the Gl oe hepatobiliary systems © Genizourinary tract dca affects 38% to 68% of patients with AIDS @ Wokterskiwe | ippncote Willams & Wikins Manifestations of infectious and neoplastic processes in patients wih AIDS are effecively demonstrated by abdominal imaging techniques (CT and US are the most useful modalities fo evaluating te solid visceral organs, adenopathy, and the peritoneal cavity 47