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CT Findings in Acute Peritonitis A Pattern-Based A
CT Findings in Acute Peritonitis A Pattern-Based A
CT Findings in Acute Peritonitis A Pattern-Based A
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C
omputed tomography (CT) became an important tool in the detection and charac-
terization of acute abdominal involvement with the development of multidetector
CT (MDCT) scanners. This technology makes the acquisition of isotropic data possible
and affords the capability of performing high-resolution multiplanar reconstructions (1).
Thus, CT imaging is often the initial modality in acute abdomen in a significant proportion
of patients, and radiologists should have a high level of suspicion in detection and interpre-
tation of peritoneal abnormalities.
As a wide variety of acute peritoneal diseases may present with similar clinical features,
the clinicians ask the interpreting radiologist to provide a concise and focused differential
diagnosis. However, several specific entities may manifest with overlapping CT findings.
This article provides an overview of MDCT appearances of acute peritoneal diseases based
on the peritoneal thickening pattern and a detailed analysis of the associated findings.
CT pattern-approach of
peritonitis
Figure 1. a, b. A 65-year-old man with hepatitis induced liver cirrhosis, fever, and abdominal pain. Axial
contrast-enhanced MDCT image (a) and schematic drawing (b) show smooth, uniform thickening of the
Inflammatory and malignant diseases of
peritoneum (arrows) due to spontaneous bacterial peritonitis.
the peritoneum can have a similar appear-
ance. Moreover, different causes of peritoni-
tis can show similar CT findings. Therefore,
a b
a CT pattern-approach may represent a fur-
ther useful diagnostic tool for correct image
assessment.
Before describing this approach, it is im-
portant to understand that the awareness of
the patient’s clinical history and presentation
is essential for an accurate image interpreta-
Main points
• Acute peritonitis presents with nonspecific clinical Figure 2. a, b. A 34-year-old man with HIV infection. Axial contrast-enhanced MDCT image (a) and
and laboratory features. schematic drawing (b) show irregular thickening of the peritoneum (arrows) due to proven tuberculous
peritonitis.
• To date multidetector CT represents the best
imaging modality to evaluate patients with
acute abdominal pain. In this setting, radiologists
should be aware of CT findings indicative of acute a b
peritoneal diseases.
• CT pattern-approach, based on the detection of
three different patterns (smooth regular, irregular
and nodular), may represent a useful diagnostic
tool for a correct image assessment.
• Starting from patient’s clinical history, the analysis
of CT peritoneal pattern together with the
associated ancillary findings is the clue for correct
image interpretation and differential diagnosis.
• When using this approach, radiologists may
accurately differentiate benign peritoneal
diseases from malignant ones and may define the Figure 3. a, b. A 42-year-old immigrant woman from Ethiopia. Axial contrast-enhanced MDCT image
underlying pathology. (a) and schematic drawing (b) show nodular thickening of the peritoneum (arrows) due to proven
tuberculous peritonitis.
Filippone et al.
masses is common in malignancy. Accord- The intraperitoneal spread of PID can cholecystectomy era; its incidence has in-
ing to the literature, metastatic cell growth cause perihepatitis, which is an inflamma- creased up to 0.9% following the introduc-
occurs at natural sites of fluid accumulation tion with smooth thickening of the perito- tion of laparoscopic cholecystectomy (13,
(7). The lower small bowel mesentery near neal covering of the liver. In women with 14). The clinical picture is determined by
the terminal ileum is one of the natural sites PID, perihepatitis associated with right up- the amount and rate of leak of bile into the
where tumor initially deposits. Therefore, the per abdominal pain is known as Fitz–Hugh– abdominal cavity. The clinical scenario com-
terminal ileum is a critical area to evaluate Curtis syndrome (9, 10). It has been demon- bined with history and MDCT location of
when searching for evidence of peritoneal strated that hepatic capsular enhancement intraperitoneal fluid should raise the suspi-
metastases (8). Different from malignancies, implying perihepatitis can be present in cion of biliary peritonitis. Loculated fluid is
the omental involvement is uncommon in women with PID without right upper ab- often located in the projection of the cystic
acute peritonitis whereas the small bowel dominal pain (9, 11). This means that hepat- duct seat, at the hepatic hilum, and in the
mesentery can be frequently involved. ic capsular enhancement can be one of the subhepatic space. A slight smooth perito-
Several different entities characterized useful ancillary CT findings for diagnosis of neal thickening is noticeable in diffuse bil-
by diffuse and localized acute peritonitis acute PID, regardless of association with iary peritonitis.
will be discussed in the order of frequency, Fitz–Hugh–Curtis syndrome.
according to the peritoneal thickening pat- Wet type tuberculous peritonitis
tern. Spontaneous bacterial peritonitis (SBP) Wet type tuberculous peritonitis is
Spontaneous bacterial peritonitis (SBP) characterized by large amounts of free or
Smooth peritoneal pattern is a primary infectious peritonitis due to an loculated viscous fluid (15). On MDCT, a
infection of the ascitic fluid typically caused smooth peritoneal thickening with pro-
Localized peritonitis secondary to acute by Escherichia coli, Streptococcus, and Kleb- nounced enhancement suggests the
abdominal inflammatory condition siella, commonly occurring in patients with wet-type tuberculous peritonitis, when
Appendicitis, diverticulitis, or Crohn’s hepatic cirrhosis (prevalence of 8%–27%).
disease may be responsible for a localized Clinical criteria are positive culture of ascit-
peritonitis. Usually localized peritonitis is ic fluid, neutrophilic count of at least 250
characterized by a small sized fluid-like col- cells for mm3 in the ascitic fluid, and no ob-
lection surrounded by smoothly thickened vious intra-abdominal source of infection.
and enhancing peritoneum abutting the in- SBP may be caused by the combination of
volved gastrointestinal (GI) tract; these find- long-term bacteremia due to deficient de-
ings are associated with increased density fense mechanisms in the host, intrahepatic
within the adjacent mesentery. shunting, and decreased bactericidal activi-
ty that occurs in ascites (12).
Peritonitis secondary to perforation of Although the diagnosis may be based
the abdominal viscera exclusively on the clinical scenario and the Figure 4. A 69-year-old woman with sudden onset
Perforation of the GI tract frequently history of cirrhosis, the referring clinicians of abdominal distension and severe abdominal
pain, initially localized in the right inferior
leads to emergency conditions that require often request a MDCT to confirm the diag- quadrant then diffuse to the whole abdomen,
surgical management. Free fluid and air in nosis and, mainly, to exclude a malignant associated with nausea, chill, and leukocytosis.
the peritoneal cavity represent the hallmark peritoneal involvement. The key MDCT fea- Axial MDCT image shows free intraperitoneal
air (asterisks), ascites, smooth pelvic peritoneal
findings at CT. Peritoneal thickening can be tures are represented by smooth thicken- thickening (arrows), and bowel wall thickening
considered in the context of peritonitis sec- ing of peritoneum that involves the whole (open arrows) indicative of peritonitis caused by
ondary to a GI tract perforation, if present abdominal cavity, with a relative sparing of intestinal perforation.
along with extraluminal gas associated with mesenteric folds, associated with gross as-
segmental bowel wall thickening, abnormal cites (Fig. 1). Diagnosis can be confirmed by
bowel wall enhancement, perivisceral fat combining the peritoneal pattern thicken-
stranding, and free fluid (Fig. 4). ing with the clinical data.
Filippone et al.
a b
Figure 9. A 52-year-old HIV positive man with Figure 11. a, b. A 41-year-old woman with a history of long-term intrauterine device (black arrow, b)
abdominal pain, low fever, and anorexia due to and mild fever, abdominal pain, and leukocytosis due to proven pelvic actinomycosis. Axial contrast-
proven tuberculous peritonitis. Axial MDCT image enhanced MDCT images (a, b) show intra- (arrowheads, a) and extra peritoneal (open arrowheads, a)
shows irregular peritoneal thickening (arrows) masses with strong enhancement in the solid component and minimal ascites (asterisk, b).
and a smudged involvement of the omentum
(arrowheads), associated with caseous lymph
nodes (open arrowheads).
cillary findings including thickening of the tures, the radiologist has to consider tuber-
ileocecal wall, splenomegaly, and splenic culous peritonitis as an alternative diagno-
calcifications may assist in guiding diagno- sis to peritoneal carcinomatosis (5, 15).
sis in the proper clinical scenario (Fig. 9).
Abdominopelvic actinomycosis
Nodular peritoneal pattern Actinomycosis is a rare infection which
manifests with abscess formation and
Peritonitis caused by abdominal viscera dense fibrosis and involves the ileoce-
perforation induced by malignancy cal region, ovary, and fallopian tube (22).
Different from benign peritonitis, nodu- Pelvic actinomycosis is usually associated
lar peritoneal thickening is the hallmark of with a history of long-term intrauterine
peritonitis induced by GI tract perforation contraceptive device use. The common CT
due to primary or metastatic neoplastic finding is a strongly enhancing solid mass
bowel involvement with peritoneal spread. with a tendency of violating normal ana-
In fact, peritoneal carcinomatosis may be tomic boundaries. The strong contrast en-
Figure 10. A 31-year-old immigrant woman from
Ethiopia with high fever, abdominal distension due to a primary abdominal tumor, such as hancement is due to the presence of gran-
and severe abdominal pain due to proven gastric or colorectal or pancreatic or ovarian ulation tissue. Ascites is usually minimal
tuberculous peritonitis. Axial contrast-enhanced cancer (20), or an extra-abdominal tumor, or absent (22). These features may raise
MDCT image shows diffuse nodular peritoneal
(arrows) and mesenteric (asterisk) thickening.
such as breast carcinoma, melanoma, or concern for neoplastic disease which has
lung cancer (21). Usually diffuse peritone- to be considered in the differential diag-
al involvement is characterized by parietal nosis. Combining clinical history (pain, leu-
capsule, spleen, and posterior peritoneal and visceral nodular implants which cover kocytosis, long-term history of intrauterine
wall (4) (Fig. 8). Although peritoneal thick- and encase the small bowel loops, leading device) with CT findings of an infiltrative
ening and calcifications are also seen in to obstruction, and occasionally to perfo- mass showing dense contrast enhance-
pseudomyxoma peritonei, certain perito- ration. Colon adenocarcinoma can lead to ment without significant ascites, pelvic ac-
neal tumor deposits, and peritoneal me- perforation proximal to the mass. The most tinomycosis should be considered before
sothelioma, combining all CT findings with commonly involved segments to perforate planning surgery (22) (Fig. 11). Moreover,
the appropriate clinical setting (i.e., small include the sigmoid colon and the cecum tubo-ovarian abscess is usually more solid
bowel dysfunction with abdominal pain (21). On CT, identifying signs of perforation in actinomycosis than it is in PID.
and progressive loss of ultrafiltration in in the setting of irregular colonic wall thick-
patients with peritoneal dialysis) allows an ening and infiltrative pericolonic soft tissue Conclusion
early, reliable, and noninvasive diagnosis can favor the diagnosis.
of EPS (4). Assessment of peritoneal thickening pat-
“Fibrotic fixed” type tuberculous tern may help to differentiate peritonitis
“Dry” or “plastic” type tuberculous peritonitis from malignant peritoneal involvement.
peritonitis Fibrotic fixed type tuberculous peri- Indeed, smooth uniform thickening is the
Dry or plastic type tuberculous peritonitis tonitis, characterized by omental mass prevalent pattern in inflammatory involve-
is characterized by caseous nodules, fibrous formation and matted bowel loops and ment, whereas nodular pattern is common
peritoneal reaction and dense adhesions mesentery, may show a nodular peritoneal in neoplastic diseases. In case of a smooth
(15). When an irregular peritoneal thicken- thickening pattern (Fig. 10). These findings pattern, radiologists can accurately identify
ing pattern is seen, tuberculous peritonitis make the differentiation from neoplastic the underlying pathology by considering
should be considered if associated with peritoneal involvement challenging. Thus, the results along with ancillary CT findings
omental smudged pattern and enlarged this condition represents a “great mimicker.” and the clinical data. In acute peritoneal dis-
caseous lymph nodes. Moreover, other an- However, when supported by clinical fea- eases presenting with uncommon irregular
Filippone et al.