ª Springer Science+Business Media New York 2015 Abdom Radiol (2016) 41:136–148
Abdominal Published online: 22 December 2015
Radiology
Multimodality approach for imaging of non-
traumatic acute abdominal emergencies
Kiran Gangadhar,1 Ania Kielar,2 Manjiri K. Dighe,1 Ryan O’Malley,1 Carolyn Wang,1
Joel A. Gross,1 Malak Itani,1 Neeraj Lalwani 1
1
Department of Radiology, University of Washington, Seattle, WA 98105, USA
2
Department of Radiology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
Abstract
‘‘Acute abdomen’’ includes spectrum of medical and
surgical conditions ranging from a less severe to life-
threatening conditions in a patient presenting with severe
abdominal pain that develops over a period of hours.
Accurate and rapid diagnosis of these conditions helps in
reducing related complications. Clinical assessment is
often difficult due to availability of over-the-counter
analgesics, leading to less specific physical findings. The
key clinical decision is to determine whether surgical
intervention is required. Laboratory and conventional
radiographic findings are often non-specific. Thus, cross-
sectional imaging plays a pivotal role for helping direct
management of acute abdomen. Computed tomography
is the primary imaging modality used for these cases due
to fast image acquisition, although US is more specific
for conditions such as acute cholecystitis. Magnetic res-
onance imaging or ultrasound is very helpful in patients
who are particularly sensitive to radiation exposure, such
as pregnant women and pediatric patients. In addition,
MRI is an excellent problem-solving modality in certain
conditions such as assessment for choledocholithiasis in
patients with right upper quadrant pain. In this review,
we discuss a multimodality approach for the usual causes
of non-traumatic acute abdomen including acute
appendicitis, diverticulitis, cholecystitis, and small bowel
obstruction. A brief review of other relatively less fre-
quent but important causes of acute abdomen, such as
perforated viscus and bowel ischemia, is also included.
CME activity This article has been selected as the CME activity for the
current month. Please visit https://ce.mayo.edu/node/6816 and follow
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Correspondence to: Neeraj Lalwani; email: neerajl@uw.edu
DOI: 10.1007/s00261-015-0586-6
Key words: Acute abdomen—ACR appropriateness
criteria—Acute appendicitis—Diverticulitis—
Cholecystitis—Small bowel obstruction—Imaging—
MRI—CT—Ultrasound
Of all patients who present to the emergency depart-
ment (ED), 4–5% of the patients are symptomatic for
acute abdominal pain [1]. There is a wide spectrum of
medical and surgical conditions that can present with
acute abdominal pain. The clinical outcome depends on
a variety of factors based on the diagnosis, severity of
the disease, and management. Abdominal pain can be
categorized as visceral, somatoparietal, or referred pain.
These types of pain can be a manifestation of a wide
spectrum of systemic and local causes. Acute appen-
dicitis, diverticulitis, cholecystitis, and bowel obstruc-
tion are ‘the usual suspects’ of acute abdominal pain.
Other important but less frequent conditions that may
cause acute abdominal pain include perforated viscus
and bowel ischemia. One of the key decisions is to
determine whether surgical intervention is necessary.
Imaging plays a major role in diagnosing these condi-
tions as well as identifying associated complications.
Imaging is also necessary for follow-up of complications
such as abscesses and in some cases image to guide
interventions. Abdominal radiographs are the most
common initial imaging modality of choice to grossly
rule out pneumoperitoneum and give an overview of the
degree of bowel wall distension and in some cases, the
presence of bowel wall thickening. US and CT have
traditionally been the most commonly used cross-sec-
tional imaging modalities for evaluating acute abdomi-
nal conditions. The high cost, limited availability, long
examination duration, and increased frequency of arti-
facts have been major limitations of MRI use in emer-
gency settings.
K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies
Imaging modalities to evaluate acute
abdominal emergencies and ACR
appropriateness recommendations
Plain radiograph
The imaging workup of patients with acute abdominal
pain often starts with radiographs including, supine and
upright abdominal radiographs, and upright chest radio-
graph [2–4]. A left lateral decubitus may replace the up-
right abdomen if the patient is severely ill and cannot be
positioned upright. The ACR appropriateness criteria rate
abdominal radiographs as a 5 out of 9, below CT and
ultrasound, though they provide a caveat of utility to as-
sess for bowel perforation. Over-utilization of radio-
graphic investigations causes significant financial wastage
to both patients and the health care provider [5–7]. A few
studies in the literature have concluded that a small bowel
obstruction (SBO) can be diagnosed with equal sensitivity
on a supine abdominal radiograph alone and routine use
of the erect abdominal radiograph in the acute abdomen
should be abandoned [8] because bowel loops are more or
less at their anatomical position. However, it remains
controversial and most institutions still obtain the upright
radiograph. A lateral chest radiograph has also been rec-
ommended by Woodring et al. to achieve a higher diag-
nostic accuracy in detecting free intraperitoneal air than
with a posterior-anterior chest radiograph [9].
Some studies have advocated plain abdominal radio-
graphs for investigation of acute abdominal pain when
related to suspected intestinal obstruction, urinary tract
calculi, or a perforated viscus [10]. However, other studies
[11] have concluded that the clinical diagnosis after evalu-
ation of plain radiographs did not change significantly
from the primary diagnosis based on clinical evaluation
alone, except in the case of bowel obstruction [11]. In a
prospective study Boleslawski et al. [12], only 6% of cases
resulted in a change in the suspected diagnosis or thera-
peutic management based on plain radiograph appear-
ances in patients presenting with right lower quadrant pain.
Ultrasound
US is inexpensive, widely available, and one of the com-
mon initial modalities of choice for evaluation of
abdominal pain in the ED. The lack of ionizing radiation
and real-time imaging are the most important advantages
of US. Another important advantage of US examination is
the possibility to correlate the US findings with the pa-
tient’s point of maximal tenderness. The most common US
technique used in patients with acute abdominal pain is the
graded-compression ultrasound technique helping to dis-
place bowel loops to achieve better images [13]. Identifi-
cation of a non-compressible bowel loop in itself is an
indication of abnormalities including appendicitis, intus-
susception, malignancy, or luminal distension resulting
137
from obstruction. Another example of dynamic exami-
nation is the evaluation of bowel hernias using Valsalva
maneuvers. This maneuver may reveal an intermittent
hernia [14]. US is also useful in evaluating transient
intussusception because of its real-time capabilities [15].
Sonography is the imaging modality of choice to
evaluate hepatobiliary pathologies and has been assigned
an ACR appropriateness score of 9/10 in patients with
RUQ pain [16]. It is a useful modality for image-guided
procedures such as abscess drainage and cholecys-
tostomy tube placement, as well as biopsy guidance.
Additionally, ultrasound is also useful in evaluating
pelvic organs, gynecological, and renal pathologies [17].
The major disadvantages of ultrasound are operator
dependence, including inter-observer variability, and
lack of tissue penetration in obese patients.
In a study by Lameris et al., using sonography as the
primary imaging modality, regardless of the body mass in-
dex, age, or location of pain, followed by CT only in cases of
negative or indeterminate sonographic findings, resulted in
the highest sensitivity for acute abdominal and pelvic con-
ditions while reducing exposure to ionizing radiation [18].
CT
The utility of CT in the diagnosis and management of
acute abdominal emergencies is well established. CT
provides greater accuracy than ultrasonography or plain
radiography for identifying pneumoperitoneum, as well
as evaluation of bowel pathology, retroperitoneal and
bony abnormalities. It has high sensitivity and specificity
for evaluating most common emergent pathologies such
as acute appendicitis and diverticulitis. Traditionally, the
typically described protocol for evaluating an acute ab-
domen was to administer both positive oral and IV
contrast media and scan using a standard radiation dose
CT technique. However, using oral contrast slows down
patient throughput and may negatively impact patient
management in the case of a surgical abdomen. More-
over, the presence of oral contrast helps radiologists in
some aspects but it has not been shown to increase
accuracy [19]. Overall, use of oral contrast should be
discouraged in the evaluation of acute abdomen [20, 21].
CT is the most often used imaging modality in pa-
tients with right lower quadrant (RLQ) pain with ACR
appropriates score of 8/10 (usually appropriate) for CT
abdomen and pelvis with IV contrast and 7/10 (usually
appropriate) for CT abdomen and pelvis without IV
contrast [22]. IV contrast and modified (increased) rate
of contrast administration may be necessary for evalu-
ating acute vascular conditions like hemorrhage, bowel
ischemia, renal infarct etc.
The major disadvantages of CT are exposure to radi-
ation and contrast media as well as being far more
expensive than ultrasound. There are new strategies to
reduce radiation exposure which include the use of itera-
138 K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies
tive reconstruction algorithms such as ‘iDose,’ ‘100%
ASIR’ (adaptive statistical iterative reconstruction), and
‘IRIS’ (iterative reconstruction in image space). The 100%
ASIR algorithm has been demonstrated to reduce noise
by 47% while a newer algorithm called Veo (General
Electric Healthcare, Milwaukee, Wisconsin, USA) de-
creases the image noise up to 70% when compared with
the gold standard filtered back projection model [23].
MRI
MRI may be on the way to becoming a potential alterna-
tive for the evaluation of acute abdominopelvic pain. Re-
cent advances in MRI have allowed the development of
rapid imaging sequences that are particularly suited for ED
indications [24]. There are special circumstances wherein
MRI is currently indicated [25]. For example, in pregnant
patients who have symptoms of appendicitis, MRI has
proven to have high sensitivity and specificity [26]. MRI
also can be used to evaluate equivocal CT findings in pa-
tients with hepatobiliary pathologies, particularly MRCP
for choledocholithiasis and to monitor previously diag-
nosed acute gastrointestinal disease, especially in young
patients, in whom radiation exposure is of concern [27].
MR imaging has also demonstrated utility in detection of
acute inflammatory diseases of the pancreas, kidneys,
collecting system, bowel, and pelvic soft tissues [28].
Basic MR imaging protocols for emergent evaluation
of the abdomen and pelvis include the following se-
quences: axial breath-hold in-phase and out-of-phase T1-
weighted GRE, axial and coronal breath-hold T2-
weighted single-shot turbo SE, axial T2-weighted fat-
suppressed turbo SE with respiratory triggering (or short
inversion time inversion recovery), and steady-state free
precession. Thick-slab MRCP, respiratory-triggered T2-
weighted turbo SE, and volumetric T1-weighted post-
contrast sequences are added as necessitated by the
clinical indication and with consideration of patient’s
ability to tolerate breath-hold acquisitions. Of note,
gadolinium is considered a class C medication in preg-
nancy and is therefore only used in circumstances where
maternal and fetal health would be in jeopardy and there
is no other suitable imaging alternatives available (26).
The duration of the MR imaging examination is typically
20–30 min, still substantially longer than CT.
The disadvantages of MRI in emergent settings in-
clude the relatively longer acquisition times, limited
availability, the presence of artifacts and to some degree,
the high cost.
In patients with RUQ pain without fever and with a
normal white count showing only gallstones on ultra-
sound, the ACR appropriateness criteria rating for use of
MRI is only 6/10 (may be appropriate) [16]. In patients
with RLQ pain with fever and with high white count as
well as in pregnant women, the ACR appropriateness
criteria rating is 7/10 (usually appropriate) [22].
Acute appendicitis
Appendicitis is the most common acute abdominal
emergency requiring surgery in both adults and pediatric
populations with an incidence of about 250,000 cases
reported in the United States each year [29]. The diag-
nosis depends mainly on clinical presentation; however,
nearly half of the patients have negative or atypical
clinical presentation [30].
There is a correlation between duration of symptoms
and risk of perforation of appendicitis. An overall per-
foration rate of 16–39% has been reported in the litera-
ture [31] which can lead to several potentially life-
threatening complications such as intrabdominal abscess,
peritonitis, and sepsis [32].
The false-negative appendectomy rates range from
13% to 30% when imaging is not used but has been as
high as 15–47% in female patients aged 10–39 years [33].
The important clinical symptoms include tenderness
at Mcburney’s point, migratory abdominal pain, and
fever. Physical examination demonstrates non-specific
positive signs of appendicitis, such as rebound tender-
ness, Rovsing’s, obturator, and psoas sign. An increase
in the C-reactive protein (CRP) correlates with the
severity of the disease and is a possible surrogate
parameter for perforation. Leukocytosis is more sensitive
for the detection of early-stage appendicitis [34].
Imaging algorithm varies depending on patient’s
demography and institutional policies. In general, ultra-
sound remains modality of choice for screening purpose,
when radiation exposure remains a concern (pregnant or
pediatric patient). MR can be performed next to ultra-
sound if non-diagnostic. Otherwise, CT is a widely ac-
cepted modality of choice to evaluate appendicitis in
general population.
Graded compression technique is used in sonographic
evaluation of right lower quadrant pain. US may
demonstrate an enlarged, non-compressible appendix,
more than 6 mm in diameter. Other ancillary findings
include the presence of an appendicolith, a fluid-filled
appendix, pericecal fluid, inflammation of surrounding
fat, and the presence of a frank abscess.
Pertinent imaging findings on CT are in many re-
spects similar to sonographic findings and may include;
increased transverse diameter of the appendix >6 mm,
increased thickness of the appendiceal wall >2 mm,
appendiceal wall hyperenhancement, the presence or
absence of a focal defect in the appendiceal wall, the
presence of an appendicolith/fecalith, periappendiceal
changes, cecal wall thickening, and right lower quadrant
free fluid (Fig. 1A). The presence of oral contrast and
intraluminar continuous column of air are negative
findings for appendicitis [35]. The CT findings of focal
defects in the appendicular wall, periappendicular ab-
scess, larger appendicular diameter (>15 mm), terminal
ileal thickening, ileus and extraluminal free air or extra-
K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies 139

Fig. 1. A Coronal CECT of the abdomen and pelvis showing ment and periappendiceal inflammatory changes (asterix); B
increased transverse diameter of the appendix (double ar- Extraluminal air along with features of inflammation consistent
rows), increased mural thickness and mural hyperenhance- with perforated appendicitis.

luminal appendicolith are helpful in differentiating early

perforated appendicitis from non-perforated appendicitis
(Fig. 1B). The presence of extraluminal gas, abscess, and
ileus were more specific for perforation. A transverse
diameter of the appendix greater than 11 mm has the
highest sensitivity (62.7%) while a focal wall defect has
the highest specificity (98.8%) [36]. Although sonography
is recommended in young patients as the first imaging
modality, some studies also advocate low dose CT for
appendicitis in young patients after equivocal findings on
ultrasound [37].
MR imaging is indicated in pregnant patients with
symptoms of RLQ pain. MR imaging has high reported
sensitivity (97–100%) and specificity (92–93%) for the
diagnosis of acute appendicitis during pregnancy [38]. T2
turbo spin-echo sequences are particularly helpful for
identifying the location of the appendix. Edema and
inflammation appear as T2 signal hyperintensity within Fig. 2. Coronal T2w fat-suppressed MR image through right
the wall or surrounding the appendix; fat-suppressed lower quadrant shows dilated appendix (arrow). There is in-
single-shot sequences are useful for depicting these fea- creased T2w signal intensity surrounding the appendix (arrow
tures (Fig. 2). Post-contrast MR sequences may be heads) suggestive of inflammation; (Fetus: f).
helpful in diagnosing appendicitis in children by
increasing the tissue contrast [39]. short axis in the right lower quadrant or pericecal region
Differential diagnosis for acute appendicitis may in- [41]. Terminal ileitis represents inflammation of terminal
clude mucocele, mesenteric adenitis, and terminal ileitis ileum due to variegated etiologies, which could be an
(Fig. 3). Mucocele is defined as dilated appendix inflammatory bowel disease or infections.
(>1.3 cm) with intraluminal accumulation of abnormal
mucus. Symptoms for complicated mucoceles can mimic Acute diverticulitis
those of acute appendicitis [40]. Underlying cause of a
mucocele could be a neoplasm (benign or malignant) and Diverticulosis occurs in 5–10% of people >45 years old
it may be associated with a superimposed appendicitis. and the condition progressively increases in incidence
Mural calcification can be seen. Mesenteric adenitis is a with advancing age. It has been reported to be found in
self-limiting inflammatory process involving mesenteric up to 80 % of people >85 years old. Acute diverticulitis
lymph nodes. On imaging, it can be diagnosed by finding is inflammation of the colonic diverticulum which could
three or more lymph nodes measuring at least 5 mm in be uncomplicated (localized inflammation) or compli-
140 K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies

Fig. 3. Differential diagnosis for acute appendicitis. A Cor- sistent with mucocele; C Thickening and mucosal enhance-
onal CECT of the abdomen and pelvis showing mesenteric ment in the terminal ileum consistent with terminal ileitis
lymphadenitis (circle); B Axial CT showing dilated appendix (double arrows).
with low attenuation intraluminal content (double arrow) con-

cated (associated with an abscess, phlegmon, fistula, The presence of free air, abscess formation, and a
obstruction, bleeding, or perforation). ‘‘target pattern’’ of contrast enhancement on CT have all
Patients often present with acute left lower quadrant been proposed to support the diagnosis of diverticulitis
pain and tenderness on clinical examination. Other pos- but with low specificity [47]. A differential diagnosis to
sible symptoms include anorexia, constipation, nausea, consider includes a locally advanced perforated colonic
diarrhea, and dysuria. Tachycardia and hypotension may cancer (Table 2) (Fig. 4).
occur and should raise suspicion for complicated diver- Buckelyet al. [48] reported that it is easier to differentiate
ticulitis [42]. diverticulitis from cancer on MRI than CT due to the fact
Using a graded compression technique, ultrasound that MRI exhibits better contrast resolution which helps in
images of diverticulitis include thickening of the wall of appreciating thickened inflamed bowel and features typical
the colon, which is surrounded by hyperechoic inflam-
matory fat with probe tenderness. Sometimes an in- Table 2. Differentiating diverticulitis and colonic cancer
flamed diverticulum can be visible with intraluminal
Features Diverticultis Sigmoid cancer
coproliths. Abscess and developing phlegmon can also be
visible on US which helps image-guided procedures [43]. Focal thickening with Usually negative Usually positive
Contrast-enhanced CT (CECT) depicts early stages of abrupt transition
between normal
diverticulitis and has become the optimal method for colon and thickened
evaluation of diverticular disease in the emergency set- colon
ting, with reported accuracy of 80–100% using helical Presence of free air Usually positive Usually negative(mass
could perforate)
CECT [44]. Acute diverticulitis is graded by using mod- Abscess Usually positive Usually negative
ified Hinchey classification [45] and the corresponding Specific target pattern Positive Usually negative
radiological findings are listed in Table 1 as described by of enhancement
Presence of diverticula Usually seen May not be seen
Kaiser et al. [46].

Table 1. Hinchey classification for acute diverticulitis

Modified Hinchey Severity Accompanying CT findings
classification

Stage 0 Clinically mild diverticulitis Diverticula with or without wall thickening of the colon
Stage Ia Confined pericolic inflammation and Colonic wall thickening and surrounding
phlegmonous inflammation inflammatory changes
Stage Ib Abscess formation (<5 cm) in the proximity of the Alterations as stage Ia + pericolic or mesocolic
primary inflammatory process abscess formation
Stage II Intra-abdominal abscess, pelvic or retroperitoneal Alteration as stage Ia + distant abscess formation
abscess, abscess distant from the (mostly pelvic or interloop abscesses)
primary inflammatory process
Stage III Generalized purulent peritonitis Free air with local or generalized free fluid and possible
thickening of the peritoneum
Stage IV Fecal peritonitis Similar findings to stage III
K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies
Fig. 4. A Colonic cancer: Axial CECT of the abdomen and
pelvis showing circumferential mural thickening (double ar-
rows) compromising the lumen (arrow head). See the peri-
colonic inflammation (asterix) is much lesser than the mural
thickening. B Diverticulitis: Axial CECT of the abdomen and
Fig. 5. Differential diagnosis for diverticulitis. A Axial CECT
of the abdomen and pelvis showing inflamed well circum-
scribed rounded lesion (circle) next to sigmoid colon (arrow
head) showing an enhancing ‘‘central dot’’(arrow) consistent
for cancer as focal thickening with abrupt transition be-
tween normal colon and thickened colon. Another study by
Oistamo et al. also suggested the usefulness of MRI to im-
prove the differentiation between sigmoid cancer and
diverticulitis [49], however, larger studies are needed to
establish the clinical utility of MRI in these issues.
Differential diagnosis for diverticulitis may include
epiploeic appendangitis and mesenteric infarction
(Fig. 5). Epiploeic appendangitis is usually seen in the
left lower quadrant or flank in adult population and
measures less than 5 cm. On imaging, they appear as
141
pelvis showing eccentric colonic wall thickening (double ar-
rows) and surrounding inflammatory changes (asterix) with a
focus of extraluminal air (curved arrow) representing localized
perforation. Note the lumen is patent despite overlying thick-
ening (arrow head) numerous engorged peri-colonic vessels.
with epiploic appendangitis; B Axial CECT of the abdomen
and pelvis showing focal area of fat stranding (circle) and
hyperdense peripheral halo consistent with mesenteric
infarction.
well-circumscribed fatty lesion with a ‘‘central dot’’
(which represents partially thrombosis vessel). Mesen-
teric infarcts usually involve right lower quadrant or
flank (because of meager blood supply at the periphery
of right mesentery) measures more than 5 cm.
Acute small bowel obstruction
SBO is either mechanical or functional and precludes
normal transit of its contents. It represents 20% of all
surgical admissions for acute abdominal pain [50]. Pa-
142 K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies
tients present with abdominal pain, distension, nausea,
and vomiting. On clinical examination, mild to moderate
dehydration, tachycardia, abdominal distension which is
tympanic to percussion, and high-pitched bowel sounds
are identified [51].
70% of all mechanical SBO are due to postoperative
adhesions [52]. Other common causes of mechanical SBO
include hernias, neoplasms, and inflammatory bowel dis-
ease. The important clinical decision is whether emergent
laparotomy is required or if a conservative approach is
sufficient [53]: imaging helps in making these decisions.
Useful radiographic signs include a distended stomach
and bowel loops (>3 cm), multiple differential air–fluid
levels, a ‘step ladder’ pattern of dilated bowel loops, a
‘String-of-beads’ sign corresponding to air bubbles trapped
in valvulae conniventes, the ‘stretch sign’ or ‘slit sign’ in
which a slit of air is caught in a valvulae, the absence of or
disproportionately smaller amount of gas in the recto-sig-
moid and increased small bowel to colon ratio. In partic-
ular, two findings derived from the upright abdominal
radiograph were found to be the most significant and most
predictive of the higher grades of small bowel obstruction:
the presence of differential air–fluid levels (>3 in number
and air-fluid levels of >1 cm height) and a mean width of
air–fluid levels measuring greater than or equal to 25 mm
[54]. Other findings suggesting strangulation or ischemia
include pneumatosis and portal venous gas.
Fluoroscopic small bowel follow-through examina-
tions have a limited role in diagnosing the cause of SBO
but may be useful in determining the severity of
obstruction [55]. The role of water-soluble high osmolar
iodine agents has been assessed recently with regard to
both diagnostic and therapeutic; proposed mechanisms
are high osmolality (approximately six times more than
extracellular fluid), which promotes shifting of fluids into
the bowel lumen and increases the pressure gradient
across obstructive sites and also facilitating its passage by
reducing edema of the intestine wall.
Fig. 6. Axial CECT of the abdomen and pelvis showing
small bowel obstruction due to adhesions. A Small bowel
feces sign (small arrow) is usually seen closer to the transition
Contrary to barium, water-soluble oral contrast
agents are safe even if intestinal perforation and peri-
toneal spread occurs [56].
Ultrasound has limitations for complete assessment
of the bowel due to poor visualization of gas-filled
structures. Sonographic appearance of bowel obstruction
includes dilated bowel loops, and hyperperistalsis. The
presence of aperistaltic loops, fluid-filled, and distended
bowel, as well as wall thickening could represent infarc-
tion in the relevant clinical context. Sonography has been
reported to have a sensitivity of 89% compared with 71%
for conventional abdominal radiography in diagnosing
small bowel obstruction and is superior to radiographs in
its ability to identify features of strangulation and to
predict the location and cause of obstruction [57].
CT is the modality of choice for evaluating suspected
SBO. It can reveal the degree, location, and cause of
obstruction as well as display signs of threatened bowel
viability. CT has a sensitivity of 81–94% and a specificity
of 96% for diagnosing high-grade obstructions. How-
ever, there is a decrease in accuracy for diagnosing low
grade and subacute obstructions (sensitivity of 64% and
specificity of 79%) [52]. IV contrast is ideally recom-
mended while assessing SBO on CT, whereas oral con-
trast can be considered based on patient tolerability. Oral
contrast should not be used if there is a request to assess
enhancement/viability of the bowel wall. The diagnosis
of SBO is made on the basis of dilated bowel loops
>3 cm in diameter with discrete transition point [51].
Passage of oral contrast material through the transition
zone into the distal bowel indicates partial or incomplete
bowel obstruction. ‘‘Small bowel feces sign’’ is often seen
closer to anticipated transition point and suggestive of
slow transit (Fig. 6A). The CT diagnosis of adhesions is
a diagnosis of exclusion as adhesions are often difficult to
visualize, however secondary findings such as acute
angulation and smooth extrinsic compressions could
indicate adhesions and are important signs for radiolo-
point; B The adhesions are not usually seen on imaging but
can be identified by acute angulation (arrows) and extrinsic
compression near the transition point.
K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies
Fig. 7. Coronal CECT of the abdomen and pelvis showing
small bowel obstruction due to cecal volvulus. A The cecum is
dilated and twisted in the upper abdomen/left upper quadrant
gists to be familiar with (Fig. 6B). In general, imaging
signs of high-grade obstruction, an abnormal vascular
course, and the presence of a transition zone are useful
predictors of a surgical intervention. However, a small
bowel feces sign inversely predicts need for surgery.
Differentiating congenital bands from adhesions is
challenging but evaluation of thickness as well as the
presence of single (bands) versus multiple matted adhe-
sions could be useful observations [58]. Delabrousse et al.
[59] showed a higher prevalence of the ‘‘beak sign’’ in
patients with bands than in patients with matted adhe-
sions, and the double beak sign has been reported in
cases of closed loop (two points along the course of a
bowel are obstructed at a single location) obstruction due
to hernias including internal hernias and volvulus [60].
Hence, identification of more than one beak sign could
represent a high risk for failure of non-surgical treatment
[61]. CT is an excellent modality for detecting hernias
and their associated complications such as strangulation,
volvulus, and ischemia. At the site of obstruction, there
may be a whirl sign, a beak sign, or triangular configu-
ration of adjacent collapsed loops (Fig. 7).
MR imaging also has been shown to be useful for
detecting bowel obstructions in acute settings and dif-
ferentiating malignant from benign causes. MR is useful
in evaluating low-grade small bowel obstruction which
occurs most commonly due to adhesions. In some cases,
143
(asterix); B The twisted cecal pedicle demonstrates ‘‘me-
senteric whirl sign’’ (arrows) in the ileocecal region.
low-signal-intensity soft-tissue bands may be seen
coursing through high-signal-intensity mesenteric fat on
T2-weighted images. MR/CT enteroclysis provides im-
proved distention of the small bowel and may demon-
strate subtle transition points or an obstruction that may
not be visible at imaging with more routine methods,
including MR/CT enterography [62]. However, MR/CT
enteroclysis are rarely needed.
Acute cholecystitis
Acute cholecystitis is the most common inflammatory
process of the biliary tree and accounts for 5% of ED
visits for acute abdominal pain [63]. The inflammatory
process may be calculous or acalculous in origin, most
commonly calculous with only 5–10% of all cases of
cholecystitis are acalculous [64].
According to Tokyo guidelines [65], a definite diag-
nosis of acute cholecystitis can be made on the basis of
diagnostic criteria in two scenarios: The first is based on
one local sign of inflammation (Murphy sign or right
upper quadrant pain with mass, or tenderness) and one
systemic sign of inflammation (fever, increased C-reac-
tive protein level, increased white blood cell count). The
second set of criteria is based on imaging findings that
are characteristic which include, a thickened gallbladder
wall or enlarged gallbladder at ultrasonography (US),
144 K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies
magnetic resonance (MR) imaging or computed tomog-
raphy (CT); positive sonographic Murphy sign; peric-
holecystic fluid collection at US and CT; or
pericholecystic high-signal intensity at MR imaging. Al-
though US is the initial imaging modality of choice for
evaluation of acute cholecystitis, CT often is used in the
clinical setting because other disease processes such as
pancreatitis, gastritis, peptic ulcer disease, and even bo-
wel obstruction may mimic right upper quadrant pain
[66]. MRCP sequences are often used to look for chole-
docholithiasis and to make sure that the patient needs an
endoscopic procedure or a surgical procedure. MR
images have excellent soft tissue contrast and can provide
more specific information regarding the complications
that arise from acute cholecystitis, such as empyema,
gangrenous cholecystitis, gallbladder perforation, ente-
rocholecystic fistula, emphysematous cholecystitis, and
hemorrhagic cholecystitis [67].
The imaging findings include the presence of sono-
graphic Murphy’s sign, gallstones, gallbladder wall thick-
ening >3 mm, gallbladder distention >5 cm in the short
axis or >8 cm in the long axis, pericholecystic fluid,
inflammatory stranding, and subserosal edema (Fig. 8) [68].
Cholecystectomy is the mainstay of the treatment of
acute cholecystitis performed either laparoscopically or
through open surgery. Minimal invasive procedures,
such as percutaneous gallbladder drainage using image
guidance or endoscopic procedures like transpapillary
drainage of the gallbladder at endoscopic retrograde
cholangiopancreatography (ERCP) and endoscopic
ultrasonography (EUS)-guided gallbladder drainage via
the transluminal route, could be a life-saving treatment
Fig. 8. Coronal T2 MR imaging showing imaging findings of
acute cholecystitis. Note gallstone (arrowhead) in the neck
region with pericholecystic fluid (arrows).
option or serve as a bridge to elective surgery in patients
with contraindications of surgery [69].
Perforated viscus
Pneumoperitoneum in a patient with acute abdominal
pain is an important diagnostic sign of gastrointestinal
(GI) perforation, which is usually indicative for need for
surgical intervention [70]. GI tract perforation is a dis-
ruption in the integrity of the gastrointestinal wall that
may be caused by various etiologies including, gastro-
duodenal ulcers, ischemic or bacterial enteritis, Crohn’s
disease, diverticulitis, ingested foreign bodies, bowel
obstruction, volvulus, intussusception, malignancy,
abdominal trauma, iatrogenic injury, and postoperative
perforation or anastomotic leakage [71].
Plain radiography is the usual screening modality for
patients with suspected GI tract perforation. The specific
finding of GI tract perforation on plain films is the
presence of air outside the gut lumen. The extraluminal
air may be in the free peritoneal cavity, retroperitoneal
spaces, mesentery, or ligaments of organs. However,
pneumoperitoneum may not be identified if the perfo-
ration is very small, self-sealed, or well-contained by
adjacent organs. The reported sensitivity in the detection
of extraluminal air on plain radiography is 50–70% [72].
The ‘‘ligamentum teres sign’’ which is free air confined
along ligamentum teres, can be seen in cases of perfo-
rated duodenal bulb or stomach [73]. The ‘‘falciform
ligament sign’’ is free air or an air-fluid level crossing the
midline and accentuating the falciform ligament. This
sign can be seen with perforation of the stomach and
small bowel [74].
CT is the most reliable modality for detecting even
small amounts of free air using ‘‘lung window’’ setting.
CT also helps identify the cause of GI tract perforation
(87). The direct CT findings of GI tract perforation in-
clude discontinuity of the bowel wall and the presence of
extraluminal air and/or extraluminal enteric contrast are
considered specific signs of gastrointestinal (GIT) per-
foration in an intact abdomen.
Indirect CT findings of bowel perforation include
bowel wall thickening, abnormal bowel wall enhance-
ment, abscess, and an inflammatory mass adjacent to the
bowel. Extravasation of oral contrast is specific at iden-
tifying the location of a perforation.
Other indirect signs identifying the location of a GI
perforation include:
1. Free air in either the supra or inframesocolic com-
partments,
2. Gas bubbles adjacent to the intestinal wall,
3. Localized extraluminal fluid,
4. Segmental wall thickening (>3 mm),
5. Perivisceral fat stranding and
6. Abscess formation [70].
K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies 145

Fig. 9. Axial A and coronal B CECT of the abdomen on lung static renal cancer. The findings are consistent with
window settings showing septated gas surrounding trans- pneumatosis intestinalis secondary to targeted molecular
verse colon in a patient who is on Sutent therapy for meta- agent therapy.

Acute bowel ischemia

Intestinal ischemia has a relatively low incidence with
estimated incidence around 1% in patients hospitalized
for acute abdomen. However recently, owing to longer
life expectancy and consequent greater incidence of
atherosclerotic vascular disease, it is more frequently
observed in current clinical practice [75]. Bowel ischemia
and infarction result in a high mortality and morbidity
with mortality rates exceeding 60% [76].
The primary causes of insufficient blood flow to the
small intestine are arterial occlusive disease (throm-
boembolism), veno-occlusive disease, non-occlusive
ischemia resulting from low-flow states such as
hypotension, bowel obstruction, neoplasms, vasculitis,
abdominal inflammatory conditions, trauma,
chemotherapy, radiation, and corrosive injury [77].
The designated ACR appropriateness score in pa-
tients with acute mesenteric ischemia for CTA abdomen
with contrast is 9/10 (usually appropriate), radiographs
of the abdomen is 7/10 (usually appropriate), MRA ab-
domen without and with contrast is 7/10 (usually
appropriate), and US abdomen is 6/10 (may be appro-
priate) [78]. Although radiography is usually the initial
test requested in patients with acute abdominal pain, but Fig. 10. Coronal CECT of the abdomen and pelvis showing
usually remains non-diagnostic in most cases of mesen- descending colon thickening and edema and increased bowel
teric ischemia. enhancement with ascites. The rectum is fluid filled and
Computed tomography angiography (CTA) has high demonstrates luminal dilation (circle). The walls are paper
sensitivity and specificity in diagnosing acute mesenteric thin, non-enhancing, and non-perceivable. These imaging
ischemia and should be considered the first-line imaging signs represent impending perforation due to ischemia.
in most cases [79].
CTA identifies atherosclerosis, thrombus, occlusion, mucosal hemorrhage predominantly in cases of venous
compression or invasion by tumor, and trauma. Other CT infarction, increased bowel enhancement in the early
findings include bowel wall thickening and edema, sub- phase or decreased enhancement of the bowel wall in later
146 K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies

Table 3. ACR appropriateness criteria for most commonly used imaging modalities in setting of RUQ pain, RLQ pain, and acute mesenteric
ischemia (Rating Scale: 1, 2, 3 Usually not appropriate; 4, 5, 6 May be appropriate; 7, 8, 9 Usually appropriate)
Variant ACR appropriateness ACR appropriateness ACR appropriateness ACR appropriateness
score-plain radiograph score-US score-CT with contrast score-MR with and without
contrast

RUQ pain-fever, elevated white blood cell N/A 9 6 6

count, positive murphy sign
RUQ pain-no fever, normal white blood N/A 9 6 6
cell count
RUQ pain-no fever, normal white blood N/A N/A 7 6
cell count, ultrasound shows only gall-
stones
RUQ pain-hospitalized patient with fever, N/A 8 6 6
elevated white blood cell count, and
positive murphy sign
RLQ pain-fever, leukocytosis, and classic 5 6 8 4
presentation clinically for appendicitis
in adults
RLQ pain-fever, leukocytosis; possible 6 6 6 5
appendicitis, atypical presentation,
adults, and adolescents
RLQ pain-fever, leukocytosis, pregnant 2 8 6 7
woman
RLQ pain-fever, leukocytosis, possible 6 8 7 5
appendicitis, atypical presentation in
children (aged <14 years)
Acute mesenteric ischemia 7 6 9 (CTA) 7(MRA)

phases, mesenteric stranding or fluid, and pneumatosis in
cases of bowel necrosis and perforation [80–83].
There are some non-ischemic factors that can induce
pneumatosis including chronic lung disease, peptic ulcer
disease, collagen vascular disease, use of steroid, and
treatment with certain molecular agents (Fig. 9). How-
ever, the clinical state of the patient generally differen-
tiates ischemia from non-ischemic causes of pneumatosis
[84]. Portal venous gas is associated with advanced
mesenteric infarction (present in 9–36% of cases), but it
does not necessarily indicate transmural bowel necrosis.
The presence of air in the portal branches can also be
caused by other diseases such as a perforated gastric
ulcer, pelvic abscesses, hemorrhagic pancreatitis, dia-
betes mellitus, necrotic neoplasia of the colon, divertic-
ulitis, or may be associated with ingestion of caustic
acids.
Impending perforation can be identified by fluid-filled
dilation of hollow viscus and paper thin, non-enhancing,
and non-perceivable walls (Fig. 10).
MRI is used for assessment of chronic mesenteric
ischemia and is currently more sparingly used in the
acute setting. MRA is a useful way of non-invasive
evaluation of mesenteric vessels: sequences such as Time
of Flight (TOF) do not require intravenous contrast
agents to visualize the vessels. However, longer acquisi-
tion time, artifacts due to patient’s inability to hold the
breath and availability are the limitations.
and/or admitted to hospital. There is a broad differ-
ential diagnosis to consider ranging from benign to
life-threatening causes. Early diagnosis and timely
management of these patients is the top priority be-
cause if delayed, may lead to poor clinical outcomes.
Imaging plays a pivotal role in solving this issue along
with appropriate history, physical exam, and labora-
tory results. Educating ED physicians regarding ACR
appropriateness criteria could be of great value in
ensuring that appropriate imaging algorithms are fol-
lowed for these patients (Table 3). Radiologists should
act as consultants with respect to performing the best
imaging based on clinical suspicion. Although each
modality has specific indications and contraindications,
the diagnosis by imaging is usually driven by ACR
appropriateness criteria for acute abdomen depending
upon location of pain and patient’s relevant history.
CT is the primary imaging modality for these cases
although US is more specific for conditions like acute
cholecystitis. MR imaging is very helpful in patients
where radiation exposure remains a concern. MR,
is the primary imaging modality for evaluating chole-
docholithiasis or acute abdomen in the pregnant pa-
tients. The usual causes of acute abdomen including
acute appendicitis, acute diverticulitis, acute cholecys-
titis, and acute SBO are to be kept in mind and have
to be thoroughly evaluated according to the clinical
scenario.

Conclusion Compliance with ethical standards

Non-traumatic abdominal pain is one of the most Conflict of interest The authors declare that they have no conflict of
common symptoms in patients presenting to the ED interest.
K. Gangadhar et al.: Multimodality approach for imaging abdominal emergencies 147

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