SCIENTIFIC EXHIBIT 725

Tailored Helical CT
Evaluation of Acute
Abdomen1
(CME available in print version and on RSNA Link)

LEARNING Bruce A. Urban, MD • Elliot K. Fishman, MD

OBJECTIVES
FOR TEST 4
After reading this Helical computed tomography (CT) allows rapid, cost-effective evalu-
article and taking ation of patients with acute abdominal pain. Tailoring the examination
the test, the reader
will be able to: to the working clinical diagnosis by optimizing constituent factors (eg,
■ Discuss the impor- timing of acquisition, contrast material used, means and rate of con-
tance of narrowing
the differential diag- trast material administration, collimation, pitch) can markedly improve
nosis into a working diagnostic accuracy. Rapid (³3 mL/sec) intravenous injection of con-
diagnosis to optimize
helical CT technique. trast material is required for optimal assessment of acute pancreatitis,
■ Recognize the CT ischemic bowel, aortic aneurysm, and aortic dissection. Narrow colli-
appearance of com- mation and small reconstruction intervals can help detect calculi in the
mon pathologic con-
ditions that manifest biliary system and genitourinary tract. Tailored helical CT in patients
with acute abdominal with acute pyelonephritis usually involves several acquisitions through
pain.
■ Understand the
the kidneys during various phases of renal enhancement. In patients
role of helical CT in with suspected renal infarction, CT protocol must include an acquisi-
the evaluation of tion during the corticomedullary phase. Helical CT with 5-mm colli-
acute abdominal
pain. mation through the lower abdomen and pelvis is used to evaluate pa-
tients with suspected diverticulitis. Use of both oral and intravenous
contrast material can help localize small bowel perforation and charac-
terize related complications. Tailored helical CT for assessment of ab-
dominal hemorrhage consists of initial unenhanced CT followed by
optional contrast material–enhanced CT. Clear communication be-
tween the radiologist, the patient, and the referring physician is essen-
tial for narrowing the differential diagnosis into a working diagnosis
prior to helical CT.

Abbreviations: HIV = human immunodeficiency virus, 3D = three-dimensional

Index terms: Abdomen, acute conditions, 72.25, 74.723, 751.291, 76.285, 762.81, 77.291, 81.2121, 82.21 • Abdomen, CT, **.12112 • Appen-
dicitis, 751.291 • Cholecystitis, 76.285 • Computed tomography (CT), helical technology • Computed tomography (CT), utilization • Gallblad-
der, calculi, 762.289, 762.81 • Intestines, stenosis or obstruction, 74.723 • Nephritis, 81.2121 • Pancreatitis, 77.291 • Stomach, ulcer, 72.25
Ureter, calculi, 82.81

RadioGraphics 2000; 20:725–749

1From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Balti-

more, MD 21287. Received March 8, 1999; revision requested May 5 and received June 3; accepted June 8. Address reprint requests to
B.A.U. (e-mail: burban@jhmi.edu).
2** indicates multiple body systems.
©RSNA, 2000
726 May-June 2000 RG ■ Volume 20 • Number 3

Table 1
Suggested Routine Helical CT Protocol for Nonlocalized Acute Abdominal Pain

Parameter Suggested Protocol

Contrast agent
Oral administration 750–1,000 mL 3% diatrizoate meglumine*
Intravenous administration 110–120 mL nonionic contrast material (iohexol);† injection rate,
2 mL/sec
Acquisition Single phase
Scan delay 70–90 sec (portal venous phase)
Scan area Diaphragm to symphysis pubis
Section thickness
Abdominal imaging 5 mm
Pelvic imaging 5–8 mm
Pitch 1.6 (table speed, 8 mm/rotation)
Reconstruction interval
Abdominal imaging 5 mm
Pelvic imaging 5–8 mm
*Hypaque; Nycomed Amersham, Princeton, NJ.
†
Omnipaque-350, Nycomed Amersham.

Introduction but also in detecting and characterizing the full

The term acute abdomen refers to any clinical con-
dition characterized by severe abdominal pain that
develops over a period of hours. Rapid, accurate
diagnosis is essential if morbidity and mortality are
to be significantly decreased. Clinical assessment
is often difficult, and laboratory and conventional
radiologic findings are often nonspecific. The de-
velopment of cross-sectional imaging has had a
tremendous impact on the diagnosis and treat-
ment of acute abdomen (1–3). In particular, com-
puted tomography (CT) has gained widespread
acceptance as a reliable and highly accurate mo-
dality in the evaluation of affected patients (1–4).
CT is most often indicated in patients with severe
abdominal pain who may require surgery or other
forms of intervention. It is probably most benefi-
cial in patients who present with confusing or con-
flicting clinical signs and symptoms. Conventional
CT has prospectively demonstrated an accuracy
of nearly 95% in acute abdomen (1). The intro-
duction of helical CT technology, with advances
in contrast dynamics and high-resolution volumet-
ric data acquisition, has further enhanced the util-
ity of CT in abdominal imaging (5,6). Helical CT
is a rapid, cost-effective procedure and provides
diagnostic information that can help determine
appropriate clinical management (7). It is useful
not only in diagnosing the primary abnormality
extent of disease. Helical CT is the imaging mo-
dality of choice for patient triage, and many hos-
pitals now have helical CT scanners on-site in
the emergency department. Undoubtedly, the
need for conventional radiology has diminished
due to the increasing utility of helical CT in ab-
dominal imaging (4,8).
In this article, we discuss various protocols and
techniques for optimizing the helical CT examina-
tion. We also discuss and illustrate helical CT
findings in a variety of conditions that can mani-
fest with acute abdominal pain, including those af-
fecting the pancreas, biliary system, spleen, geni-
tourinary tract, gastrointestinal tract, and vascular
system.
Helical CT Technique
Suggested routine helical CT protocol for pa-
tients with nonlocalized signs and symptoms of
acute abdominal pain is shown in Table 1. How-
ever, it is also important to try to tailor the CT
examination to the specific clinical findings and
area of interest. Scanning parameters will vary
depending on the working clinical diagnosis
(Table 2). The remainder of the examination is
performed following targeted evaluation. Failure
to tailor the examination can greatly reduce the
ability to accurately and confidently detect dis-
ease. Communication between the radiologist,
the patient, and the referring physician is essen-
tial for narrowing the differential diagnosis into
a working diagnosis prior to scanning.
RG ■ Volume 20 • Number 3 Urban and Fishman 727

Table 2
Variations in Helical CT Protocol for Acute Abdomen Based on Working Clinical Diagnosis

Variation Working Diagnosis

No intravenous contrast agent Ureteral stone
No oral contrast agent Ureteral stone, high-grade small bowel obstruction*
Negative oral contrast agent (water) Peptic ulcer disease,† vascular disease†
Rectal contrast agent Appendicitis,† diverticulitis†
Increased rate of administration of intra- Vascular disease,‡ hemorrhage,‡ bowel ischemia,‡ pancreatitis,‡
venous contrast agent (3–4 mL/sec) renal infarct‡
Dual-phase acquisition§ Pancreatitis,† pyelonephritis†
Delayed acquisition (5-min delay) Pelvic disease,† pyelonephritis†
Narrow collimation (3 mm) Ureteral stone, choledocholithiasis, pancreatitis, vascular disease||
Small reconstruction intervals (3 mm) Ureteral stone, choledocholithiasis, pancreatitis,† vascular
disease||
*Evaluated with intravenous bolus administration of contrast agent.
†
Variation in protocol optional.
‡
Evaluated with arterial-phase acquisition beginning 30 sec after intravenous injection.
§
Arterial-phase acquisition (30 sec after contrast agent administration) combined with portal venous phase ac-
quisition (70–90 sec).
||
Three-dimensional (3D) imaging (variation in protocol optional).

Contrast Material Orally Administered Contrast Material.—Use

Intravenously Administered Contrast Mate-
rial.—Use of intravenous contrast material is
recommended in most cases. Exceptions include
evaluation of suspected ureteral colic and, in some
instances, dedicated evaluation of suspected ap-
pendicitis and diverticulitis. Intravenous contrast
material opacifies the abdominal vasculature and
provides useful information regarding enhance-
ment of the parenchymal organs and intestine
(5).
The amount of contrast material administered
and the rate of injection will vary depending on
the working diagnosis. In general, 120 mL of io-
dinated contrast material injected at a rate of 2
mL per second is adequate. Images are usually
obtained during the portal venous phase of en-
hancement beginning approximately 70 seconds
after initiation of injection.
In dedicated vascular scanning for evaluation
of certain conditions such as suspected aortic an-
eurysm or dissection, initial precontrast images
can be helpful in localizing intramural hematoma
or impending rupture. CT (especially CT angiog-
raphy) should be performed after intravenous
bolus administration of contrast material; injec-
tion of 150 mL of contrast material at a rate of
3–4 mL per second is recommended. Scanning
should be initiated during the arterial phase of
enhancement beginning 20–30 seconds after ini-
tiation of injection (9).
of oral contrast material is also recommended in
most cases. Typically, 750–1,000 mL of water-
soluble contrast agent containing 3% iodine is ad-
ministered. Exceptions include cases in which high-
grade small bowel obstruction or ureteral colic is
suspected. In some patients with suspected gastric
disease or gastrointestinal bleeding, water can be
used as an oral contrast agent (10–14). In addition,
oral contrast material should not be used for CT
angiography because it can interfere with 3D imag-
ing (9). When oral contrast material is used to ex-
clude appendicitis or pelvic disease, it is recom-
mended that imaging be delayed at least 1 hour to
allow optimal bowel opacification. Rectal contrast
material is not routinely used, although its use has
been advocated as an alternative protocol for eval-
uation of suspected appendicitis or diverticulitis
(15,16).
Collimation
Scanning parameters will vary somewhat depend-
ing on the type of scanner available. In general, a
collimation of 5–7 mm is preferred for routine
scanning. Narrow (3-mm) collimation is suggested
for CT angiography, evaluation of suspected ure-
teral colic, and dedicated evaluation of suspected
acute pancreatic or biliary conditions (9–12). How-
ever, use of narrow collimation can also increase
noise and degrade image quality, especially in the
pelvis and in obese patients.
728 May-June 2000
Figure 1. Glandular enlargement in a 49-year-old
woman with acute pancreatitis. Axial CT scan ob-
tained with intravenous contrast material shows a
moderate amount of inflammatory fluid (arrows) sur-
rounding a minimally enlarged pancreas (p). The
pancreas demonstrates normal attenuation without
evidence of necrosis.
Pitch
Most scanners provide high-quality diagnostic im-
ages with a pitch of 1.5–1.6. An increased pitch of
2 is necessary in cases requiring narrow collima-
tion and significant patient coverage (eg, evalua-
tion of ureteral colic and vascular disease) (9–12).
Phases of Acquisition
Single acquisitions performed during either the
arterial phase (beginning 20–30 seconds follow-
ing intravenous injection of contrast material) or
the portal venous phase (beginning 70–90 sec-
onds after injection) are adequate in most pa-
tients. Occasionally, images should be acquired
during both phases, especially for dedicated con-
trast material–enhanced evaluation of the liver or
kidneys. Delayed images (acquired beginning 4
minutes after injection) are also helpful in cases
of suspected pyelonephritis or in the work-up of
suspected pelvic disease, when opacification of
the bladder may be desired (17–19).
Helical CT
Findings in Acute Abdomen
Pancreas
Patients with acute pancreatitis often present with
midepigastric pain, nausea, and vomiting. It has
been shown that the clinical severity of disease
correlates well with CT findings; thus, helical CT
can often be used to predict clinical outcome in
RG ■ Volume 20 • Number 3
Figure 2. Pancreatic abscess in a 38-year-old man
with acute pancreatitis. Axial CT scan obtained with
rapid bolus administration of intravenous contrast mate-
rial shows an air-fluid level (A) in the lesser sac anterior
to the underlying pancreas (arrow), whose enhancement
implies viability.
affected patients (20,21). Tailored evaluation
with helical CT requires rapid (3 mL/sec) intra-
venous bolus administration of contrast material
to optimize glandular enhancement as well as
narrow collimation for improved resolution (22–
24). Dual-phase scanning incorporating portal
venous phase images optimizes opacification of
the veins surrounding the pancreas but is not
necessary for diagnosis in most patients with
acute pancreatitis (23,24).
Helical CT findings in acute pancreatitis in-
clude glandular enlargement due to interstitial pa-
renchymal edema as well as increased attenuation
and stranding in the peripancreatic fat (Fig 1).
Glandular enlargement is typically diffuse rather
than focal. Focal enlargement may be indistin-
guishable from cancer (25,26). The pancreatic
contour in acute pancreatitis may be irregular,
with focal areas of decreased attenuation repre-
senting necrosis or edema (27). Acute pancreatitis
can progress to a pathologic condition character-
ized by extensive phlegmon formation along with
peripancreatic fluid collections, hemorrhage, peri-
pancreatic abscess, and extraglandular fat necrosis
(Fig 2). Pancreatic exudate most often collects in
the immediate peripancreatic space, the anterior
pararenal space, the lesser sac, and eventually in
the peritoneum itself, with dissection pathways
that include the transverse mesocolon and the
mesenteric root (25,26). Helical CT offers several
advantages in the evaluation of acute pancreatitis
(23,24). Most important, it can help stage disease
involvement and detect complications. Helical CT
can demonstrate necrosis or hemorrhage within
RG ■ Volume 20 • Number 3
Figure 3. Hemorrhagic pancreatic pseudocyst in a 44-
year-old man who presented with acute abdominal pain.
Axial CT scan obtained with intravenous contrast mate-
rial demonstrates calcifications from chronic pancreatitis
in the head of the pancreas. A high-attenuation focus of
blood (arrow) is seen within the low-attenuation pseudo-
cyst, a finding that is consistent with hemorrhage.
the pancreas itself as well as extension of the in-
flammatory process into contiguous organs (28).
Thrombosis of the portal or splenic vein with col-
lateral vessel formation is clearly depicted. Helical
CT can also help detect an unsuspected, life-
threatening pseudoaneurysm. Pancreatic abscesses
may develop with superinfection in acute pancre-
atitis and contribute significantly to mortality in
this setting. Gas within a fluid collection is highly
suggestive of abscess formation (25,26).
Acute pancreatic fluid collections can evolve
into true pseudocysts as the inflammatory reac-
tion walls itself off around the periphery. In con-
trast to the dynamic fluid collections in acute
pancreatitis, pseudocysts have defined capsules
and are more often seen in the setting of sub-
acute or chronic pancreatitis (25,26). The fluid
in pseudocysts usually has homogeneous low at-
tenuation similar to that of water. Pseudocyst
contents that exhibit a heterogeneous pattern of
increased attenuation suggest the possibility of
superimposed hemorrhage or infection (Fig 3).
Helical CT can clearly define the location and
extent of pseudocysts and is helpful for surgical
planning in affected patients. Pancreatic pseudo-
cysts may invade vascular structures adjacent to
the pancreas such as the portal or splenic vein
with consequent compression or even obstruction
(29). Pseudocysts may also erode into the spleen
or into pancreatic or peripancreatic arteries with
resultant acute hemorrhage (29,30).
Urban and Fishman 729
Figure 4. Acute cholecystitis in a 40-year-old man.
Axial CT scan obtained with intravenous contrast ma-
terial demonstrates the classic features of acute chole-
cystitis: distention of the gallbladder (gb), wall thicken-
ing with enhancement, and focal pericholecystic fluid
and inflammation. Surgery revealed acute cholecystitis
with a xanthogranulomatous component.
If hemorrhage is clinically suspected, initial
unenhanced CT should be included in the exami-
nation because visualization of hemorrhagic fluid
can be difficult following intravenous injection of
contrast material.
Biliary System
Acute Cholecystitis.—Although CT is not typi-
cally used to screen patients with presumed chole-
cystitis, patients with acute abdominal pain often
undergo CT as an initial diagnostic work-up. Rou-
tine helical CT protocol with intravenous contrast
material is used for most patients. The most sensi-
tive helical CT findings in acute cholecystitis are
inflammation and significant thickening (>3 cm)
of the gallbladder wall with increased attenuation
in the setting of a distended gallbladder (31).
Transient focal areas of increased attenuation in
the liver can be seen adjacent to the inflamed gall-
bladder, findings that probably indicate hepatic
arterial hyperemia and early venous drainage
(32,33). Other findings include haziness of the
pericholecystic fat, pericholecystic fluid, and in-
creased attenuation of the bile (34). A combina-
tion of some or all of these findings is highly spe-
cific for acute cholecystitis, approaching the sensi-
tivity of ultrasonography (US) (Fig 4).
Helical CT can also demonstrate complica-
tions of acute cholecystitis. Air within the gall-
bladder lumen or wall indicates the presence of
730 May-June 2000 RG ■ Volume 20 • Number 3

Figure 5. Emphysematous cholecystitis in a 66-year-

old man. Axial CT scan obtained with intravenous con-
trast material shows air filling the distended gallbladder
lumen (gb) and wall (arrow). Pathologic analysis revealed
extensive necrosis with adherence to the adjacent liver.
Figure 6. Infectious cholangitis in an 82-year-old
woman with acute cholecystitis. Axial CT scan ob-
tained with intravenous contrast material demon-
strates multiple hepatic abscesses (arrows), which
were a complication of cholecystitis in this case.

emphysematous cholecystitis, which in turn im-

plies underlying gangrenous changes (Fig 5). Care
must be taken not to mistake air introduced at re-
cent endoscopic retrograde cholangiopancreatog-
raphy or prior surgery for acute emphysematous
cholecystitis. Infectious cholangitis can complicate
cholecystitis, manifesting as hepatic abscesses (Fig
6) (35). Perforation is a relatively late finding in
patients with cholecystitis and often necessitates
surgical intervention. CT is reasonably sensitive
in diagnosing and localizing gallbladder perfora-
tion (Fig 7) (36). Some patients may present
with acute cholecystitis and have fairly unremark-
able CT findings. Correlation of CT findings
with those at other modalities, especially US and
nuclear magnetic resonance imaging, is vital if
Figure 7. Gallbladder perforation in a 59-year-old
the diagnosis of cholecystitis remains in doubt. woman with acute cholecystitis. Axial CT scan obtained
This is particularly important for early diagnosis after bolus injection of intravenous contrast material
leading to rapid intervention in the intensive care demonstrates a liver abscess with heterogeneous attenu-
unit patient or the severely ill patient in whom ation (A) adjacent to the distended gallbladder (gb).
the gallbladder may be distended at baseline Continuity is demonstrated between the gallbladder and
evaluation (37). the abscess, indicating the site of rupture (arrow). Aspi-
ration yielded frank pus.
Choledocholithiasis.—Patients with choledo-
cholithiasis often present with recurrent episodes
of right upper quadrant pain, fever, and jaundice. and choledocholithiasis. In older studies, conven-
Tailored helical CT protocol includes narrow tional CT demonstrated sensitivities as high as
collimation and small (2–3-mm) reconstruction 90% for the detection of common bile duct
intervals to optimize detection of cholelithiasis stones (38). In a study by Neitlich et al (39),
helical CT demonstrated a sensitivity of 88%, a
specificity of 97%, and an accuracy of 94% in the
diagnosis of common bile duct stones. The most
RG ■ Volume 20 • Number 3 Urban and Fishman 731

a. b.
Figure 8. Biliary obstruction from an impacted common bile duct stone in an 81-year-old
woman with choledocholithiasis. (a) On an axial CT scan obtained with intravenous con-
trast material, the common bile duct (cbd) is moderately dilated and tortuous. (b) CT scan
obtained inferior to a shows an impacted high-attenuation nidus from a gallstone at the am-
pulla (arrow).

attenuation rings seen with mixed cholesterol-cal-

cium stones, which often result in distal common
bile duct obstruction. In the absence of a pancre-
atic head mass or a detectable cause of obstruc-
tion, the differential diagnosis of a distal common
bile duct obstruction should include stone, biliary
stricture, and small ampullary mass.

Figure 9. Gallstones in a 75-year-old man with
choledocholithiasis and pancreatitis. Axial CT scan
obtained with intravenous contrast material shows
very subtle gallstones within the gallbladder lumen
(white arrow) and common bile duct (black arrow).
Stranding is seen in the peripancreatic fat.
reliable CT finding is a high-attenuation nidus
within the duct (Figs 8, 9) (38,39). Helical CT
with narrow collimation and small reconstruction
intervals is particularly helpful in detecting small
stones and the subtle, alternating low- and high-
Spleen
Patients with splenic infarction typically present
with left upper quadrant pain, although in some
cases the disease may be clinically silent. Com-
mon causes of splenic infarction include bacterial
endocarditis, portal hypertension, and underlying
splenomegaly (29). Pancreatitis can also extend
into the splenic hilum and result in infarction
(29,30). Tailored helical CT protocol requires
intravenous bolus administration of contrast ma-
terial. At helical CT, focal infarcts appear as
wedge-shaped areas of decreased attenuation that
extend to the surface of the spleen (Fig 10) (41–
43). Most infarcts are easily appreciated against
the normal inhomogeneous pattern of early
splenic enhancement. Global infarction can
manifest as diffuse areas of decreased attenuation
in the spleen and can mimic splenic abscess or
732 May-June 2000 RG ■ Volume 20 • Number 3

10. 11.
Figures 10, 11. (10) Splenic infarction in a 41-year-old woman. Axial CT scan obtained with
intravenous contrast material demonstrates multiple infarcts in an enlarged spleen (arrows). Most
splenic abnormalities, including infarcts, can be differentiated from normal inhomogeneous splenic
enhancement. (11) Global splenic infarction in a 32-year-old man with human immunodeficiency
virus (HIV) infection who presented with severe left upper quadrant pain. Axial CT scan obtained
with intravenous contrast material demonstrates an enlarged, infarcted spleen (S) resulting from
portal vein thrombosis. The spleen appears similar to a large abscess.

tumor (Fig 11). In some cases of global infarction,
the splenic periphery remains enhanced due to
perfusion from capsular vessels. Helical CT per-
formed during peak contrast material enhance-
ment allows reliable depiction of the splenic ar-
tery and vein (41).
Genitourinary Tract
Acute Pyelonephritis.—Acute pyelonephritis is a
common clinical diagnosis in patients who present
with fever, chills, and flank tenderness. Infections
typically result from ascending retrograde spread
through the collecting ducts into the renal paren-
chyma. Patients are referred for CT evaluation of
acute pyelonephritis when symptoms are poorly
localized or complications are suspected (44–46).
Tailored helical CT in patients with acute pyelo-
nephritis usually consists of several acquisitions
through the kidneys during various phases of renal
enhancement (47). Typically, images are acquired
during the corticomedullary phase beginning 30
seconds after initiation of injection and during ei-
ther the nephrographic phase (70–90 seconds after
injection) or the excretory phase (5 minutes after
injection).
Helical CT findings in acute pyelonephritis
consist of focal areas of striated or wedge-shaped
hypoperfusion, resulting in a characteristic
“patchy” nephrogram (Fig 12) (48–50). Stria-
tions result from stasis of contrast material within
edematous tubules that demonstrates increasing
attenuation over time. The infected kidney is usu-
ally enlarged, and there is often stranding in the
perinephric fat (Fig 13). Poorly enhanced areas of
focal pyelonephritis can mimic a renal mass at
conventional CT. Helical CT is probably more
specific in differentiating infection from tumor
(47). It is also helpful in detecting subtle cases of
acute pyelonephritis; clues to the diagnosis in-
clude loss of normal, sharp corticomedullary dif-
ferentiation and delayed appearance of the corti-
cal nephrogram, abnormalities that are visualized
only during early dynamic contrast enhancement.
Delayed views of the infected kidney may dem-
onstrate a nephrogram with increased attenua-
tion (17).
Renal Infarction.—Patients with renal infarc-
tion typically present with acute flank pain and
may have hematuria. Renal infarcts are typically
the result of embolism (usually in a diseased
heart), aortic dissection, trauma, or thrombosis
(51,52). Tailored helical CT must include an ac-
quisition during the corticomedullary phase of
enhancement (beginning 30 seconds after initia-
tion of injection) when renal arterial and venous
opacification is greatest. Helical CT findings in-
clude one or more focal parenchymal defects that
RG ■ Volume 20 • Number 3 Urban and Fishman 733

12. 13.
Figures 12, 13. (12) Acute bilateral pyelonephritis in a 34-year-old woman. Axial CT scan obtained with intrave-
nous contrast material demonstrates patchy, striated nephrograms. (13) Acute pyelonephritis in a 69-year-old man.
Axial nephrographic-phase CT scan obtained with intravenous contrast material reveals patchy enhancement of the left
kidney. The kidney is minimally enlarged with perinephric stranding, secondary findings that also suggest infection.

14. 15.
Figures 14, 15. (14) Abdominal aortic aneurysm and renal infarction in a 67-year-old man. On an axial arterial-
phase CT scan obtained with intravenous contrast material, the lateral aspect of the left kidney demonstrates the char-
acteristic appearance of renal infarction (arrow). (15) Global infarction in a 67-year-old man with aortic dissection.
The patient presented with acute left flank pain. Axial CT scan obtained with intravenous contrast material reveals a
dissection flap occluding the left renal artery (arrow). Flow to the left kidney is obstructed.

involve both the cortex and medulla and extend
to the capsular surface of the kidney. Segmental
infarcts of the anterior or posterior renal arteries
demonstrate a characteristic appearance at CT
(Fig 14) (53). The larger ventral branch supplies
the anterior lateral portion of the kidney, whereas
the smaller dorsal branch supplies the posterior
medial aspect. With global infarction, the entire
kidney is nonperfused (Fig 15). Characteristic
rim enhancement representing collateral capsular
perfusion may be seen surrounding the nonfunc-
tioning, infarcted kidney (51).
734 May-June 2000 RG ■ Volume 20 • Number 3

16a. 16b.
Figures 16, 17. (16) Obstructing ureteral
calculus in a 51-year-old woman. (a) Axial
unenhanced CT scan demonstrates right hy-
dronephrosis. (b) CT scan obtained inferior
to a clearly depicts an obstructing calculus in
the midureter (arrow). (17) Ureteral calculus
in a 24-year-old man. Axial unenhanced CT
scan shows focal stranding around the middle
of the right ureter, a finding that helps local-
ize a subtle calculus (arrow).

Ureteral Stones.—Patients with acute pain from

ureteral calculi present with hematuria and flank
pain radiating to the groin. Helical CT provides a
rapid and accurate test for the presence of ureteral
calculi (10–12). A significant advantage of using
helical CT is the ability to document the presence
of stones without intravenous injection of contrast
material because the vast majority of calculi are
radiopaque at CT (54). In addition, lack of breath-
ing misregistration with helical CT ensures con-
tinuous coverage of the entire collecting system
and improves detection of small stones. These
advantages make helical CT the screening mo-
dality of choice at most institutions (12). Helical
CT has proved as sensitive as intravenous pyelog-
raphy in detecting ureteral obstruction and more
sensitive in identifying calculi as the source of ob-
struction (11). In clinical studies, helical CT ob-
viated intravenous pyelography in 90% of cases
(55). In 292 patients with 100 proved ureteral
stones, Smith et al (10) found helical CT to be
97% sensitive, 96% specific, and 97% accurate in
the depiction of ureteral calculi.
17.
Tailored helical CT in patients with suspected
ureteral calculi requires a continuous breath-hold
acquisition from the top of the kidneys to the
bladder base. Narrow (3-mm) collimation and
small reconstruction intervals (also 3 mm) are es-
sential for optimal detection of small calculi (10–
12). Identification of hydronephrosis, hydroureter,
and obstructing calculi is usually straightforward
(Fig 16). Characteristic locations of obstructing
calculi include the ureteropelvic junction and the
ureterovesical junction. Prone scans may be
needed to differentiate a ureterovesical junction
stone from a recently passed stone. Secondary
signs of perinephric stranding and edema provide
supporting evidence for acute obstruction (55,
56). Focal periureteral stranding can also help lo-
calize subtle calculi (Fig 17). In addition, helical
CT can be used to document stone size and pre-
dict clinical outcome (12,57). Rarely, phleboliths
RG ■ Volume 20 • Number 3
Figure 18. Tubo-ovarian abscess and pyosalpinx
in a 41-year-old woman. On a CT scan obtained
with intravenous contrast material, the left fallopian
tube is dilated and filled with fluid. Subtle tubular
enhancement is also seen (arrows).
can mimic renal calculi and present a diagnostic
dilemma. Furthermore, HIV–positive patients
undergoing indinavir therapy can present with
nonopaque stones (58). In such cases, intrave-
nous contrast material may be required to local-
ize the ureter. However, we have found that
unenhanced CT provides rapid and accurate di-
agnosis in most patients.
Pelvic Inflammatory Disease.—Patients with
pelvic inflammatory disease typically present with
vaginal discharge, pelvic pain, fever, and an ele-
vated white cell count. US is the initial modality
of choice in most patients. Occasionally, patients
are referred for CT when signs and symptoms are
poorly localized or complications such as tubo-
ovarian abscess are suspected. Helical CT with
intravenous contrast material is required to de-
fine the adnexal anatomy and potential disease
(18,19). Occasionally, delayed images obtained
following bladder opacification (5 minutes after
contrast material injection) are needed to help
differentiate a cystic mass or collection from the
bladder (18,19). Typical helical CT findings in
patients with pelvic inflammatory disease include
unilateral or bilateral adnexal masses, hydrosal-
pinx, and pelvic ascites (59). Tubo-ovarian ab-
Urban and Fishman 735
scesses manifest as complex masses with septa-
tions and thick, irregular walls (59,60). Helical
CT demonstrates characteristic peripheral en-
hancement of the fallopian tubes and abscess cap-
sule (Fig 18) (18,19). Tubo-ovarian abscesses
can be difficult to differentiate from ovarian neo-
plasms or from abscesses secondary to other causes
such as inflammatory bowel disease or appendici-
tis. In addition, ovarian cysts and a small amount
of ascites are normal in premenopausal patients,
and correlation with clinical history and US find-
ings remains essential.
Gastrointestinal Tract
Appendicitis.—Acute appendicitis is one of the
most common causes of acute abdominal pain.
Patients present with right lower quadrant pain,
nausea, and vomiting and often have an elevated
white cell count. CT has long been recognized as
having a high diagnostic accuracy in patients with
acute appendicitis (61,62). Initial studies have
shown conventional CT with both oral and intra-
venous contrast material to be highly diagnostic
for appendicitis (61). More recently, other inves-
tigators have shown that tailored helical CT eval-
uation with 5-mm collimation with or without
oral or intravenous contrast material can be just
as accurate in the diagnosis of appendicitis, hav-
ing a reported accuracy of 94%–98% (15,63).
Unenhanced helical CT is helpful in that it elimi-
nates the risk of an adverse reaction to intravenous
contrast material as well as the time required for
oral or rectal administration of contrast material.
Obviously, if intravenous or oral contrast material
is not used, this technique has limited value in
patients with minimal intraabdominal fat. Un-
enhanced helical CT with oral or rectal contrast
material alone has been implemented in the com-
munity hospital setting in a study of 100 patients
and has demonstrated excellent diagnostic accu-
racy (95%) (64).
A dilated, fluid-filled appendix is the most
specific helical CT finding in acute appendicitis
(15,63). Calcified appendicoliths and periappen-
diceal inflammation are helpful secondary find-
ings. Enhancement of the appendiceal wall is of-
ten seen following intravenous bolus administra-
tion of contrast material and is another specific
736 May-June 2000 RG ■ Volume 20 • Number 3

a. b.
Figure 19. Acute appendicitis. Axial CT scans obtained with intravenous contrast material
in a 27-year-old woman (a) and a 62-year-old man (b) show a minimally distended appen-
dix with an enhancing wall (arrow). Stranding is seen in the periappendiceal fat. These find-
ings are pathognomonic for acute appendicitis.

a. b.
Figure 20. Perforating appendicitis in a 44-year-old man. (a) Axial CT scan obtained with in-
travenous contrast material demonstrates subtle findings of a minimally enhancing, tortuously di-
lated appendix (arrowheads). This finding was initially misinterpreted as the normal terminal ileum.
(b) CT scan obtained inferior to a demonstrates minimal fluid in the pelvis (arrow). B = bladder. In
this case, use of oral contrast material would likely have aided in making the correct diagnosis. Al-
though reported sensitivities for detecting acute appendicitis are similar with any combination of
oral, intravenous, and rectal contrast material (or with none of the three), we prefer using a com-
bination of the first two whenever possible.

sign of inflammation (Fig 19). However, in pa-
tients with adequate intraperitoneal fat, diagnosis
can be made without oral or intravenous contrast
material because the focal nature of the periap-
pendiceal stranding is obvious. Helical CT can
also demonstrate complications of appendicitis,
including perforation, small bowel obstruction,
and mesenteric venous thrombosis (Fig 20).
Many other conditions can lead to inflammation
and abscess formation in the right lower quad-
rant and mimic findings of acute appendicitis at
both clinical examination and radiography (65–
RG ■ Volume 20 • Number 3
Figure 21. Crohn disease mimicking acute appendici-
tis in an 18-year-old woman. Axial CT scan obtained
with intravenous contrast material shows minimal thick-
ening of the distal terminal ileum (white arrow). Focal
abscesses in the right lower quadrant (black arrows)
mimic perforating appendicitis.
Figure 23. Diverticular abscess in a 49-year-old
man. Axial CT scan obtained with intravenous
contrast material shows a small abscess adjacent
to an abnormally thickened sigmoid colon (ar-
row). The rim enhancement of the fluid collection
implies infection.
67). These include Crohn disease and cecal di-
verticulitis, among others (Fig 21). Essentially all
inflammatory processes of the gastrointestinal
tract, including inflammatory bowel disease and
infectious enteritis and colitis, can manifest with
pain and produce inflammatory stranding in the
mesenteric fat. One must be certain that the ap-
pendix is the cause of inflammation before mak-
ing the diagnosis of acute appendicitis.
Diverticulitis.—Diverticular disease of the co-
lon is common, affecting up to 65% of patients
with acute abdominal pain by age 65 years and
Urban and Fishman 737
Figure 22. Acute diverticulitis in a 62-year-old man.
Axial CT scan obtained with intravenous contrast ma-
terial demonstrates focal thickening and pericolonic
stranding (arrow), both of which are classic features of
acute diverticulitis.
typically involving the sigmoid colon. Up to 25%
of these patients will develop diverticulitis (68).
Patients often present with fever, left lower quad-
rant pain, and an elevated white cell count. CT is
sensitive in proved cases of diverticulitis and has
replaced barium enema examination in the initial
evaluation of patients with suspected diverticulitis.
CT findings in acute diverticulitis include colonic
wall thickening in the presence of diverticula, peri-
colonic fat stranding, phlegmon, air bubbles, ab-
scess, and dependent free fluid (Fig 22) (69,70).
CT is up to 93% sensitive and approaches 100%
specificity and accuracy in the diagnosis or exclu-
sion of diverticulitis (16,71). CT is also much
more sensitive than barium enema examination
in determining the presence and nature of peri-
colonic complications (72). In addition, CT is
excellent for detecting other causes of left lower
quadrant pain that may mimic diverticulitis and
can suggest alternative diagnoses in 78% of cases
when other causes are present (16).
Tailored helical CT evaluation of patients with
suspected diverticulitis includes 5-mm-collimation
scanning through the lower abdomen and pelvis.
Although helical CT with rectal contrast material
alone is highly accurate for diagnosis (16), intrave-
nous bolus administration of contrast material is
helpful in the detection and characterization of
pericolonic inflammation and is therefore recom-
mended in most patients. Helical CT with intra-
venous contrast material accentuates the charac-
teristic rim enhancement of pericolonic abscesses
and helps differentiate neighboring bowel loops
from surrounding inflammatory changes (Fig
23). Bowel lumen opacification is helpful for
738 May-June 2000 RG ■ Volume 20 • Number 3

24. 25.
Figures 24, 25. (24) Duodenitis in a 72-year-old man. The patient presented with postoperative nausea, vom-
iting, and abdominal pain. Axial CT scan obtained with intravenous contrast material shows moderate duodenal
thickening (arrowheads). (25) Perforated duodenal ulcer in a 62-year-old man. Axial CT scan obtained with
intravenous contrast material demonstrates stranding in the right anterior pararenal space (arrow), a common
location for the traversal of fluid in patients with perforated ulcer. Surgery confirmed the presence of a large
perforated ulcer.

depiction of wall thickening and is best achieved if
rectal rather than oral contrast material is used.
Most authors suggest the administration of 400–
800 mL of 3% iodinated contrast material (16).
In practice, however, the diagnosis can be estab-
lished in most patients without use of rectal con-
trast material, which can be reserved for the oc-
casional patient with equivocal findings.
Peptic Ulcer Disease.—Patients with peptic ulcer
disease present with epigastric pain, nausea, and
vomiting. At times, symptoms are nonlocalized or
indistinguishable from those in acute pancreatitis
or cholecystitis, and CT is often performed in such
cases. Alternatively, patients with known ulcer
disease may undergo CT for assessment of severe
complications of ulcer penetration, including pan-
creatitis, perforation, and abscess formation.
Tailored helical CT of the stomach and duode-
num is best performed after adequate distention
following the ingestion of either water or positive
oral contrast agent. Intravenous bolus administra-
tion of contrast material is also necessary if water
is used (13,14). Peptic ulcer disease often mani-
fests at CT as focal thickening (Fig 24). Unfortu-
nately, gastric and duodenal thickening are often
nonspecific, and correlation with the patient’s
symptoms is poor (73). In addition, many patients
have chronic thickening, often due to infection
with Helicobacter pylori, which can produce sub-
stantial thickening in the body and antrum of the
stomach (74). Helical CT is probably most help-
ful and specific in patients with complications
from penetrating ulcers (Fig 25) (75), who will
demonstrate inflammatory changes in the adja-
cent soft tissues and organs, including the pan-
creas, liver, and lesser omentum. These changes
are easily identified at helical CT (75,76). CT is
also valuable in the detection of clinically unsus-
pected perforation, although determining the pre-
cise site of perforation is often difficult (76).
Small Bowel Obstruction.—Small bowel ob-
struction is a common cause of acute abdominal
pain. Patients often present with nausea, vomiting,
and abdominal tenderness. Small bowel obstruc-
tion has a variety of causes, the most common of
which are adhesions (64%–79% of cases), hernia
(15%–25%), and tumor (10%–15%) (77). The
utility of CT in the evaluation of small bowel ob-
struction depends somewhat on the degree and
suspected cause of obstruction. At most institu-
tions, CT has supplanted the small bowel follow-
through study as the initial examination of choice
because it can help confirm the need for or obviate
surgery. CT has proved to be very useful in cases
of high-grade small bowel obstruction, with a sen-
sitivity of 90%–96%, a specificity of 96%, and an
accuracy of 95% (78,79). In low-grade obstruc-
tion, however, the accuracy of CT is only about
50%, and follow-up CT or barium examination
may be indicated. In all cases of small bowel ob-
struction (including low-grade obstruction), sensi-
tivity drops to about 60%, with a specificity of
80% and an accuracy of 66% (80). For this rea-
RG ■ Volume 20 • Number 3
a.
Figure 26. Small bowel obstruction from inguinal hernia in a 55-year-old man. (a) Axial CT scan obtained with
intravenous contrast material shows moderately dilated small bowel loops with minimal mural thickening and en-
hancement. (b) CT scan obtained inferior to a shows a transition point at the site of an incarcerated right inguinal
hernia (arrow).
Figure 27. Small bowel obstruction from metastatic
gastric cancer in a 68-year-old man. Axial CT scan ob-
tained with bolus administration of intravenous contrast
material demonstrates a markedly distended small bowel
with air-fluid levels. An enhancing serosal implant is seen
involving a bowel loop in the midabdomen (arrow).
son, a small bowel follow-through study is often
performed following CT if clinical concerns for
low-grade obstruction persist.
Tailored helical CT evaluation for suspected
high-grade small bowel obstruction is best per-
formed without oral contrast material. Patients
with high-grade small bowel obstruction already
have large amounts of fluid in the bowel that acts
as a natural contrast agent, especially when com-
bined with intravenous bolus injection of contrast
Urban and Fishman 739
b.
material, allowing opacification of the normal
bowel wall as well as bowel masses. Intravenous
contrast material also allows accurate assessment
of the extent of bowel wall thickening. However,
in cases of low-grade obstruction or vague pain,
use of oral contrast material is indicated because
it improves accuracy in the detection of inflamma-
tion and abscesses and can optimize identification
of a transition zone by increasing the load factor
on the bowel lumen.
The essential helical CT finding in small
bowel obstruction is a definable transition from
dilated to decompressed small bowel. Careful in-
spection of the transition point and luminal con-
tents of the bowel will often reveal the underlying
cause of obstruction (78,79). Hernias are the most
common positive finding and are usually seen in
the inguinal region or abdominal wall (Fig 26)
(81,82). Abdominal wall hernias account for the
great majority of external hernias (82,83). A con-
genital or acquired weakness or defect in the mus-
cular layers of the abdominal wall produces the
potential hernia site. Other types of abdominal
wall hernias include incisional hernias, parastomal
hernias, and spigelian hernias (78,82,83). Indirect
inguinal hernias are also very common and are
caused by acquired weakness and dilatation of the
internal inguinal ring, which results from a defect
in the transverse fascia (83). Less frequently, an
obstructing mass or tumor implant may be identi-
fied (Fig 27). Intussusception may also result in
740 May-June 2000
Figure 28. Small bowel obstruction from adhesions in
a 61-year-old man who had undergone renal transplanta-
tion. Axial CT scan obtained with intravenous contrast
material shows a moderately dilated proximal small
bowel. Collapsed small bowel loops are seen in the right
lower quadrant (arrowheads). No discrete mass is seen
in the region of transition in the lower abdomen, and
there is no evidence of hernia or intussusception.
obstruction and is often associated with an under-
lying mass that serves as a lead point (84,85). In
the absence of an obstructing mass or hernia at
CT, small bowel obstruction is most likely due to
adhesions, especially in patients with a history of
surgery (Fig 28). A finding of adhesions as the
cause of small bowel obstruction effectively ex-
cludes an obstructing mass or hernia in the ma-
jority of patients.
Helical CT can also be useful in differentiating
simple from strangulated small bowel obstruction
(86,87). Strangulated small bowel obstruction
involves mechanical obstruction proximal to the
involved loop and closed-loop obstruction with
venous congestion of the involved loop (88). Ini-
tially, venous outflow is occluded in the involved
loop, resulting in distention and engorgement of
vessels. Bowel hemorrhage ensues, resulting in
transudation of fluid into the peritoneal cavity.
Findings that suggest strangulation include poorly
enhanced or unenhanced bowel wall and the ser-
rated beak sign, both of which are 100% specific
for strangulation (86). The serrated beak sign is
caused by twisting of bowel with regional engorge-
ment of the mesenteric vasculature, mesenteric
edema, and bowel wall thickening. Closed-loop
RG ■ Volume 20 • Number 3
Figure 29. Closed-loop small bowel obstruction from
adhesions in a 44-year-old woman. Axial CT scan ob-
tained with intravenous contrast material shows dis-
tended small bowel loops in the left midabdomen with
collapsed loops in the right lower quadrant. Strangu-
lated obstruction is suggested by the bowel wall thicken-
ing with mesenteric edema radiating toward the point of
strangulation (arrow). Surgery revealed extensive trans-
mural ischemia with mucosal and submucosal hemor-
rhage.
obstructions may have a peculiar C- or U-shaped
configuration, and fluid in the mesenteric leaves
may radiate out from the point of strangulation
(Fig 29). An unusual course and diffuse engorge-
ment of the mesenteric vasculature with mesen-
teric haziness are highly specific for strangulation
(86).
Ischemic Bowel.—Patients with bowel ischemia
can present with symptoms ranging from rela-
tively minor discomfort to acute abdominal pain,
which makes clinical diagnosis difficult (89). Pre-
dominant causes of intestinal ischemia include
vascular occlusion or thrombosis, whether from
arterial or venous disease, and hypoperfusion.
Usually, a combination of these factors is seen,
and the degree to which a given factor predomi-
nates determines patient outcome. Ischemia can
also result from secondary vascular compromise
in patients with bowel obstruction, including
closed loop obstruction, hernia, and intussus-
ception. CT plays a key role in identifying early
changes of ischemia and in determining the un-
derlying cause of ischemic bowel (90–92). How-
ever, CT findings in patients with ischemic
bowel, even when newer helical CT techniques
are used, can be nonspecific (93). In patients
with obstruction, helical CT has only an 80%
positive predictive value for ischemia, and up to
RG ■ Volume 20 • Number 3 Urban and Fishman 741

a. b.
Figure 30. Diffuse bowel ischemia in a 49-year-old woman. The patient presented with recurrent pancreatic
cancer and had a history of Whipple disease. (a) Axial CT scan obtained with intravenous contrast material
reveals a tumor surrounding the pancreas and mesenteric vessels (white arrowheads). The superior mesenteric
artery is patent (straight arrow), but the superior mesenteric vein is thrombosed (curved arrow). Infarcts are seen
in the left kidney (black arrowheads). (b) On a CT scan obtained inferior to a, minimal bowel wall thickening
is seen in both the small and large intestine (arrows). Surgery revealed diffuse ischemia.

Figure 32. Ischemic colitis in a 79-year-old

Figure 31. Intussusception and secondary bowel isch-
emia in an 80-year-old woman. Axial CT scan obtained
with intravenous contrast material shows a colocolic in-
tussusception (black arrow). There is no evidence for a
lead point. Low-attenuation bowel wall ischemia is also
seen (white arrow) and was confirmed at surgery.
20% of patients will have negative findings at lap-
arotomy for ischemia (94). However, helical CT
has a 95% negative predictive value for ischemia
and may help indicate when a more conservative
initial approach is warranted (94).
Tailored evaluation with helical CT requires
rapid (³3 mL/sec) intravenous administration of
contrast material for optimal vascular opacifica-
tion. Helical CT is very helpful in defining the
patency of the major intestinal vessels, particu-
man. Axial CT scan obtained with intravenous
contrast material reveals a focal low-attenuation
area representing thickening in the transverse co-
lon (arrowheads). Focal stranding is seen in the
pericolonic fat.
larly the superior mesenteric artery and superior
mesenteric vein (Fig 30). Intravenous contrast
material is also helpful in characterizing bowel
wall thickening, which can manifest as a low-at-
tenuation ring of edema (Fig 31) (94). However,
a finding of bowel wall edema is nonspecific and
can be seen with inflammatory or infectious causes
as well (Fig 32) so that clinical correlation is re-
quired. Water can be used as an alternative to
742 May-June 2000 RG ■ Volume 20 • Number 3

33. 34.
Figures 33, 34. (33) Ischemic small bowel and pneumatosis intestinalis in a 41-year-old woman. The patient
presented with acute thrombosis of multiple vessels including the superior mesenteric artery. Unenhanced CT
scan reveals air within the bowel wall (arrow). Pneumatosis is often best appreciated with a lung window setting.
(34) Bowel necrosis and mesenteric air in a 53-year-old woman. Unenhanced CT scan demonstrates air within the
mesenteric vessels (arrowheads). Surgery revealed transmural necrosis of the distal ileum, cecum, and sigmoid co-
lon.

positive oral contrast agent in patients with pre-
sumed ischemia, especially in the setting of ob-
struction. In these patients, intravenous contrast
material is essential for depiction of the thickened,
edematous bowel wall, which can easily be appre-
ciated against the obstructed, fluid-filled intestine.
Air within the bowel wall (pneumatosis intesti-
nalis), mesentery, and portal venous system are late
CT signs of bowel ischemia and usually portend a
grave prognosis (Figs 33, 34). A multitude of en-
tities can manifest with air in the bowel wall, in-
cluding conditions that disrupt the bowel mucosa
(eg, bowel obstruction, inflammatory bowel dis-
ease), entities that increase bowel permeability
(eg, graft-versus-host disease, acquired immuno-
deficiency syndrome, steroid therapy), and pul-
monary disease (eg, chronic obstructive pulmo-
nary disease) (95,96). CT findings must always
be correlated with clinical history and symptoms
in patients with pneumatosis intestinalis (96).
Gastrointestinal Perforation.—Patients with
bowel perforation usually present with obvious in-
dications of peritonitis, although symptoms can
be masked in immunosuppressed patients or in
patients undergoing steroid therapy. Spontaneous
bowel perforation usually occurs with underlying
disruption of the mural integrity of the intestine.
Perforation generally indicates a catastrophic com-
plication that can result from a multitude of po-
tential causes, including severe intestinal inflam-
mation, peptic ulcer disease, diverticulitis, infarc-
tion, trauma, and closed-loop obstruction (97).
Perforation can also complicate neoplasms, and
the search for an underlying mass is warranted in
the appropriate clinical setting. Iatrogenic perfora-
tion is occasionally seen following endoscopic pro-
cedures, especially endoscopic biopsy or sphinc-
terotomy (Fig 35) (98).
Helical CT is ideally suited for rapid evaluation
of the abdomen in patients with acute pain from
suspected perforation. CT is often indicated when
free air is seen but the perforation site is unclear at
conventional radiography. Because CT is more
sensitive than conventional radiography in the de-
tection of subtle pneumoperitoneum, it is also in-
dicated when free air is strongly suspected despite
normal abdominal radiographic findings (99,100).
Unenhanced CT is often performed to expedite
evaluation. If possible, oral and intravenous con-
trast material should be used to help localize the
perforation and characterize complications includ-
ing peritonitis and abscess formation. In supine
CT, the anterior peritoneal surface of the liver is
the most nondependent portion of the body and is
often the location where extraluminal air can first
be detected. However, detection of the actual site
of perforation is often challenging because the lo-
cation of the free air does not necessarily correlate
with the site of perforation (76,101). Extravasation
RG ■ Volume 20 • Number 3 Urban and Fishman 743

35. 36.
Figures 35, 36. (35) Perforating gastric cancer in a 61-year-old man who had undergone endoscopy. Axial
CT scan obtained with intravenous contrast material demonstrates extensive extraluminal air, predominantly
in the retroperitoneum. The exact site of perforation can be difficult to determine if there is a large amount of air,
especially in patients with iatrogenic perforation. (36) Perforated benign gastric ulcer in an elderly man. Axial CT
scan obtained with intravenous contrast material demonstrates free air anterior to the liver (black arrow) as well
as focal extraluminal oral contrast material (white arrow), which helped localize the perforation in the stomach.

many institutions helical CT angiography has es-

Figure 37. Ruptured abdominal aortic aneurysm in a
69-year-old man. Axial CT scan obtained with intrave-
nous contrast material demonstrates massive extrava-
sation of contrast material. Intraoperative repair was
unsuccessful, and the patient died.
of oral contrast material is the most accurate local-
izer but is absent in many patients (Fig 36). If
present, focal fluid, air, or inflammatory changes
near the site of perforation are often helpful for
localization.
Vascular System
sentially replaced conventional angiography in the
evaluation of aortic aneurysms (9,102). Tailored
evaluation requires rapid (³3 mL/sec) intravenous
bolus administration of contrast material for opti-
mal vascular opacification. Narrow (3-mm) colli-
mation is also preferred for optimal vascular opaci-
fication and high-quality 3D images. Oral contrast
material is not administered because it can inter-
fere with CT angiographic reconstruction. Helical
CT can be used to accurately measure the diam-
eter of the aneurysm and allows direct visualiza-
tion of mural thrombus and the outer aneurysm
wall. In addition, the origin and length of the an-
eurysm and its relationship to the renal and iliac
arteries can readily be assessed (102,103).
Rupture is a catastrophic complication of ab-
dominal aortic aneurysm, with mortality rates ap-
proaching 95%. Up to 40% of patients die within
1 hour of the onset of symptoms (104). Some pa-
tients survive long enough to receive medical at-
tention and undergo imaging evaluation for acute
abdominal pain. CT is the modality of choice for
evaluation of suspected aortic aneurysm rupture.
Pertinent helical CT findings include retroperito-
neal hematoma and extravasation of intravenous
contrast material (Fig 37). Helical CT can often
help localize the exact site of bleeding (Fig 38).
Hemorrhage is most often seen in the retroperito-
neum involving the perirenal spaces (105). The

Aortic Aneurysm Rupture.—With the advent

of helical CT, quality multiplanar and 3D vascu-
lar images can now readily be produced, and at
744 May-June 2000
Figure 38. Ruptured abdominal aortic aneu-
rysm in an elderly man. Axial CT scan obtained
with intravenous contrast material demonstrates
acute extravasation of contrast material from an
aneurysm leak (black arrow). Note the interrup-
tion of intimal calcifications at the site of rupture
(white arrow).
presence of an area of increased attenuation sur-
rounding the aorta does not always indicate rup-
ture; patients with perianeurysmal fibrosis can
demonstrate a thick, often calcified mantle of
chronic inflammatory tissue. Care must be taken
not to mistake perianeurysmal fibrosis for hemor-
rhage; both may demonstrate dramatic enhance-
ment following bolus infusion of contrast material.
At times, patients present with chronic abdomi-
nal pain from impending rupture of enlarging ab-
dominal aortic aneurysms. Aneurysm size is the
most accurate positive predictive factor in deter-
mining which patients are at risk for aneurysm
rupture. Studies have shown that in approximately
30%–40% of patients with aneurysms larger than
5 cm in diameter, the aneurysm will rupture with-
in 5 years of detection. An increase of 1 cm or
more in the diameter of an abdominal aortic aneu-
rysm over the past 6 months is also a worrisome
sign for impending rupture (106). Other indica-
tions for impending rupture include the draped
aorta sign, the high-attenuation crescent sign, and
focal discontinuity of a calcified rim. The draped
aorta sign occurs when an area in the posterior
wall of the aortic aneurysm is undefinable and is
in proximity to the spine. These findings are
highly indicative of aortic wall deficiency and
RG ■ Volume 20 • Number 3
Figure 39. Aortic dissection in a 54-year-old man.
Axial CT scan obtained with intravenous contrast ma-
terial clearly depicts an intimal flap caused by aortic
dissection (arrowhead).
contained leak (107). The high-attenuation cres-
cent sign is the result of hemorrhage within the
mural thrombus or wall of the aneurysm and may
represent the first stage of rupture (108).
Aortic Dissection.—Aortic dissection is defined
as the presence of a hematoma in the middle to
outer third of the aortic wall with subsequent
proximal and distal propagation. The vast major-
ity of dissections lead to a tear in the weakened
aortic intima and break into the aortic lumen
(109). There are a multitude of predisposing fac-
tors for dissection, the most common of which is
hypertension. Patients with aortic dissection typi-
cally present with sharp, tearing chest pain. Dis-
section proximal to the aortic root can lead to in-
volvement of the coronary arteries, resulting in
arrhythmia, cardiac tamponade, infarction, or
even death. Less frequently, aortic dissection can
manifest with acute abdominal pain. This is most
commonly seen when origins of the renal arteries,
celiac axis, or superior mesenteric artery are in-
volved by the dissection flap, resulting in symp-
toms of ischemia or infarction in the involved
vascular distribution.
Helical CT is now considered the screening
modality of choice for aortic dissection (110).
The accuracy of helical CT in this setting is ex-
tremely high, with a sensitivity and specificity of
nearly 100% (110). Tailored helical CT requires
rapid (³3 mL/sec) injection of contrast material
for optimal vascular opacification. Narrow colli-
mation is also optimal for vascular imaging, espe-
RG ■ Volume 20 • Number 3
Figure 40. Bleeding Meckel diverticulum in a 25-
year-old man. Axial CT scan obtained with intrave-
nous contrast material demonstrates bleeding from ec-
topic gastric mucosa within the diverticulum (arrow).
Figure 42. Small bowel hematoma in a 68-year-old
man who was undergoing anticoagulation therapy. The
patient presented 7 days after undergoing heart surgery.
Unenhanced CT scan demonstrates a high-attenuation
hematoma in the proximal small bowel (arrows).
cially 3D imaging. Findings of a contrast material–
filled double channel with an intervening intimal
flap are diagnostic (Fig 39) (110). If one lumen is
thrombosed, it may be difficult to differentiate
dissection from an aneurysm with mural throm-
bus. Associated findings that favor the diagnosis
of dissection include dilatation of the aorta with
compression of the true lumen, irregular contour
of the contrast material–filled portion of the aorta,
Urban and Fishman 745
Figure 41. Peritoneal hemorrhage in a 33-year-old
man who had undergone paracentesis. Axial CT scan
obtained with intravenous contrast material demon-
strates hemorrhagic ascites throughout the abdomen. A
bleeding vessel is identified near the site of recent needle
insertion (arrow).
and differential flow to the kidneys from the dis-
secting intimal flap secondary to involvement of
the renal artery origins.
Hemorrhage.—Patients can present with pain
due to acute abdominal hemorrhage in various
locations, including the gastrointestinal tract, ret-
roperitoneum, and abdominal musculature. A
falling hematocrit and hypotension are indicators
of significant bleeding. Tailored CT evaluation
for abdominal hemorrhage consists of initial
unenhanced CT, which is useful in detecting the
hyperattenuating hematoma, followed by op-
tional contrast-enhanced helical CT with intrave-
nous bolus injection of contrast material (111).
The rate of injection should approach 3–4 mL
per second for optimal vascular opacification.
This helical CT technique has the potential to lo-
calize sites of bleeding, which appear as a blush
of intravenous contrast material from the in-
volved vessel (Figs 40, 41) (111,112). Spontane-
ous bowel hematomas are often seen in the set-
ting of underlying coagulopathy (Fig 42) (113).
The rectus sheath represents one of the most
common sites of spontaneous musculoskeletal
hemorrhage, which can mimic an obstructing or
incarcerated abdominal wall hernia (114,115).
Another relatively common site of spontaneous
746 May-June 2000
Figure 43. Hematoma in a 38-year-old man with he-
mophilia who presented with acute abdominal pain.
Axial CT scan obtained with intravenous contrast ma-
terial demonstrates bilateral hematomas with heteroge-
neous attenuation causing minimal enlargement of the
psoas muscles (arrows).
muscular hemorrhage is the psoas muscle (Fig
43). Bleeding can also result from an underlying
abdominal tumor, especially renal cell carcinoma
(Fig 44) (116).
Conclusions
Helical CT is a rapid and efficient means of evalu-
ating patients with acute abdominal pain. Atten-
tion to proper technique and protocol is essential
for optimizing the CT examination and maximiz-
ing diagnostic accuracy.
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