Abdominal Imaging I

.Qais A. Altimimy DMRD, CABMS-RAD

Assistant Professor of Radiology
qtimeme@yahoo.com
qaystimeme@gmail.com

Al-Kindy College of Medicine, University of Baghdad 2019-2020

 Objectives

1. To know the common key findings in abdominal imaging such as pneumoperitoneum, ascites,
bowel dilatation and fat stranding

2. To know the causes and radiological appearance of these key findings

3. To know the definition and advantages of FAST

 :Key Findings in Abdominal Radiology

:Pneumoperitoneum
Describes gas within the peritoneal cavity and is often indicating a critical illness,
.often perforation of a hollow viscus

Most common cause is bowel perforation (DU, trauma, surgical interventions). It may
result from perforation of any part of bowel except the perforated appendix
which seldom causes a pneumpoperitoneum. Other causes include gas tracking
from elsewhere pneumothorax, mechanical ventilation. It is a normal finding
.postoperative for 7 days

Investigation
Erect chest radiograph is the best plain radiograph
Can be detected on an abdominal radiograph
CT much more sensitive than any plain radiograph
Radiographic features

Erect CXR
 .Usually performed after sitting erect for 10 minutes
Look for air under the diaphragm, but don't
.misinterpret gas within bowel or the stomach for free gas

AXR
Performed supine. Gas can be seen when it outlines certain structures. The most
apparent is often when gas within the peritoneum lies adjacent to a bowel loop full of
.gas making the bowel wall appear particularly prominent - Rigler's sign

CT abdomen
Much more sensitive than plain film. Can identify even tiny amounts of free gas. Look
for low-density gas out with bowel, particularly anteriorly in the abdomen (almost all
.patients will be scanned supine)
Double bubble sign
Riglr’s sign Falciform ligament sign

Football sign

Continuous diaphragm sign

 Bowel dilatation
Is a relatively non-specific sign
Small bowel dilatation: mechanical SBO, ileus (e.g. post-operative)
Large bowel dilatation: mechanical LBO, pseudo-obstruction, toxic megacolon

Radiographic features
Normal bowel caliber can be remembered using the 3-6-9 rule: small bowel: <3 cm,
large bowel: <6 cm, caecum/sigmoid: <9 cm
Plain radiograph: Abdominal radiographs are often performed as an initial
imaging test in patients with abdominal pain and distension. Bowel dilatation is
.only visible when the bowel contains gas

CT: Bowel dilatation is much more clearly demonstrated on CT. The degree of
dilatation can be assessed independent of whether the bowel is filled with fluid or
.gas. In addition, the bowel wall and other structures can be interrogated

US: Bowel dilatation can be seen on ultrasound, but this is usually dependent on the
.bowel being fluid-filled and there being no gas-filled bowel anteriorly

MRI: Bowel caliber can be assessed on MRI. With fluid-filled loops of bowel, this is
.most clearly demonstrated on T2 weighted sequences
 Fat stranding
Is a sign that is seen on CT. It describes the change in density of fat around an inflamed
.structure and is a very helpful sign for intra-abdominal pathology

Fat-stranding just means that there is inflammation close by

.Common causes: appendicitis, pancreatitis, cholecystitis, diverticulitis

:Investigation
Fat-stranding is primarily seen on CT. Inflammatory fat may be seen on US and MRI

Radiographic features
CT: Usually fat is dark grey, but when there is oedema in the fat, the density increases
​.and it becomes progressively closer to the color of muscle
 Free intraperitoneal fluid
.May be termed free fluid or (less correctly) free intra-abdominal fluid
Free fluid may be physiological in female patients, usually maximal around ovulation
Inflammation in the abdomen, intra-abdominal sepsis, haemorrhage in trauma

US Abdomen: US is variably sensitive depending on the size of the patient and the
operator. In thin patients, relatively small volume of fluid can be found. Clear fluid
 .without internal echoes is likely to be reactive
Low-volume free fluid in the Pouch of Douglas is often seen in female patients of child-
.bearing age and is often physiological and of no clinical significance

Liver

bowel
bowel
RT kidney
CT Abdomen: CT is more sensitive for generalized free-fluid, useful for assessing
location, associated findings may narrow differential, fat-stranding in inflammation
Fluid on CT is relatively hypo dense (dark). It can be compared to fluid in the
gallbladder or stomach. Dense fluid may suggest haemoperitoneum, especially in
the context of trauma. Fluid may sit within the peritoneal space or paracolic gutters,
.or may be interposed between bowel loops or around solid organs, e.g. the liver
 FAST
Focused assessment with sonography in trauma (FAST)
is a rapid bedside ultrasound examination performed by surgeons, emergency
physicians and certain paramedics as a screening test for blood around the heart (
.pericardial effusion) or abdominal organs (hemoperitoneum) after trauma

:The four classic areas that are examined for free fluid are
,The perihepatic space (also called Morison's pouch or the hepatorenal recess)
 ,The perisplenic space
The pericardium, and
.The pelvis

With this technique it is possible to identify the presence of intraperitoneal or

pericardial free fluid. In the context of traumatic injury, this fluid will usually be due
.bleeding to
Advantages of FAST

FAST is less invasive than diagnostic peritoneal lavage, involves no exposure to

radiation and is cheaper compared to computed tomography, but achieves a similar
.accuracy

Numerous studies have shown FAST is useful in evaluating trauma patients. It also
.appears to make emergency department care faster and better

A good quality FAST can probably reliably detect about 200 mL of free
 .intraperitoneal fluid

Overall, the FAST exam is about 90% sensitive for detecting any amount of
intraperitoneal free fluid
 Liver
Liver

Rt kid
Rt kid

Morison's pouch. A positive FAST - fluid (black stripe, indicated by red arrows) within
spleen e en
spl

A positive FAST - fluid (black stripe, indicated by red

.arrow) within perisplenic space
Interpretation of FAST
TAKE-HOME MESSAGE

1. Pneumoperitoneum is often indicating a critical illness, usually caused by perforated DU

2. Erect CXR is the most sensitive view to detect air under diaphragm
3. Air under diaphragm may be a normal finding post operatively for 1 week
4. Maximum normal bowel diameter is according to the rule of 3/6/9
5. Fat stranding is a useful CT sign to locate the site of inflammatory pathology
6. Free fluid in cul de sac may be physiological in females of child bearing age
7. FAST is a rapid bedside US screening test for free fluid/blood in trauma patient
8. A good FAST can reliably detect 200 ml of intraperitoneal free fluid
Radiographic features

Ultrasound
Ultrasound is the first line investigation for the assessment of jaundice. It is a quick
and cheap test and effective in diagnosing biliary dilatation in the hands of an
experienced operator. It can also help characterize lesions and determine the level of
.obstruction

MRI
MRCP (MR cholangiopancreatography) is
a specific type of MRI of the abdomen. It
looks specifically at the fluid within the
biliary tree and is very helpful when
.determining the level of biliary obstruction

CT
CT is used for the assessment of extrahepatic mass lesions that cause biliary
obstruction and also to determine if there is distant spread in suspected malignancy