Acute and chronic inflammation, such as CD and radiation enteritis, can lead to fibrosis, strictures, and, in more severe cases, obstruction. Weight loss, malabsorption, and perianal fistulas and fissures are also frequently observed. Fatty infiltration of the bowel wall may occur in chronic IBD and was thought to be pathognomonic of this disease. Abdominal Radiology seeks to meet the professional needs of the abdominal radiologist by publishing clinically pertinent original, review and practice related articles on the gastrointestinal and genitourinary tracts and abdominal interventional and radiologic procedures. The upper gastrointestinal (GI) tract, including the esophagus, stomach, and duodenum, is a common but potentially overlooked site of disease that may prompt presentation to the emergency department (ED), including inflammation and infection, obstruction, and perforation. Esophageal obstruction by a malignant stricture usually manifests with short segment involvement and mucosal shouldering on fluoroscopy. This three-day course is designed to provide the practicing radiologist an intensive hands-on experience in imaging interpretation of traumatic and non-traumatic emergencies. Bleeding usually occurs within the submucosal layer. In addition, the fluid within the distended loops of bowel acts like a natural neutral oral contrast, as long as nasogastric tube decompression is not performed before imaging ( Fig. Angioedema is not a true inflammatory disease, but it can mimic inflammation because it presents with bowel wall thickening. 13-56 ). Colonoscopy can be performed to reduce the volvulus, but surgical intervention, including cecopexy or resection, is indicated in complicated cases. Click on the volume number you want transferred to your PC. Online case-based review of abdominal emergency radiology featuring over 6 hours of video recordings by Dr Vikas Shah, Dr Jeremy Jones and Dr Andrew Dixon. Another helpful imaging feature in SBO is the “small bowel feces sign,” or the presence of mottled, particulate matter and gas within the lumen that simulates the appearance of feces. Computed tomography can help determine whether small or large bowel is affected, assess the location and severity of obstruction, and identify the cause and potential complications. Contrast-enhanced CT has become the imaging modality of choice in cases of suspected ischemic colitis with imaging features of circumferential bowel wall thickening and pericolic inflammation ( Fig. 13-8 ). The findings that indicate strangulation include bowel wall thickening and hyperattenuation, a halo or target sign, mesenteric fat stranding and/or fluid, pneumatosis intestinalis, and mesenteric or portal venous gas, but these findings are not entirely specific. Jejunoileal diverticula are less common but usually multiple and localized to the proximal jejunum. Larger ulcers are seen with cytomegalovirus and human immunodeficiency virus (HIV) esophagitis. Imaging of Gastrointestinal and Abdominal Emergencies in Binge Drinking. Duodenal peptic ulcers are more common than gastric ulcers, typically solitary, and located in the duodenal bulb in 5% to 11% of patients. Bacteria, viruses, and fungi may penetrate the damaged colonic mucosa and proliferate in the setting of a compromised immune system and neutropenia, leading to subsequent colonic edema and inflammation. A false diagnosis of colonic obstruction, particularly in patients with obstructive symptoms, may lead to inappropriate surgical exploration. Although the incidence of peptic ulcers has decreased since the advent of H. pylori treatment and proton pump inhibitors, they remain a potential cause for presentation to the ED. 13-49 ). Abdominal pain is one of the most frequent reasons that elderly people visit the emergency department (ED). There are no clear guidelines when or when not to request an abdominal X-ray (AXR). Differentiation will depend on the clinical history, distribution pattern, and often biopsy. Potential advantages include the indirect assessment of bowel transit time, which may aid in the diagnosis of partial low-grade obstruction, and the progressive dilution of contrast as the contrast column approaches the transition point, which may help to determine its location ( Fig. Normal esophageal wall thickness on CT is less than or equal to 5 mm. Although these organs have traditionally been evaluated by fluoroscopy, which offers mucosal detail, computed tomography (CT) is now the first-line imaging modality in most EDs, warranting knowledge of the appearance of these diseases on cross-sectional imaging as well. These include (1) confirming (or excluding) SBO and elucidating alternative diagnoses in the absence of SBO; (2) assessing complexity/severity of the obstruction (simple versus closed-loop, complete versus partial, low-grade versus high-grade), and identifying the presence of complications (strangulation, perforation); (3) determining the presence and location of the transition point; and, whenever possible, (4) establishing the underlying cause ( Box 13-1 ). As opposed to ulcerative colitis (UC), rectal involvement is very rare in CD. In patients with Ogilvie syndrome, CT readily demonstrates marked colonic distention with a long segment of relative transition to more collapsed bowel occurring in the absence of an obstructing lesion. ED abdominal x-rays, in one observational study, lead to a change in management only 4% of the time. Colonic intussusception refers to invagination or telescoping of a proximal loop of bowel (intussusceptum) into the lumen of an adjacent, distal segment of bowel (intussuscipiens). Sepsis from a perirectal abscess usually resolves after antibiotic treatment and surgical drainage; however, in approximately 25% of patients the abscess cavity does not resolve completely, and the infection decompresses to the skin. The imaging appearance of groove pancreatitis may overlap with pancreatic adenocarcinoma considerably, but groove pancreatitis classically manifests with low-attenuation cystic areas (“cystic degeneration”) in the descending duodenal wall and soft tissue in the pancreaticoduodenal groove resulting from fibrosis. Careful and systematic travel through the bowel loops in multiple planes is the key to success. Age>65 Immunocompromised (e.g. Aphthous ulcers with a target appearance, deep fissuring ulcers, and lymphoid hyperplasia are characteristic findings on colonoscopy. The gastric antrum demonstrates a thicker wall on CT and can normally demonstrate mural stratification, owing to its greater muscular composition and increased peristalsis in this segment. The second (descending) portion of the duodenum contains the ampulla of Vater and abuts the pancreas, forming the pancreaticoduodenal groove. 13-10 ). If you are from a low or middle-income region you may be eligible for free access to all Radiopaedia.org courses. Mucosal hyperenhancement reflects inflammation, and the degree of enhancement correlates with the degree of inflammation. 13-35 ). Intussusception is a benign and common condition in children younger than 3 years old, but a rare cause of bowel obstruction in adults. On imaging, gastric volvulus presents with a distended stomach, nonpassage of oral contrast, and an abnormal lie to the stomach. Although colonic dilatation is nonspecific, additional imaging findings that may be identified in patients with toxic megacolon include thickened bowel wall and markedly edematous haustra. Differentiation between partial and early SBO can be challenging in the absence of clinical information. The most common cause of acute colonic obstruction is malignancy, usually occurring in the sigmoid colon ( Fig. Computed tomography diagnosis relies on the identification of a blind-ending, tubular, round, or oval structure in the right lower quadrant or periumbilical region, with surrounding inflammation. Conservative management is preferred when possible, and surgery is performed much more selectively than in the past. On CT a distended colon with a markedly thickened and nodular bowel wall and submucosal edema may be seen ( Fig. The initial periumbilical abdominal pain represents referred pain from visceral innervation due to appendiceal luminal distention, and localized right lower quadrant pain is secondary to inflammation of the parietal peritoneum. It can be secondary to intraperitoneal seeding, hematogenous spread, or direct extension from an adjacent visceral malignancy. Extrinsic causes of obstruction, such as hernias and CD, are associated with other extraintestinal findings. It is characterized by stricture formation and obstruction. In selected cases, delayed scans can be performed to confirm complete obstruction, although this is rarely performed because the patient’s clinical progression is the primary determinant of management approach in the absence of clear signs of high-grade or closed-loop obstruction. Whipple disease is a rare multisystemic bacterial infection caused by the Whipple bacillus (Tropheryma whipplei) , involving the small bowel (particularly the jejunum), lymph nodes, joints, and central nervous system. In many cases the offending diverticulum may be directly visualized on CT, further increasing reader confidence in the diagnosis of acute diverticulitis. Located on the antimesenteric side of the colon, the epiploic or omental appendages are small, lobulated masses containing adipose tissue and blood vessels, arising from the serosal surface of the colon. Findings in typhlitis include circumferential mural thickening, predominantly of the cecum and ascending colon. Colonic volvulus is associated with a high morbidity, particularly in cases of late presentation. English Radiology.

* There are so many potential causes of abdominal pain that the EMT should not be concerned with diagnosing a particular cause. When present, it is generally located immediately proximal to the transition point and is thus extremely helpful to locating the site of obstruction, which is the next step in the evaluation of SBO ( Fig. In 15% to 20% of patients with UC a fulminant form of the disease may develop that is characterized by extensive inflammation with severe symptoms and colonic dilatation. Extraintestinal manifestations are common, particularly when the colon is involved, and they include abnormalities of the skin, joints, eyes, kidneys, and liver and biliary tree. 13-55 ). Small bowel obstruction is suspected when multiple gas- or fluid-filled loops of dilated small bowel are present. Trichobezoars are composed of hair and are most common in women and psychiatric patients, often those with long hair. Common predisposing factors for ileus include sepsis, electrolyte disturbances, GI infection, and recent surgery. The utility of US for the diagnosis of acute appendicitis is highly operator dependent, and this modality is limited in obese patients and in the presence of gas-filled bowel. Although the pathophysiologic process is not fully understood, typhlitis is likely secondary to a combination of ischemia, infection, and mucosal hemorrhage. In the assessment of small bowel disease, CT enterography, with negative or neutral oral contrast material, can be used to achieve bowel distention and to improve evaluation of bowel wall morphologic characteristics, thickness, and enhancement. Protocols are variable but generally include multiphasic coronal fluid-sensitive sequences. The focus of your assessment process will be to accurately perform a physical examination and SAMPLE history to describe the condition and identify potentially serious conditions such as shock

Due to wide MDCT technology availability, the first-line assessment of vascular abdominal emergencies is CTA. Thumbprinting, nodules, inflammatory polyps, and ulcers are additional findings that may be identified in cases of infectious colitis on barium enema. Treatment of duodenal diverticulitis may be operative or nonoperative (i.e., antibiotics), depending on the clinical condition and stability of the patient. Nonetheless, lymph nodes larger than 10 mm in short axis should prompt evaluation for superimposed lymphoma or carcinoma ( Figs. In cases of suspected ischemic colitis the mesenteric vessels should be closely scrutinized for obstructing arterial or venous thrombi. Adynamic ileus is associated with bowel distention that may include the colon, in addition to the small bowel and stomach. These tears may have no imaging findings, particularly on CT. On barium studies they may manifest as linear collections of contrast, classically in the distal esophagus, corresponding to mucosal tears identified on endoscopy ( Fig. Acute colonic obstructions are emergencies requiring early detection to prevent complications such as perforation or ischemia. Crohn disease is more common in white and Jewish populations and in northern Europe and North America and typically occurs in the second and third decades of life, affecting both sexes equally. Cytomegalovirus can be reactivated in the setting of immunosuppression and can result in hemorrhagic enteritis. 13-13 ). Gastric adenocarcinoma is complicated by perforation in 0.4% to 6.0% of cases and is more common in patients older than 65 years of age. A potential advantage over CT that has been proposed is the characterization of malignant versus benign strictures. Gastroduodenal Crohn disease (CD) is rare, causing clinical symptoms in 0.5% to 4% of all patients with CD. However, this imaging finding is nonspecific and may be seen in patients with CD, pseudomembranous colitis, ischemic and radiation enterocolitis, infectious colitis, and bowel edema. As opposed to sigmoid volvulus, in which the cause is usually acquired, the most common predisposing factor to cecal volvulus is an abnormal embryologic connection of the right colon to retroperitoneum resulting in increased mobility of the cecum. 13-28 ). There are numerous additional inflammatory conditions of the small bowel that will present with nonspecific bowel wall thickening, including eosinophilic gastroenteritis, amyloidosis, Behçet syndrome, and primary lymphangiectasia. Gastritis has many potential underlying causes, including Helicobacter pylori infection, nonsteroidal antiinflammatory medications, and alcohol. As a result the radiologist plays a central role in answering specific questions to diagnose SBO and to guide conservative versus surgical management. Gastric outlet obstruction due to gallstones, termed Bouveret syndrome , is a rare subset of gallstone ileus that presents classically with a triad of pneumobilia, an ectopic gallstone, and bowel obstruction ( Fig. 13-51 ). On CT, abnormally increased mucosal and serosal enhancement of affected colonic segments, bowel wall thickening, and ascites are suggestive of infectious colitis ( Fig. Magnetic resonance imaging is the imaging modality of choice to depict the anatomy of the anal sphincter and perianal structures. Freed will thoroughly review all imaging aspects of your case and correlate with clinical history made available to the interpreting radiologist at the time of imaging. 13-48 ). The first segment of the small intestine, the duodenum is typically 25 to 38 cm in length and extends from the gastric pylorus to the duodenojejunal flexure (ligament of Treitz). The major advantage over endoscopy and classic barium studies is the assessment of extraenteric findings, which are relatively common in CD. In addition, imaging findings of septic thrombophlebitis may be visualized on CT, including thrombus in mesenteric and portal veins. Infectious esophagitis may have characteristic findings on barium fluoroscopy depending on the causative pathogen. Presenting signs and symptoms in patients with acute ischemic colitis include the acute onset of mild to severe crampy abdominal pain, nausea, and vomiting; bloody diarrhea and rectal bleeding may also occur several hours after the onset of abdominal pain. Perforation complicates peptic ulcer disease in approximately 2% to 10% of affected patients. Computed tomography findings of active inflammation in CD include significant mural enhancement and stratification due to submucosal edema (target or “double-halo” appearance), adjacent mesenteric fat stranding, and engorged vasa recta (“comb” sign). It results from incomplete absorption of the omphalomesenteric duct and is frequently associated with heterotopic gastric or pancreatic mucosa in up to 50% of cases, with gastric heterotopia being most common. The role of CT and MRI in CD has expanded with recent advances in technology allowing for rapid acquisition of high-resolution images of the bowel. Adhesions can be differentiated from fistulas because they are fibrotic and tend to be thinner and enhance later. Although subjective, features favoring high-grade obstruction include (1) the presence of multiple air-fluid levels, particularly when discrepant levels are seen within the same loop, (2) dilated loops averaging more than 2.5 cm in diameter and/or exceeding 50% of the caliber of the largest visible colonic loop, and (3) a large number of distended loops of bowel. It should be noted that adhesions, the most common cause of SBO in the United States, are typically not visible on CT and can be suggested in regions of an abrupt transition point when no clear cause is seen. Comorbidities include psychiatric conditions, advanced age, and institutionalization in medical facilities. In addition to benign causes, primary or metastatic esophageal tumor may also perforate, particularly following palliative dilatation and/or stenting. Although a strict size limit for normal appendices, similar to ultrasonographic imaging, is not applicable to CT given the lack of compression, acutely inflamed appendices are typically dilated and approach or exceed 1 cm in diameter. Computed tomography is the imaging study typically requested in the ED. Gastric volvulus requires at least 180 degrees of rotation and gastric outlet obstruction. In addition, CT may show inflammation or fluid tracking along the connector tubing and/or port; when seen, this should prompt evaluation of the band as the site of erosion or infection ( Fig. Bouveret syndrome has a high mortality rate and is typically treated surgically. The epiploic appendages may become inflamed or torsed, resulting in infarction. Chronic perforation of the stomach complicates 1% to 3% of patients with gastric bands and results from erosion of the band into the stomach lumen. When the hair extends from the stomach into the small and/or large bowel this has been termed Rapunzel syndrome ( Fig. Magnetic resonance enterography can play an important role in the follow-up of patients with established IBD, or it can be used to exclude IBD in a young patient who presents with symptoms suggesting the disease. There is often a skin opening with erythema and focal granulation tissue with purulent or serosanguineous discharge. The inflamed and edematous appendix is dilated and fluid filled and exhibits surrounding periappendiceal edema and fat inflammation ( Fig. As described earlier, deformity of bowel loops, such as pseudodiverticulum formation, is caused by asymmetric involvement by longitudinal ulcers and scars, both of which are well demonstrated on both axial and coronal images. Although a fair amount of gas is normally seen within the stomach and colon, the small bowel should contain little gas. Strangulation is defined as closed-loop obstruction associated with intestinal ischemia, and its occurrence depends on the time and degree of rotation of the incarcerated loops. More specific findings include absent, asymmetric, or delayed bowel wall enhancement, with or without focal mesenteric fluid or hemorrhage ( Fig. Small bowel obstruction (SBO) and inflammation are common conditions, often presenting with nonspecific signs and symptoms, similar to those seen in other acute abdominal disorders. It can cause bowel wall thickness of 1 cm or more, but it will often extend for less than 15 cm in length. 13-40 ). The diagnosis of partial low-grade obstruction is more challenging and considered a relative “blind spot” for CT because the degree of caliber change is generally less striking. Computed tomography is useful in select cases for definitive diagnosis and localization, and identifying suspected complications such as esophageal perforation ( Fig. Computed tomography findings include the pathognomonic bowel-within-bowel configuration, with or without mesenteric fat and mesenteric vessels. 13-20 ). The port is usually placed outside the peritoneal cavity, either within the rectus abdominis muscles sheath or under the external thoracic fascia. On imaging, marked dilatation of the colon is seen on abdominal radiography with the cecum and ascending and transverse colons more severely affected. Delayed images can provide confirmation of a complete obstruction in the appropriate setting. Watch Now. If the hemorrhage is acute, the hematoma may have high density. There is a large overlap in the CT appearance of infectious and noninfectious esophagitis, such as from reflux or radiation. It is estimated to affect approximately 5% of women of reproductive age. Finally, a central “dot” of increased attenuation within the inflamed appendage may be identified and represents an engorged or thrombosed central vein. On imaging, acute diverticulitis may yield abnormalities on abdominal radiographs, including pneumoperitoneum, bowel obstruction, or the presence of a focal region of increased soft tissue density related to the presence of an abscess. Share. 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