The Acute Abdomen

 Chapter Outline
 Technical Considerations
 Appendicitis
 Diverticulitis
 Bowel Obstruction
 Acute Cholecystitis
 Choledocholithiasis
 Peptic Ulcer Disease
 Pancreatitis
 Perforation
 Intestinal Ischemia
 Abdominal Sepsis
 Epiploic Appendagitis
 Omental Torsion and Infarction
 Mesenteric Adenitis
 Infectious Enterocolitides
 Inflammatory Bowel Disease
 Small Bowel Diverticulitis
 Abdominal Aortic Disease
 Hemorrhage
 Hepatosplenic Vascular Disease
 Renal Colic
 Conclusions
The term acute abdomen  defines a clinical syndrome characterized by the sudden onset of severe abdominal pain
requiring emergency medical or surgical treatment. A prompt and accurate diagnosis is essential to minimize morbidity
and mortality. The differential diagnosis includes an enormous spectrum of infectious, inflammatory, obstructive, and
neoplastic disorders ranging from benign self-limited diseases to conditions that require emergency surgery ( Fig. 124-
1 ). In a review of approximately 30,000 patients with acute abdomen, Shah observed that 28% of patients had
appendicitis, 9.7% had acute cholecystitis, 4.1% had obstruction of the small bowel, 4% had acute gynecologic
disease, 2.9% had acute pancreatitis, 2.9% had acute renal colic, 2.5% had perforated peptic ulcer, and 1.5% had
diverticulitis. For one third of patients, no cause could be determined.

Figure 124-1
Leading causes of acute abdominal pain by quadrants.
A. Causes of right upper quadrant pain: 1, cystic duct obstruction; 2, cholecystitis; 3, cholangitis, biliary obstruction; 4,
duodenitis, duodenal ulcer; 5, gastritis, gastric ulcer; 6, pancreatitis, pancreatic cancer; 7, pyelonephritis, renal
infarction, renal or ureteric stone, hydronephrosis; 8, subhepatic appendicitis; 9, pneumonia, pleural effusion,
pulmonary embolism; 10, hepatitis, liver abscess, hemorrhage in liver tumor, acute hepatic congestion (right-sided
heart failure), Budd-Chiari syndrome, portal vein thrombosis. B. Causes of left upper quadrant pain: 1, gastritis, gastric
ulcer; 2, pancreatitis, pancreatic cancer; 3, subphrenic abscess; 4, splenic infarction and infection; 5, cardiac causes,
including pericarditis, pericardial effusion, myocardial infarction; 6, left lower lobe pneumonia, effusion, pulmonary
embolism; 7, hiatal hernia, gastroesophageal reflux disease; 8, pyelonephritis, renal infarction, ureteric
stone. C. Causes of right lower quadrant pain: 1, appendicitis; 2, mesenteric adenitis, torsion of the greater omentum;
3, Meckel’s diverticulum, ileal diverticulitis; 4, Crohn’s disease, infectious or ischemic ileitis; 5, diverticulitis of a
redundant sigmoid colon; 6, infectious, ischemic, or inflammatory colitis, epiploic appendagitis; 7, renal infection or
infarction, ureteric stone; 8, ovarian disease, including cyst rupture, torsion, pelvic inflammatory disease, ectopic
pregnancy; 9, infectious and inflammatory cystitis. D. Causes of left lower quadrant pain: 1, diverticulitis, epiploic
appendagitis; 2, infectious, inflammatory, or ischemic colitis; 3, ovarian disease, including cyst rupture, torsion, pelvic
inflammatory disease, ectopic pregnancy; 4, pyelonephritis, renal or ureteric stone; 5, infectious and inflammatory
cystitis.
(From Dieter B, Modder U: Diagnostic Imaging of the Acute Abdomen. Berlin, Springer-Verlag, 1988, p 5.)
The clinical diagnosis of acute abdomen can be challenging because results of physical examination, clinical
presentation, and laboratory examination are often nonspecific and nondiagnostic. Sonography has developed a niche
in evaluating the gallbladder in all patients and the appendix in children and pregnant women. Magnetic resonance
(MR) is being used with increasing frequency in pregnant women. Multidetector computed tomography (MDCT),
however, has become the premier technique for triage of most patients with acute abdomen. MDCT has earned this
role because it can provide a global perspective of the gut, mesenteries, omenta, peritoneum, retroperitoneum,
subperitoneum, and extraperitoneum uninhibited by the presence of bowel gas and fat. MDCT scanning allows thinner
contiguous images to be obtained without increasing radiation exposure and without respiratory misregistration.
Multiplanar reformatted images can be obtained with virtually isotropic data sets. The rapidity of scanning allows
several acquisitions to be obtained during different phases of a single intravenous bolus of contrast material. The
cross-sectional imaging features of the most common abdominal disorders causing the acute abdomen are discussed
in this chapter.
Technical Considerations
A variety of MDCT protocols for preparation of the patient and scanning have been created to study the diversity of
diseases that can cause acute abdomen. The selection of an imaging technique depends on the most likely diagnosis,
clinical setting, and local expertise. The examination should be tailored to each patient. See Chapter 5 for a more
complete discussion of abdominal CT protocols.
It is best to obtain a general survey examination that includes the entire abdomen and pelvis. Diagnostic errors will
occur if the anatomic coverage is dictated solely by the vagaries of clinical diagnosis. Scans are obtained from the
diaphragm to beneath the symphysis pubis. Coronal and sagittal reformatted images are helpful in establishing a
diagnosis.
Intravenous administration of contrast material is helpful in the diagnosis of splanchnic venous thrombosis, bowel
ischemia, aneurysms, and active arterial extravasation as well as solid parenchymal organ abnormalities.
Inflammatory mural changes in appendicitis, cholecystitis, diverticulitis, Crohn’s disease, and infectious enterocolitis
are also better depicted with vascular enhancement. Neoplasms, abscesses, and infarcts in the liver, spleen, and
kidneys are well portrayed on contrast-enhanced scans. Intravenously administered iodinated contrast material carries
the risk of nephrotoxicity and potential reaction to the agent, and it may obscure renal and ureteral stones. However,
in most patients, the information provided justifies the risk and extra expense. Between 125 and 150 mL of 60%
iodinated contrast material should be injected intravenously at a rate of at least 3 mL/s. Scans are obtained during the
portal venous phase with a 60- to 70-second delay. Arterial phase imaging (40-second delay) is useful in patients with
suspected hemorrhage, bowel ischemia, and arterial thrombosis. Delayed scans through the kidneys and pelvis can
reveal pyelonephritis, renal masses, and bladder disease that might have been overlooked during earlier phases.
When bowel obstruction, intestinal ischemia or infarction, ileus, intestinal infection, or inflammation is suspected, the
intrinsic fluid in the gut often serves as an excellent gastrointestinal luminal contrast agent. Positive contrast agents
may lead to algorithm undershoot or overshoot and may interfere with assessment of bowel enhancement and
viability. No oral contrast agent, water, or a low-contrast agent such as VoLumen may be given in these cases. For
suspected kidney or ureteric stones and ruptured abdominal aortic aneurysms, scans without oral or intravenous
administration of contrast material should first be obtained.
For patients with nonspecific symptoms and signs, we prefer to give 800 to 1000 mL of a 2% solution of oral, diluted,
water-soluble contrast material at least 1 hour before scanning. Oral contrast material is administered primarily to
differentiate bowel loops from abdominal and pelvic masses and abscesses. Oral contrast material may obscure the
diagnosis of bowel hemorrhage or ischemia and limit the detection of ureteral stones, appendicoliths, and bile duct
stones. Practical difficulties of using oral contrast material include the time it takes to opacify the gut, the randomness
of contrast opacification, and the inability of sick patients to consume and to retain sufficient quantities of the agent.
The use of rectal contrast material is advocated by some investigators to optimize the detection of appendicitis,
diverticulitis, and epiploic appendagitis. With the patient in the left decubitus position, 400 to 600 mL of a 3% solution
of water-soluble contrast agent is administered by gravity through a soft rubber rectal catheter without use of a
balloon. The patient is then turned to the supine position for scanning.
An alternative approach to the patient with acute abdomen is to perform CT without oral, intravenous, or rectal
administration of contrast media. This technique is fast, is virtually risk free, and causes no patient discomfort.
However, these scans are the most difficult to interpret, particularly in patients with little abdominal or pelvic fat.
Appendicitis
Acute appendicitis ( Fig. 124-2 ) is the most common abdominal surgical emergency, affecting approximately 250,000
people annually in the United States. Although the correct diagnosis can be made in most patients on the basis of the
history, physical examination findings, and laboratory test results, the diagnosis is uncertain in 20% to 33% of patients
who present with atypical symptoms. The diagnosis is most difficult for infants, young children, elderly patients, and
women of reproductive age. In the past, an average negative laparotomy rate of 20% was acceptable. The
widespread use of MDCT for patients with suspected appendicitis positively affects patient outcomes and increases
the number of laparotomies with positive results. The surgical misdiagnosis rate has been reduced from 20% to 40%
without imaging to a current rate of approximately 5% to 10%.

Figure 124-2
Appendicitis.
This intraoperative image shows an enlarged and diffusely inflamed appendix.
The MDCT, ultrasound, and MR findings of acute appendicitis reflect the extent and severity of inflammation ( Fig.
124-3 ). In mild disease, the appendix appears as a slightly distended (6-15 mm in diameter), fluid-filled structure that
shows circumferential symmetric mural thickening ( Fig. 124-4 ). Sometimes, only the tip is inflamed (so-called tip
appendicitis). On sonographic examination, periappendiceal inflammation may be encountered, and pain over the
appendix may be elicited. The inflamed appendix is often hypervascular on color Doppler ultrasound.
Figure 124-3
Appendicitis: sonographic features.
A. A dilated, inflamed appendix is visualized along its long axis on this sonogram of the right lower quadrant. B. The
inflamed appendix, imaged along its transverse axis, shows mural thickening and increased color Doppler flow to the
appendiceal wall, attesting to the hyperemia accompanying the inflammation.

Figure 124-4
Appendicitis: CT features.
Axial image shows a dilated, fluid- and gas-filled appendix ( arrow  ), with mural thickening and periappendiceal
inflammatory changes.
Homogeneous, dense contrast enhancement of the wall is typical on MDCT, but a target sign may be seen on axial
images (see Fig. 124-4 ). Periappendiceal inflammation is manifested as slight haziness of the mesoappendix fat. A
calcified appendicolith is more reliably revealed on CT than on plain radiography. When it is present, the appendicolith
is less well visualized than on CT or ultrasound. With disease progression and perforation, the appendix becomes
fragmented, destroyed, and replaced by a phlegmon or abscess ( Fig. 124-5 ). Associated mural thickening of the
adjacent distal ileum and cecum may also occur. In patients with these symptoms, the specific diagnosis of
appendicitis can be made if an appendicolith is seen in the abscess or phlegmon. If not, the diagnosis of appendicitis
can only be suggested within a differential diagnosis that includes cecal diverticulitis, ileal diverticulitis, Meckel’s
diverticulitis, perforated neoplasm (cecal, appendiceal, or ileal), and Crohn’s disease with abscess formation.

Figure 124-5
Appendiceal abscess.
A right lower quadrant abscess ( arrows ) is identified along the medial aspect of the cecum.
MR ( Fig. 124-6 ) is becoming increasingly used in pregnant patients with high clinical suspicion of appendicitis. The
MR features are similar to those seen on CT. The appendix is distended to a caliber greater than 6 to 7 mm in
diameter with surrounding inflammatory change in the mesoappendix. See Chapter 56 for a more complete discussion
of appendicitis.

Figure 124-6
Appendicitis: MR features.
An inflamed appendix ( arrows and arrowhead ) characterized by mural thickening, intraluminal fluid, and
periappendiceal inflammation is depicted along the lateral aspect of the placenta on this T2-weighted coronal image
obtained in a pregnant woman in the third trimester.
Diverticulitis
Diverticulitis occurs in 10% to 25% of patients with known diverticulosis. It results from a microperforation or, much
less commonly, a macroperforation of a diverticulum into the rich pericolic fat in the subperitoneal spaces surrounding
the colon. These patients typically present with left lower quadrant pain, fever, and leukocytosis. Clinical misdiagnosis
rates range from 34% to 67%. The role of CT for these patients is to confirm the diagnosis, to establish the presence
of complications (e.g., abscess), to provide a road map for percutaneous or surgical therapy, and to suggest
alternative diagnoses for patients in whom diverticulitis has been excluded.
The CT hallmark of diverticulitis is inflammatory change in the pericolic fat, which is observed in 98% of patients ( Fig.
124-7 ). Minimal haziness of adjacent fat occurs in mild cases. Small fluid collections, fine linear strands, and
extraluminal gas bubbles may also occur. In more severe cases, phlegmon or frank abscess formation can occur.
Diverticula are evident in more than 80% of patients, and symmetric mural thickening of more than 4 mm is seen in
about 70% of patients. Other typical features include engorgement of the vasa recta and the presence of fluid in the
inferior portion of the combined interfascial plane.

Figure 124-7
Diverticulitis of the sigmoid colon: CT findings.
Coronal reformatted image shows mural thickening of the junction of the sigmoid and descending colon and a
phlegmon ( arrows  ) in the sigmoid mesocolon.
In some patients, contrast material collects in an arrowhead shape adjacent to the inflamed colonic diverticulum (i.e.,
arrowhead sign of diverticulitis). The offending inflamed diverticulum may appear as a rounded paracolic outpouching
centered in the paracolic inflammation with soft tissue calcium, barium, or air attenuation.
A perforated carcinoma is the major differential diagnostic consideration for patients with sigmoid diverticulitis.
Although the colon wall is usually less than 1 cm thick in acute diverticulitis, in patients with severe muscle
hypertrophy, the wall may be 2 to 3 cm thick, simulating carcinoma. CT findings favoring the diagnosis of acute
diverticulitis include a tethered or saw-toothed luminal configuration, the presence of fluid in the combined interfascial
plane, and engorged vasa recta. An abrupt zone of transition with normal bowel, enlarged local lymph nodes, and
mural thickness greater than 1.5 cm favors carcinoma.
Complications of acute diverticulitis include abscess formation ( Fig. 124-8 ), obstruction of the large and small bowel,
secondary inflammation of the appendix, fistula, sinus tracks, and frank intraperitoneal perforation. Right-sided
diverticulitis is usually difficult to diagnose clinically. Compared with patients with appendicitis, individuals with right-
sided diverticulitis have a more protracted history, milder pain, and a higher point of maximum tenderness, which may
clinically simulate acute cholecystitis. A palpable mass is present in up to one third of patients and can mimic an
appendiceal or cecal tumor.

Figure 124-8
Abscess due to sigmoid diverticulitis.
A large abscess (A) with an air-fluid level is identified in the sigmoid mesocolon.
The MDCT findings of right-sided diverticulitis consist of focal pericolic inflammatory change, slight mural thickening,
and visualization of diverticulum as an outpouching of the right colon at the level of maximum wall thickness. The
offending diverticulum contains gas, fluid, contrast material, or calcified material. The normal appendix should be
seen. If the appendix is not visualized, appendicitis, epiploic appendagitis, typhlitis, or perforated cecal carcinoma
must be considered in the differential diagnosis. See Chapter 55 for a more complete discussion of diverticulitis.
Bowel Obstruction
Obstruction of the small intestine and colon accounts for approximately 20% of acute abdominal surgical conditions.
MDCT has replaced conventional contrast studies because it can more reliably answer several questions. Is
obstruction present? What is the level of obstruction? What is the cause of obstruction? What is the severity of
obstruction? Is the obstruction simple or a closed loop? Is strangulation or ischemia present?
It is important to differentiate between simple and closed-loop obstruction ( Fig. 124-9 ) because the simple
obstruction can be treated conservatively, whereas closed-loop obstruction requires prompt surgical intervention. For
patients with bowel obstruction, scans are best obtained without oral contrast material because intraluminal fluid and
gas serve as natural contrast agents. Intravenous contrast material is important in assessing intestinal perfusion and
ischemia and in delineating the size, configuration, and patency of the mesenteric vessels. If oral contrast material is
given, a delayed plain abdominal radiograph obtained several hours later can determine if the contrast material has
passed into the colon.
Figure 124-9
Strangulated small bowel obstruction.
The intraoperative photograph shows a hemorrhagic-necrotic small bowel due to strangulation caused by a volvulus
surrounding an adhesion.
The CT hallmark of bowel obstruction is the delineation of a transition zone between dilated and decompressed bowel.
Careful inspection of the transition zone and luminal contents often reveals the underlying causes of obstruction. CT is
most helpful in patients with internal and external hernias, neoplasms, gallstone ileus, various forms of enteroenteric
intussusception, and afferent loop obstruction after a Billroth II operation. If no mass, hernia, intussusception, abscess,
or inflammatory thickening is present, adhesion is the most likely diagnosis. The typical adhesion has a beaklike
narrowing, and the affected gut may be difficult to view, depending on the orientation of the loop relative to the axial
plane. Use of the scroll or leaf function and multiplanar reformations in the coronal and sagittal planes can help
establish the correct diagnosis.
The anterior abdominal wall should be carefully inspected to search for prior surgical scars. The small bowel feces
sign is often seen just proximal to the obstruction. If positive oral contrast material is present, it becomes progressively
more dilute as it approaches the level of obstruction. Also the degree of small bowel dilation is largest closest to the
level of obstruction.
An incarcerated or closed-loop obstruction is manifested as a loop-shaped, fluid-filled structure causing proximal
segments to dilate with gas and fluid. The mesenteric vessels have a radial distribution (  Fig. 124-10 ) because they
become stretched and converge toward the U- or C-shaped loop. Two adjacent and collapsed round, oval, or
triangular segments typically represent the afferent and efferent entry points of the torsion site. The mesenteric
vasculature may have an unusual course. When ischemia develops, the bowel wall may thicken and have a target
appearance caused by submucosal edema. Enhancement of the involved bowel wall may be poor or delayed. Fluid
and hemorrhage may collect in the mesentery, bowel wall, and lumen of the involved segment. The mesentery
becomes hazy in appearance, and ascites may develop.
Figure 124-10
Closed-loop small bowel obstruction: CT features.
Axial image shows the obstructed ileal loops converging to a central point in this patient with a transmesenteric
internal hernia. There is mural thickening of the obstructed loops, hypoenhancement of several of the loops ( arrows ),
and edema of the adjacent small bowel mesentery. Ischemic bowel was found at the time of surgery.
In patients with high-grade obstruction of the small bowel, CT has a reported sensitivity of 90% to 99%. CT is less
accurate in patients with low-grade obstruction. Obstruction of the large bowel ( Fig. 124-11 ) can also be
demonstrated by MDCT. See Chapters 46 and 62 for a more complete discussion of bowel obstruction.
Figure 124-11
Carcinoma of the sigmoid colon causing large bowel obstruction.
The coronal reformatted image shows the obstructing sigmoid mass ( curved arrows  ). The cecum is dilated ( double-
headed arrow ), and there are liver metastases.
Acute Cholecystitis
Acute cholecystitis results from obstruction of the gallbladder and its attendant mural inflammation associated with
infection and sometimes necrosis. Most cases are caused by obstructing gallstones in the gallbladder neck or cystic
duct. Because acute cholecystitis develops in only 20% of patients with gallstones, many patients with gallstones with
right upper quadrant pain have other pathologic conditions responsible for their symptoms.
Only 20% to 30% of patients with right upper quadrant pain have acute cholecystitis. The primary sonographic
diagnostic criterion is the sonographic Murphy sign associated with gallstones. Secondary signs of acute cholecystitis
include mural thickening (>3 mm) and stratification, a distended or hydropic gallbladder with loss of the normal tapered
neck and development of an elliptical or rounded shape, and pericholecystic fluid ( Fig. 124-12 ).
Figure 124-12
Acute cholecystitis: sonographic features.
Transverse sonogram of the right upper quadrant shows sludge and shadowing stones within the gallbladder. Mural
thickening ( arrows  ) is associated with edema, producing wall stratification. The patient also had a sonographic
Murphy sign.
Although sonography is the preferred method for diagnosis of acute cholecystitis, CT is frequently the initial
examination because the diagnosis is unclear. The most sensitive CT findings of acute cholecystitis are mural
thickening greater than 3 mm (in the setting of a distended gallbladder) and enhancement of the inflamed wall ( Fig.
124-13A ). Transient, focally increased attenuation of the liver may develop adjacent to the inflamed gallbladder,
resulting from hepatic artery hyperemia and early venous drainage ( Fig. 124-13B ). Less specific signs include
pericholecystic fluid, haziness of the pericholecystic fat, and increased attenuation of the gallbladder bile. CT can also
depict complications of acute cholecystitis, including perforation and gangrene. Intramural or intraluminal gas is
present in emphysematous cholecystitis. See Chapter 77 for a complete discussion of acute cholecystitis.

Figure 124-13
Acute cholecystitis: CT features.
A. Two large stones ( curved arrows  ) are identified within a thick-walled gallbladder. Notice the pericholecystic fluid
( straight arrow  ). B. The more cephalad scan, displayed with a narrow window, shows a region of transient hepatic
attenuation difference ( arrows ) surrounding the inflamed gallbladder (GB).
Choledocholithiasis
Patients with choledocholithiasis typically present with acute right upper quadrant pain, fever, jaundice, and
pancreatitis. Thin-collimation scans are needed to optimize the detection of stones on MDCT. A high-density nidus
may be visualized in the duct, or alternating low- and high-density rings of mixed cholesterol-calcium stones may be
seen. Biliary dilation may be evident proximally. MDCT has a sensitivity of 88%, specificity of 97%, and accuracy of
94% in the detection of choledocholithiasis; however, positive intraluminal and intravascular contrast agents can
obscure the detection of peripherally calcified stones. MR and MR cholangiopancreatography are the premier means
of establishing the diagnosis of choledocholithiasis.
Peptic Ulcer Disease
Patients with peptic ulcer disease often present with nonlocalizing signs and symptoms indistinguishable from those of
acute pancreatitis or cholecystitis, and MDCT is normally the first examination ordered. The most common MDCT
result is focal mural thickening, which is a nonspecific finding. On occasion, an active ulcer or perforation (  Fig. 124-
14 ) is identified, accompanied by inflammatory change of the adjacent fat, mesenteries, and omenta.
 Acute Abdomen - Practical approach
Adriaan van Breda Vriesman and Robin Smithuis
Radiology department of the Rijnland Hospital, Leiderdorp, the Netherlands

 Radiological strategy
 Clinics, laboratory, and plain abdominal film
 Confirm or exclude the most common disease
o RLQ : Appendicitis
o LLQ : Diverticulitis
o RUQ : Cholecystitis
 Screen for general signs of pathology
o Inflamed fat
o Bowel wall thickening
o Ileus
o Ascites
o Free air
 Differential diagnosis
o Mesenteric lymphadenitis.
o Bacterial ileocecitis
o Right-sided diverticulitis
o Pelvic inflammatory disease
o Epiploic appendagitis.
o Urolithiasis
o Ruptured Aneurysm
o Pancreatitis

Publicationdate 2005-10-20

The 'acute abdomen' is a clinical condition characterized by severe abdominal pain, requiring the clinician to make an urgent
therapeutic decision.
This may be challenging, because the differential diagnosis of an acute abdomen includes a wide spectrum of disorders, ranging
from life-threatening diseases to benign self-limiting conditions (Table 1).
Indicated management may vary from emergency surgery to reassurance of the patient and misdiagnosis may easily result in
delayed necessary treatment or unnecessary surgery.
Sonography and CT enable an accurate and rapid triage of patients with an acute abdomen.
We present practical guidelines on the radiological approach of these patients.
Interactive cases are presented in the menubar to test your knowledge.

Radiological strategy

Table 1. Common causes of acute abdomen from life-threatening to self-limiting.

Before you perform an examination, obtain relevant information from the referring clinician.
Don't let the clinician simply 'order' a sonogram or CT, but discuss the patient's age and posture, laboratory results and the number
one clinical diagnosis and differential diagnosis.
Based on that information and your own degree of confidence with the modalities decide for yourself whether to perform
sonography or CT.
Sonography has the advantage of close patient contact, enabling assesment of the spot of maximum tenderness and the severity of
illness without ionizing radiation.
In general the diagnostic accuracy of CT is higher than sonography.
In patients with inconclusive US-results, CT can serve as an adjunct to sonography, and vice versa.
We advocate the following two-step radiological approach of an acute abdomen.
1. Confirm or exclude the most common disease
2. Screen for general signs of pathology
You have to be familiar with all the diagnoses listed in Table 1 to be able to recognize them.

Clinics, laboratory, and plain abdominal

film
The clinical presentation of patients with an acute abdomen is often nonspecific.
Both surgical and nonsurgical diseases may present with a similar clinical history and symptoms.
Laboratory findings (leucocyte count, erythrocyte sedimentation rate, CRP) are equally nonconclusive.
Findings may be normal in patients who need emergency surgery (such as appendicitis) and may be abnormal in patients without a
surgical disease (like salpingitis).
A plain abdominal film has a limited value in the evaluation of abdominal pain.
A normal film does not exclude an ileus or other pathology and may falsely reassure the clinician.

LEFT: Plain abdominal film in a patient with an acute abdomen, showing no abnormalities. RIGHT: Subsequent CT
shows distended small bowel loops (arrowheads) that are not seen on plain abdominal film because they are filled with
fluid only and do not contain intraluminal air.

An ileus may not be appreciated on a plain abdominal film if bowel loops are filled with fluid only without intraluminal air
(figure).
Alternatively if a plain abdominal film does indicate an ileus than sonography or CT are usually needed to identify its cause.
Thus, a plain abdominal film is seldomly useful, with the exception of detection of kidney stones or a pneumoperitoneum.
For all other indications use sonography or CT.

Confirm or exclude the most common

disease

Many disorders may cause an acute abdomen, but fortunately only a few of these are common and clinically important.
Focus on confirming or excluding these frequent disorders:

RLQ : Appendicitis

Pain in the RLQ, regardless of any other symptom or laboratory results, should be considered to be appendicitis until proven
otherwise.
If you are unable to find the appendix you cannot rule out the diagnosis of appendicitis unless a good alternative diagnosis is
found.
If you do not find the appendix and there is no altermative diagnosis call the results of the examination indeterminate. Do not call
it:' no appendicitis'.

Normal appendix : Longitudinal (A) sonogram depicts a blind-ending tubular structure (arrowheads) with 'gut-
signature', with a maximum outer diameter of 6 mm, with noninflamed surrounding fat. On an axial view (B) the appendix
can be compressed crossing the iliac vessels.

Normal Appendix.
Your first task is to identify the appendix.
At sonography and CT the appendix is seen as a blind-ending nonperistaltic tubular structure arising from the base of the cecum.
Do not mistake a small bowel loop for the appendix.
Secondly determine if the appendix is normal or inflamed.
The outer-to-outer diameter of the appendix is the most important imaging criterium.
Although an overlap of appendiceal diameters in normal and inflamed appendices can incidentally be found, a threshold value of
6-7 mm is generally used.

Normal appendix: CT shows an air-containing non-distended appendix (arrowheads), with homogeneous low-
density periappendiceal fat.

A normal appendix has a maximum diameter of 6 mm, is surrounded by homogeneous non-inflamed fat, is compressible and often
contains intraluminal gas.
 Inflamed appendix at sonography. Longitudinal (A) and transverse (B) cross-section show a distended
noncompressible appendix, surrounded bij hyperechoic inflamed fat (arrowheads).

Inflamed Appendix
An inflamed appendix has a diameter larger than 6 mm, and is usually surrounded by inflamed fat. The presence of a fecolith or
hypervascularity on power Doppler strongly supports inflammation.

Inflamed appendix at CT. The appendix (arrows) is fluid-filled and distended with periappendiceal fat-stranding.

CT depicts an inflamed appendix as a fluid-filled blind-ending tubular structure surrounded by fat-stranding.

In the case on the left a hyper-attenuating wall is seen on the enhanced CT.
In patients who lack intra-abdominal fat the use of iv. contrast can be helpfull in depicting the inflamed appendix.

Sigmoid diverticulitis at sonography. A hypoechoic thickened diverticulum is surrounded by hyperechoic inflamed

fat (arrows).
LLQ : Diverticulitis

If the pain is located in the LLQ your main concern is sigmoid diverticulitis.
In diverticulitis sonography and CT show diverticulosis with segmental colonic wall thickening and inflammatory changes in the
fat surrounding a diverticulum.

Uncomplicated sigmoid diverticulitis. Fat stranding and focal thickening of the colonic wall in an area with
diverticula. No abscess formation.

Complications of diverticulitis such as abscess formation or perforation, can best be excluded with CT.

LEFT: Sigmoid diverticulitis. Diverticulum (arrow) is surrounded by hyperattenuating fat. The sigmoid wall is
thickened. RIGHT: Sigmoid carcinoma with limited fat stranding.

An important pitfall is colon cancer, which may present with similar imaging features, especially when the colon cancer is
surrounded by fat stranding due to invasive groth, desmoplastic reaction or inflammation.
Frequently it is not possible to reliably distinguish diverticulitis from colon cancer and therefore we routinely include colon cancer
in the differential diagnosis of sigmoid diverticulitis.

RUQ : Cholecystitis

Cholecystitis occurs when a calculus obstructs the cystic duct. The trapped bile causes inflammation of the gallbladder wall.
As gallstones are often occult on CT, sonography is the preferred imaging method for the evaluation of cholecystitis, also
allowing assesment of the compressiblity of the gallbladder.
The diagnosis of a hydropic galbladder is solely made on the non-compressability of the galbladder. Do not rely on measurements.
Some galbladders happen to be small and others are large.

Longitudinal and transverse US show thickened gallbladder wall. The gallbladder is noncompressible ('hydropic')
and causes an impression in the anterior abdominal wall (arrowheads).

The imaging appearance of cholecystis consists of an enlarged hydropic (meaning non-compressible) gallbladder with a thickened
wall in the region of maximum tenderness (the so-called 'Murphy sign')

Cholecystitis at CT. The gallbladder is enlarged with edematous thickening of its wall (arrowhead), and some
regional fat-stranding can be found.
The inflamed gallbladder usually contains stones or sludge, whereas the obstructing calculus itself may or may not be identified
because it is located deep within the galbladder neck or cystic duct.
The gallbladder may be surrounded by inflamed fat, but on sonography this frequently is not seen, while CT sometimes does show
fat-stranding.
Potential pitfalls are pancreatitis, hepatitis or right-sided heart failure, which all may lead to thickening of the gallbladder wall
without cholecystitis.
Therefore be certain that hydropic obstruction of the gallbladder is present before assigning the diagnosis of cholecystitis.

Pain in LUQ
An acute abdomen with LUQ pain is rare.
Its most common cause is gastric pathology in which radiological imaging plays a minor role.

Screen for general signs of pathology

After excluding these frequent disorders, search for signs of any other pathology, by systematically screening the whole abdomen.
Look for inflamed fat, bowel wall thickening, ileus, ascites and free air.

Inflamed fat at sonography. Extended-view of the ventral abdomen depicting an area of hyperechoic
noncompressible inflamed fat in the omentum (red arrows). Compare this to the echogenicity of normal abdominal or
subcutaneous fat (green arrows). This patient had an omental infarction.
Inflamed fat

Inflamed fat is hyperechoic, space occupying and noncompressible at sonography.

Same patient as above. Unenhanced CT depicts an area of fatty tissue with slightly increased density (arrowheads),
in the right-upper quadrant. Compare this to normal low-density subcutaneous fat. Diagnosis: omental infarction.

Inflamed fat is shown as fat-stranding at CT. Inflamed fat usefully points out where and what the problem is.
As a rule, the organ or structure in the centre or nearest to the inflamed fat is the cause of the inflammation.

Diffuse thickening of bowel wall in a patient with colitis.

Bowel wall thickening

Thickening of bowel wall indicates inflammation or tumor, and has an extensive differential diagnosis.
Thickening of small bowel loops usually indicates regional inflammation, as small bowel tumors (carcinoid, lymphoma, GIST)
are relatively infrequent.
In patients with local colonic wall thickening a carcinoma is a prime concern.

Obstructive ileus. CT depicts distended small bowel loops, but part of the small bowel and the whole colon is
nondistended. Therefore this must be an obstructive small bowel ileus, and in this case its cause can easily be identified:
intussusception (arrowhead).
Ileus

Pathologic distention of bowel loops may be caused by obstruction or paralysis.

Firstly determine which parts of the gut are affected: small bowel, large bowel, or both.
Look for normal nondistended bowel loops, which, if present, strongly suggest an obstructive cause for the ileus.

Scroll through the imagesSmall Bowel Feces Sign: Feces in the dilated small bowel just proximal to the site of obstruction.
Obstruction was due to adhesions

Small bowel obstruction (SBO) accounts for approximately 4% of all patients presenting with an acute abdomen.
The diagnosis of SBO is made when you see dilated small bowel and collapsed small bowel loops.
If obstruction is present, try to identify its cause and location (adhesion, tumor, volvulus, intussusception, inguinal hernia).
Adhesions account for 60-80% of all cases and are the likely cause when a smooth transition from dilated to collapsed small-
bowel loops is noted.

The 'Small Bowel Feces Sign' (SBFS) is a very useful sign as it is seen at the zone of transition thus facilitating identification of
the cause of the obstruction.
The SBFS has been defined as gas and particulate material within a dilated small-bowel loop that simulates the appearance of
feces.
Scroll through the images on the left to see the small bowel feces sign indicating the site of obstruction.

Alternatively, an ileus without any normal bowel loops strongly suggests a paralytic cause.
This is usually a response to general peritonitis, wich may have many possible causes of the inflammation.

Clinically appendicitis. US only showed a little bit of ascites. A diagnostic puncture (arrow marks needletip) revealed
blood. In a woman this finding is very suspicious of an EUG.
Ascites

Asymptomatic volunteers do not have a detectable amount of free intraperitoneal fluid, with the exception of an incidental drop of
fluid in Douglas in fertile women.
The presence of ascites is a nonspecific sign of abdominal pathology, indicating that 'something is wrong'.
You may want to perform a US-guided diagnostic puncture of the ascites, in order to investigate whether it is sterile reactive fluid,
pus, blood, urine, or bile.

Intraperitoneal air in a patient suspected of having appendicitis. Air better seen on images with lungsetting on the
right.
Free air

The presence of free intraperitoneal air is proof of bowel perforation, and indicates a surgical emergency.
A pneumoperitoneum has only two frequent causes:

- Perforation of a gastric ulcer

- Perforation of colonic diverticulitis

Free air is usually not seen in perforated appendicitis).

Always examine the images in lungsetting for better detection of free intraabdominal air (figure).

Differential diagnosis

A complete list of all possible causes of an acute abdomen is of little use in daily practice, therefore we just provide some imaging
examples of several frequent causes of acute abdominal pain

US shows enlarged mesenteric lymph nodes in the right lower quadrant, with no other abnormalities
Mesenteric lymphadenitis.

Mesenteric lymphadenitis is a common mimicker of appendicitis.

It is the second most common cause of right lower quadrant pain after appendicitis.
It is defined as a benign self-limiting inflammation of right-sided mesenteric lymph nodes without an identifiable underlying
inflammatory process, occurring more often in children than in adults..
This diagnosis can only be made confidently when a normal appendix is found, because adenopathy also frequently occurs with
appendicitis.
Key finding: Lymphadenopathy with a normal appendix and normal mesenteric fat.

Normal appendix (green arrow) and enlarged mesenteric lymphnodes (yellow arrows).
On the left a CT of mesenteric lymphadenitis in a child suspected of appendicitis.

US typically shows submucosal wall thickening (arrowheads) of the terminal ileum and cecum without inflammation
of the surrounding fat.
Bacterial ileocecitis

Infectious enterocolitis may cause mild symptoms resembling a common viral gastroenteritis, but it may also clinically present
with features indistinguishable from appendicitis especially in bacterial ileocecitis, caused by Yersinia, Campylobacter, or
Salmonella.

Key finding: ileocecal wall thickening without inflamed fat, adenopathy, normal appendix

CT shows an inflamed cecal diverticulum (arrowhead) with regional colonic wall thickening.
Right-sided diverticulitis

Right-sided colonic diverticulitis may clinically mimic appendicitis or cholecystitis, though the patient's history is generally more
protracted.
In contrast to sigmoid diverticula, right-sided colonic diverticula are usually true diverticula, that is, outpouchings of the colonic
wall containing all layers of the wall.
This may possibly explain the essentially benign self- limiting character of right-sided diverticulitis.

Enlarged adnex due to salpingitis

Pelvic inflammatory disease

Pelvic inflammatory disease is a common mimicker of both of appendicitis and diverticulitis.

Transvaginal sonography depicts an inhomogeneous enlarged inflamed ovary.

CT characteristic of epiploic appendagitis with a right-sided fatty mass surrounded by a hyperattenuating ring.
Epiploic appendagitis.

Epiploic appendages are small adipose protrusions from the serosal surface of the colon.
An epiploic appendage may undergo torsion and secondary inflammation causing focal abdominal pain that simulates appendicitis
when located in the right lower quadrant or diverticulitis when located in the left lower quadrant.
The characteristic ring-sign corresponds to inflamed visceral peritoneal lining surrounding an infarcted fatty epiploic appendage.

Left sided epiploic appendagitis in patient clinically suspected of having a diverticulitis.Characteristic

hyperattenuating ring sign.

Epiploic appendagitis has been reported in approximately 1% of patients clinically suspected of having appendicitis.
It is very important to make a positive diagnosis of this characteristic entity since epiploic appendagitis is a self-limiting disease.
Both US and CT will depict an inflamed fatty mass adjacent to the colon.

Key finding: inflamed fatty mass adjacent to the colon with characteristic ring sign.

Small stone in right ureter (arrow) causing right flank pain.

Urolithiasis

Urolithiasis often causes flank pain, but an ureteral stone (arrowhead) may occasionally present with clinical signs simulating
appendicitis, cholecystitis or diverticulitis.
Appendicitis on the other hand may cause hematuria, pyuria and albuminuria in up to 25% of patients because of ureteral
inflammation from an adjacent inflamed appendix.

Left retroperitoneal fluid collection due to ruptured aneurysm.

Ruptured Aneurysm

Most abdominal aortic aneurysms rupture into the left retroperitoneum (4).
Clinically this may simulate sigmoid diverticulitis or renal colic due to impingement of the hematoma on adjacent structures.
However most patient will present with the classic triad of hypotension, a pulsating mass and back pain.
Continuous leakage will lead to rupture into the peritoneal cavity and eventually death.
Sonography is a quick and convenient modality, but it is much less sensitive and specific for the diagnosis of aneurysmal rupture
than CT.
The absence of sonographic evidence of rupture does not rule out this entity if clinical suspicion is high.

Pancreas surrounded by fat stranding due to exsudative pancreatitis.

Pancreatitis

CT depicts fat-stranding (arrowheads) surrounding the primary focus of the inflammation: the pancreas.

Conclusion
In patients with an acute abdomen 'the stakes are high'.
A misdiagnosis may have serious consequences. We advocate a systematic approach:
1. First focus on the most common diseases and make a firm diagnosis or exclude them.
2. Always screen the whole abdomen for general signs of pathology.