Abdominal Radiograph - System and anatomy

Ahmed Ghanem M.D

PGMD,PRB,JRB,ARB

Head of Radiology Dep. NNUH

[email protected]
Bowel Obstruction
Small bowel obstruction (SBO)

Small bowel obstruction (SBO) is a common clinical syndrome for which effective
treatment depends on a rapid and accurate diagnosis.

Despite advances in imaging and a better understanding of small bowel

pathophysiology, SBO is often diagnosed late or misdiagnosed, resulting in
significant morbidity and mortality.

Small bowel obstruction (SBO) is a common clinical condition that occurs secondary
to mechanical or functional obstruction of the small bowel, preventing normal transit
of its contents.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Small bowel obstruction (SBO) is a common clinical condition that occurs secondary to
mechanical or functional obstruction of the small bowel, preventing normal transit of its contents.
Radiology assumes considerable relevance in assisting the therapeutic decision of the surgeon in
cases of SBO by addressing the following questions :

Is the small bowel obstructed?

How severe is the obstruction, where is it located, and what is its cause?

Is strangulation present?

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
CAUSES OF SMALL BOWEL OBSTRUCTION

Mechanical
Adhesions
Postsurgical
Postinflammatory
Incarcerated hernia
Malignancy: usually metastatic
Intussusception
Volvulus
Gallstone ileus
Parasites: Ascaris
Foreign body
Tumors of the small bowel
Crohn disease
Radiation enteritis
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
 Functional (Ileus)
Ileus is a term used for aperistaltic bowel not caused by a mechanical obstruction.

This phenomenon is common after abdominal surgery.

The radiological features can be similar to those of obstruction.

Patients present clinically with crampy abdominal pain, abdominal distention, and vomiting.

Sentinel loop
Intra-abdominal inflammation, such as with pancreatitis, can lead to a localized ileus.

This may appear as a single loop of dilated bowel known as a 'sentinel loop.'

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Imaging

Plain abdominal radiography continues to be the initial examination in these patients due to its
wide availability and relatively low cost.

However, radiographs are diagnostic in only 50%–60% of cases and have high sensitivity only for
high grade obstructions.

Nevertheless, the results of this modality should serve as a basis for triage for further imaging
work-up and assist in the therapeutic decision.
Findings:

(1) dilated loops of small bowel (>3 cm),

(2) small bowel air–fluid levels that exceed 3 cm in width,
(3) air–fluid levels at differing heights within the same loop
(4) small bubbles of gas trapped between folds in dilated, fluid-filled loops producing the “string of pearls” sign, a row of small gas
bubbles oriented horizontally or obliquely across the abdomen.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
CT has become the imaging method of choice to confirm small bowel obstruction and to identify
its cause.

CT reveals the cause of obstruction in 70%to 90% of cases.

CT diagnosis is based upon demonstration of a transition site between small bowel loops dilated
with fluid or air and collapsed bowel loops distal to the obstruction

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Patients present clinically with crampy abdominal pain, abdominal distention, and vomiting.
Conventional radiographs are diagnostic in only 50% to 60% of cases.
Findings of small bowel obstruction on conventional radiography are

(⑴)dilated loops of small bowel (>3 cm),

(2) small bowel air–fluid levels that exceed 3 cm in width,

(3) air–fluid levels at differing heights within the same loop

(4) small bubbles of gas trapped between folds in dilated, fluid-filled loops producing the “string of
pearls” sign, a row of small gas bubbles oriented horizontally or obliquely across the abdomen.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
 Small Bowel Obstruction—Conventional Radiograph. Erect radiograph of the abdomen reveals dilated
air-filled loops of small bowel containing air-fluid levels at different heights within the same loop (arrows).
Note the valvulae conniventes (arrowhead) that extend across the entire diameter of the bowel lumen. The
small bowel obstruction was due to adhesions.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 Images in a 50-year-old man with abdominal pain, nausea, and vomiting. (a) Supine abdominal
radiograph shows dilated small-bowel loops out of proportion to gas in the colon. (b) Upright
abdominal radiograph shows multiple air fluid levels (large and small arrows), fluid levels greater
than 2.5 cm (large arrows), and fluid levels of unequal heights in the same dilated loop of small
bowel (horizontal black lines).

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 Contrast-enhanced axial CT scan in a 65-year-old woman with history of lymphoma. (a) Note the C-shaped fluid-
filled jejunum with a heterogeneously enhancing thickened wall (arrow) with associated mesenteric edema
(arrowhead). At surgery there was a closed loop obstruction with volvulus and jejunal ischemia. (b)
Superimposed schematic illustrates closed-loop obstruction with volvulus, twisted mesenteric vessels, and bowel
ischemia.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 54-year-old man with a remote history of abdominal surgery and intermittent abdominal pain. (a) Dilated
and fluid-filled jejunum (arrow) with beaklike narrowing (arrowheads) both proximally and distally,
consistent with closed-loop obstruction without volvulus or ischemic changes. Note proximal bowel is
dilated and filled with contrast material. (b) Superimposed schematic shows a closed loop obstruction
caused by an adhesion that isolates a loop of fluid-filled bowel.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 Contrast-enhanced CT scan in a 48year-old woman with vomiting and peri-umbilical pain shows dilated fluid and
gas-filled small bowel consistent with SBO. There is an incarcerated loop of small bowel (arrowhead) within a
ventral hernia.
Note the rim of fluid (open arrow) abutting the incarcerated bowel. A decompressed loop of small bowel (solid
arrow) exits the hernia sac

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
LARGE BOWEL OBSTRUCTION
CAUSES OF Large BOWEL OBSTRUCTION

Obstruction
Colon carcinoma (50%–60%)
Metastatic disease, especially pelvic malignancies
Diverticulitis
Volvulus: cecal, sigmoid, transverse
Fecal impaction
Amebiasis
Ischemia
Adhesions
Pseudoobstruction
Ogilvie syndrome
Adynamic ileus
Toxic megacolon
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
 The most common causes of large bowel obstruction are colo-rectal carcinoma and diverticular
strictures.

Less common causes are hernias or volvulus (twisting of the bowel on its mesentery).

Adhesions do not commonly cause large bowel obstruction.

Radiological appearances of large bowel obstruction differ from those of small bowel
obstruction, however, with large bowel obstruction there is often co-existing small bowel
dilatation proximally.

Dilatation of the caecum >9cm, and >6cm for the rest of the colon is considered abnormal.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Conventional radiographs are commonly diagnostic in large bowel obstruction,
demonstrating dilation of the colon from the cecum to the point of obstruction.

The colon distal to the obstruction is devoid of gas (No Gas distally).

When the ileocecal valve is competent, the small bowel usually contains little gas;
the colon is unable to decompress into the small bowel and gaseous distension of the
cecum is progressive.

When the ileocecal valve is incompetent, gaseous distension of the small bowel is
present; the colon can decompress into the ileum and jejunum, and risk of perforation
of the cecum is reduced

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Volvulus

Twisting of the bowel - or 'volvulus' - is a specific cause of bowel obstruction which can have
characteristic appearances on an abdominal X-ray.
The two commonest types of bowel twisting are sigmoid volvulus and cecal volvulus.

Sigmoid volvulus 'coffee bean' sign

The sigmoid colon is more prone to twisting than other segments of the large bowel because it is
'mobile' on its own mesentery, which arises from a fixed point in the left iliac fossa (LIF).

Twisting at the root of the mesentery results in the formation of an enclosed loop of sigmoid colon
which becomes very dilated.

If untreated this can lead either to perforation, due to excessive dilatation, or to ischemia due to
compromise of the blood supply.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
 Sigmoid Volvulus. Radiograph of the abdomen
demonstrates the characteristic massive dilation of the
sigmoid colon (S)
arising from the pelvis and extending to the left diaphragm.
The three
lines representing the walls of the twisted loop converging to
the left
lower quadrant are evident (1, 2, 3).

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Cecal volvulus

The caecum is most frequently a retroperitoneal structure, and therefore not susceptible to twisting.

However, in up to 20% of individuals there is congenital incomplete peritoneal covering of the

caecum with formation of a 'mobile' caecum on a mesentery, such that it no longer lies in the right
iliac fossa.

This is a normal variant but is associated with increased incidence of folding or twisting of the
caecum (cecal volvulus), which may be complicated by obstruction, vascular compromise, or
perforation.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
 Cecal Volvulus. Supine abdominal radiograph
demonstrates displacement of the dilated cecum
(C) to the epigastrium. The more distal colon is
collapsed. The diagnosis was confirmed at
surgery.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Liver trauma
The Liver is one of the most frequently damaged organs in blunt trauma, and liver trauma is associated with a
significant mortality rate.

Aetiology
The mechanism for liver trauma can be from
-blunt (e.g. motor vehicle collision, fall, direct blow, etc.) or
-penetrating trauma (e.g. gunshot, stabbing).
-It can also be iatrogenic (e.g. transcutaneous liver biopsy).

Types

Most (80%) of liver injuries are minor (grades I to III). There is a range of injuries:
laceration (most common)
hematoma - subcapsular or intraparenchymal
active hemorrhage
major hepatic vein injury
Arterio-Venous fistula
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
Radiographic appearance
CT-scan:

CT is the investigation of choice for evaluating for liver trauma.

lacerations appear as irregular linear/branching areas of hypoattenuation.

hematomas appear as a hypodensity between the liver and its capsule (and can be differentiated
from intra-peritoneal hematoma as these distort the liver architecture).

or can be intraparenchymal acute hematomas/hemorrhage are typically hyperdense (40-60HU)

compared to normal liver parenchyma.

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 The AAST (American Association for the Surgery of Trauma) liver injury scale 1994 revision is the most widely used grading
system at the time of writing (mid 2016).
Classification
grade I
hematoma: subcapsular, <10% surface area
laceration: capsular tear, <1 cm parenchymal depth
grade II
hematoma: subcapsular, 10-50% surface area
hematoma: intraparenchymal <10 cm diameter
laceration: capsular tear 1-3 cm parenchymal depth, <10 cm length
grade III
hematoma: subcapsular, >50% surface area of ruptured subcapsular or parenchymal hematoma
hematoma: intraparenchymal >10 cm or expanding
laceration: capsular tear >3 cm parenchymal depth
grade IV
laceration: parenchymal disruption involving 25-75% hepatic lobe or involves 1-3 (within one lobe
grade V
laceration: parenchymal disruption involving >75% of hepatic lobe or involves >3 (within one lobe)
vascular: juxta-hepatic venous injuries (retrohepatic vena cava / central major hepatic veins)
grade VI
vascular: hepatic avulsion
Ahmed Ghanem M.D
Head of Radiology Dep. NNUH
grade I
hematoma: subcapsular, <10% surface area
laceration: capsular tear, <1 cm parenchymal depth

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
grade II
hematoma: subcapsular, 10-50% surface area
hematoma: intraparenchymal <10 cm diameter
laceration: capsular tear 1-3 cm parenchymal depth, <10 cm
length

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
grade III
hematoma: subcapsular, >50% surface area of ruptured
subcapsular or parenchymal hematoma
hematoma: intraparenchymal >10 cm or expanding
laceration: capsular tear >3 cm parenchymal depth

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
grade IV
laceration: parenchymal disruption involving 25-75%
hepatic lobe or involves 1-3 (within one lobe

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
grade V
laceration: parenchymal disruption involving >75% of
hepatic lobe or involves >3 (within one lobe)
vascular: juxta-hepatic venous injuries (retrohepatic vena
cava / central major hepatic veins)

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
 Arteriovenous malformation

Ahmed Ghanem M.D

Head of Radiology Dep. NNUH
?