Gastric volvulus requires at least 180 degrees of rotation and gastric outlet obstruction. Angioedema is not a true inflammatory disease, but it can mimic inflammation because it presents with bowel wall thickening. The small bowel has always been a challenging organ for clinical and radiologic evaluation. Findings in typhlitis include circumferential mural thickening, predominantly of the cecum and ascending colon. Additional findings include pseudosacculations or pseudodiverticulum formation, which occur as a consequence of relative sparing of the antimesenteric border within an affected segment. The major advantage over endoscopy and classic barium studies is the assessment of extraenteric findings, which are relatively common in CD. 13-9 ). Although US is often used in the diagnosis of intussusception in children, its role in the assessment of the small bowel in the adult population is very limited, particularly in the United States. Role of radiology in Abdominal Emergencies. The small bowel mucosa is primarily affected, resulting in progressive villus inflammation and destruction, with resulting induction of crypt hyperplasia. In simple obstruction the bowel is occluded at one or more points along its course. The diagnosis of cecal volvulus may be confirmed on contrast enema or CT. On contrast enema examination a beaklike tapering of the cecum is seen at the level of the volvulus, and contrast usually does not pass into the proximal colon or small bowel. Complications related to typhlitis include the formation of abscesses or fluid collections, bowel perforation, bowel necrosis, and sepsis. 13-11 ). Gastroduodenal Crohn disease (CD) is rare, causing clinical symptoms in 0.5% to 4% of all patients with CD. The upright view of the chest is best for the detection of free air under the diaphragm (pneumoperitoneum), which is an ominous sign of bowel perforation. Although a fair amount of gas is normally seen within the stomach and colon, the small bowel should contain little gas. Ogilvie syndrome, also known as colonic pseudo-obstruction , is characterized by colonic dilatation with obstructive symptoms in the absence of a true mechanical obstruction. A narrow pedicle can be formed leading to torsion of the loops and producing a small bowel volvulus. Pseudopolyps, which are nodular masses of inflamed mucosa, may be seen projecting into the lumen of affected colon. Perforation of peptic ulcers within the duodenal bulb and stomach remains one of the most common causes of GI perforation, warranting close examination of the stomach and proximal duodenum for ulcers when free intraperitoneal gas is identified on CT ( Fig. Primary esophageal disease may result in aortic fistulization as well: esophagitis, foreign body perforation, and advanced esophageal cancer have all been described as underlying causes. 13-28 ). Like CD elsewhere in the GI tract, gastroduodenal involvement may be complicated acutely by obstruction, perforation, abscess, and fistula formation. Note the infiltration of the fat in the lesser sac, Coronal contrast-enhanced computed tomography shows positioning of the pylorus, Contrast-enhanced computed tomography shows an ulcer crater in the gastric antrum, Contrast-enhanced computed tomography shows changes from laparoscopic banding procedure. Toxic megacolon represents acute transmural fulminant toxic colitis resulting in colonic dilatation greater than 6 cm in a patient with clinical signs of toxicity. C. jejuni is one of the most common causes of infectious diarrhea in the United States and is the leading cause of infectious colitis worldwide. Ischemic colitis commonly occurs in the so-called watershed areas supplied by the SMA and IMA at the splenic flexure and decreased perfusion between the IMA and hypogastric artery at the rectosigmoid junction. 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. Emergency Radiology. 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. Even in hospitals with a wide range of diagnostic facilities it can be difficult to rapidly assess and diagnose an abdominal emergency, therefore it is often hard for a first aider to assess abdominal … 13-32 ). With disease progression the bowel wall thickens and becomes featureless due to the loss of haustral folds. Sigmoid volvulus represents torsion or twisting of the sigmoid colon around the mesenteric axis. Computed tomography should be performed with intravenous contrast. If the hemorrhage is acute, the hematoma may have high density. 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. Crohn disease can affect any part of the GI tract but predominantly affects the small bowel (up to 80% of cases) and right colon. Inflammation of the stomach is most commonly diffuse, but it can also be focal process. Ongoing luminal distention and bacterial overgrowth result in lymphatic and venous obstruction leading to mucosal ischemia. The “coffee bean” sign refers to the inverted U shape of the sigmoid colon with a dense white line formed by the apposed colonic walls, which is directed from the pelvis to the right upper quadrant. 13-6 ). The less common internal hernia occurs when there is protrusion of the viscera through a defect in the peritoneum or mesentery into another compartment within the abdominal cavity. This condition can be seen after instrumentation, foreign body impaction, or forceful vomiting. An inflammatory tract develops between a primary internal opening in the anal crypt at the dentate line and extends to a secondary external opening in the perianal skin. Whereas superficial ulcers can be seen only with endoscopy or with barium fluoroscopy, deeply penetrating ulcers may be identified on CT as a focal mucosal outpouching, submucosal edema, perigastric fat stranding, and in the case of perforation, extraluminal gas ( Fig. In the case of malignant duodenal obstruction, many such cases are generally classified as causing “gastric outlet obstruction,” leading to ambiguity as to the precise level of obstruction. Common predisposing factors for ileus include sepsis, electrolyte disturbances, GI infection, and recent surgery. These fistulas can result from primary duodenal perforation, such as from malignancy, ulcer disease, or trauma, or from an extrinsic source, as is often the case with aortoduodenal fistulas. 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. Continuous and symmetrical involvement is the hallmark of UC with distinct transitions between diseased and unaffected segments of colon, which again is in contrast to CD, in which the entire digestive tract may be affected in a discontinuous manner with transmural involvement. Acute exacerbations also require emergent medical attention. ... (Usually it associated with lower risk than other emergency conditions). The duodenum is the shortest segment, with retroperitoneal location and lacking a mesentery. Esophageal foreign bodies are most often ingested by children and patients with cognitive defects. Careful and systematic travel through the bowel loops in multiple planes is the key to success. Patients with infectious colitis may be found to have electrolyte imbalances and leukocytosis. Acute colonic obstructions are emergencies requiring early detection to prevent complications such as perforation or ischemia. In certain patients, such as young women or generally thin patients, US of the right lower quadrant may be the first-line imaging modality. However, it may be indicated in selected cases, such as in the follow-up of patients with inflammatory bowel disease (IBD) or critically ill patients. At the junction of the lesser curvature and antrum lies the incisura angularis. 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. The treatment for infectious colitis varies depending on the organism; however, most cases are self-limiting. In contrast to peptic ulcers in the stomach, duodenal ulcers have very low malignant potential and typically occur because of increased peptic acid secretion, including in the setting of chronic H. pylori infection. Computed tomography may readily identify complications, including bowel ischemia or perforation. Patients with toxic megacolon are typically quite ill with abdominal pain and tenderness, fever, leukocytosis, dehydration, altered mental status, and tachycardia. The duodenum is the most common site for aortoenteric fistulas, owing to the proximity of these two structures in the retroperitoneum. The ileum has an abundance of lymphoid follicles, which are nearly absent in the jejunum. The diverticulum can be associated with mural thickening and hyperenhancement, with focal calcifications at the base (enteroliths), and adjacent mesenteric fat stranding and fluid collections. The findings of various types of vessel injury include laceration, rupture with active haemorrhage, occlusion and, for arteries formation of aneurysm, pseudoaneurysm, dissection or fistula. The rectum is typically spared secondary to extensive collateral blood supply. High-grade obstruction should be suggested when there is a substantive caliber difference between proximal and distal loops of bowel (and absent passage of contrast material through the transition point if delayed imaging is performed). Advanced cases of adenocarcinoma can present with SBO, with pronounced asymmetric and irregular mural thickening noted at the transition point ( Fig. Special Section on Celiac Disease. Acute radiation enteritis occurs within the first few days or weeks after exposure. Colonoscopy can be performed to reduce the volvulus, but surgical intervention, including cecopexy or resection, is indicated in complicated cases. Perforation complicates peptic ulcer disease in approximately 2% to 10% of affected patients. Note the rich pattern of mucosal folds of the jejunum in the left upper quadrant, Causes of Small Bowel Obstruction in Adults, Axial computed tomography (CT) obtained after oral and intravenous contrast administration in a patient with history of treated lymphoma and suspected small bowel obstruction (SBO) shows evidence of complete bowel obstruction at the proximal jejunum, with absence of oral contrast beyond the transition point, Coronal unenhanced computed tomographic (CT) image demonstrates mottled material within the obstructed loop of proximal small bowel (“small bowel feces” sign), adjacent to the transition point, Unenhanced axial computed tomographic (CT) image obtained in an obese patient with abdominal pain and an unremarkable physical examination demonstrates a right paramedian ventral hernia containing a short segment of small bowel, Coronal contrast-enhanced computed tomographic images performed in a middle-age woman with diagnosis of ovarian cancer show multiple liver metastases, Coronal contrast-enhanced computed tomographic image obtained in a young woman with recurrent abdominal pain and gastrointestinal (GI) bleeding shows a long segment of jejunojejunal intussusception, Unenhanced axial computed tomographic (CT) image obtained at the level of the pelvis in a patient with typical features of small bowel obstruction (SBO) show an intraluminal mottled-appearing density causing significant distention of the bowel lumen at the transition point, consistent with an obstructing bezoar, Axial contrast-enhanced computed tomographic image performed in a patient with 3-day history of low-grade fever, abdominal pain, and diarrhea demonstrates diffuse mural thickening of a long segment of distal ileum associated with mucosal hyperenhancement and submucosal edema, as well as a moderate amount of free fluid. Contrast-enhanced CT is the imaging modality of choice to evaluate the bowel in cases of suspected intussusception. It is a C-shaped structure that extends to the ligament of Treitz. Celiac disease in now recognized as a common but largely underdiagnosed disease, with typical diagnostic delay of more than 10 years from the onset of symptoms. In early disease, mucosal edema and hyperemia are encountered, and with disease progression the mucosa develops punctate ulcers that enlarge and may extend into the lamina propria. Endometrial implants may manifest as contiguous or penetrating soft tissue nodules along the antimesenteric border of the bowel wall. At presentation a majority of patients (>95%) are found to have rectosigmoid involvement, which not uncommonly progresses to pancolitis and rarely affects the small bowel. A “beak” sign is seen at the site of the torsion as a fusiform tapering. Imaging, particularly CT, is essential in assessing crucial information that has therapeutic implications. Acutely, obstruction from peptic ulcer disease occurs because of mucosal ulceration and submucosal edema. The nitrous oxide created from the inflammation is believed to inhibit smooth muscle tone, resulting in bowel distention. 13-48 ). If the band slips distally, it may surround a larger portion of the stomach and lead to gastric outlet obstruction. In the acute stage, bowel wall thickening greater than 3 mm is the most consistent cross-sectional imaging finding ( Fig. Ulcerative colitis typically affects patients between 15 and 25 years of age with women slightly more frequently affected than men. January 2017, issue 1 Coronal volume-rendered image obtained from computed tomography (CT) enterography in a patient with small bowel obstruction (SBO) depicts the small bowel anatomy and fold pattern. Click on the volume number you want transferred to your PC. 13-37 ). Gastrointestinal involvement sometimes mimics an acute abdomen or rarely can cause life-threatening hypovolemic shock. Treatment can either be conservative, including nasogastric decompression and nutritional supplementation, or surgical such as duodenojejunostomy. The clinical presentation and imaging findings of esophageal perforation depend on the thickness of the esophageal tear. Trichobezoars are composed of hair and are most common in women and psychiatric patients, often those with long hair. The vascular supply of the small and large bowel is supplied by the celiac trunk, which provides the blood supply from the distal esophagus to the descending duodenum; the SMA, which supplies the distal duodenum, jejunum, ileum, and the large bowel to the splenic flexure; and the inferior mesenteric artery (IMA), which supplies the more distal colon. Because the mucosa receives a majority of the vascular supply to the colonic wall, it is most susceptible to ischemia. This is most commonly seen with gastric adenocarcinoma but can be seen with pancreatic and biliary tumors, primary duodenal tumors, and rarely lymphoma. 13-55 ) and the mesentery is present and “beaking” due to tapered narrowing of the afferent and efferent bowel loops may be seen. Contrast-enhanced CT of the abdomen and pelvis is currently the study of choice in patients with suspected acute diverticulitis, which manifests with pericolic inflammation, engorgement of the adjacent mesenteric vasculature, and focal colonic wall thickening with or without abscess formation ( Fig. On imaging, gastric volvulus presents with a distended stomach, nonpassage of oral contrast, and an abnormal lie to the stomach. Conventional radiography, ultrasonography (US), and computed tomography (CT) are frequently used in the diagnostic work-up of patients with acute abdominal pain. Small bowel obstruction is suspected when multiple gas- or fluid-filled loops of dilated small bowel are present. It affects multiple organs and has been called pseudo-Whipple disease because of clinical, histologic, and radiologic similarities. In contrast to the detailed mucosal evaluation afforded by barium fluoroscopy, CT findings of infectious esophagitis are nonspecific and insensitive, demonstrating a sensitivity of approximately 55% in one study. Due to wide MDCT technology availability, the first-line assessment of vascular abdominal emergencies is CTA. Over 6 hours of on-demand video. Other motility disorders, such as scleroderma and administration of anticholinergic or opioid medications, also may lead to the performance of CT, in patients presenting with acute abdominal pain. Ulcerative colitis, another form of IBD, represents a chronic, idiopathic, diffuse inflammatory process in the colon. {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Monash Emergency & Critical Care Special Interest Group (MECCSIG) - 2020, Abdominal Emergency Radiology Course - Online, bonus abdominopelvic trauma radiology videos, emergency medicine consultants and trainees, junior doctors with interest in radiology, physician assistants, nurses, medical students, University of Queensland Medical Society (UQMS) - 2020. Patients present with abdominal pain of acute or insidious onset, nausea, and vomiting. In addition, depending on the underlying cause, air-fluid levels, pericolic inflammation, and mesenteric lymphadenopathy may also be visualized on CT in cases of infectious colitis. Disadvantages include operator variability and incomplete evaluation of the small bowel due to intervening gas and obese habitus. 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