IMAGING IN ABDOMINAL PAIN

Sianny Suryawati, dr., Sp.Rad

Radiology Department Faculty of Medicine

Wijaya Kusuma University Surabaya

INTRODUCTION
Abdomen is a part of trunk that lies between the
thorax and pelvis
It is divided into 9 parts by 2 vertical lines : right and
left midclavicular lines; and also 2 horizontal lines :
subcostal and intertubercular lines

9 REGIONS OF ABDOMEN

ABDOMINAL PAIN

Acute abdominal pain is the chief complaint

in about 5% of ED visits
Most patients are discharged after ED
evaluation
Only about 10% require urgent surgery

APPROACH TO ABDOMINAL PAIN

THOROUGH HISTORY

CAREFUL EXAMINATION

HISTORY OF PAIN
Sudden onset
Perforation
Torsion/volvulus

Colicky pain
Hollow viscus obstruction/spasm
Constant pain

Inflammation
Radiation
Shoulder tip/back/loin to groin

EXAMPLES OF NON-TRAUMATIC CAUSES

Role, indications and limitations of each imaging

modality : radiography, US, CT, MRI, scintigraphy
Appropriateness criteria

ACUTE ABDOMEN : A CLINICAL CHALLENGE

Severe abdominal pain develops over a period of

hours

Common chief complaints :

In USA,stomach and abdominal pain ranked first in patient

presentation to emergency departments

Difficult diagnosis :

Broad differentials
Nonspecific history and clinical examination
Nonspecific lab tests

Require all resources to reach accurate diagnosis, timely

management and proper disposition

CONVENTIONAL RADIOGRAPHY

Often the first imaging evaluation

Acute abdominal series

Upright chest to evaluate for pneumonia, subdiaphragmatic

pneumoperitoneum

Upright and supine abdomen

Decubitus view of abdomen if upright radiograph not

possible

To detect small pneumoperitoneum

The patient must be in decubitus position for several minutes

(usually 15') before radiograph taken to allow relocation of
pneumoperitoneum to perihepatic space

Helpful for the detection of :

Pneumoperitoneum

Bowel obstruction

Pneumonia mimicking abdominal pain

Suspected emphysematous pyelonephritis or emphysematous

cholecystitis on ultrasound

Pitfalls/Limitations

Poor sensitivity to detect several causes of acute abdomen

including appendicitis, cholecystitis and diverticulitis

Poor sensitivity to detect small pneumoperitoneum and free

fluid

Low interobserver agreement on the diagnosis of bowel

obstruction (particularly with low-grade small bowel
obstruction)

ULTRASOUND

Right upper quadrant (RUQ) ultrasound

Renal ultrasound

Abdominal ultrasound

Limited ultrasound

RUQ ULTRASOUND

Evaluation of biliary tree (i.e. liver, intrahepatic biliary

duct, common bile duct and gallbladder), pancreas, right
kidney
Indications :

Right upper quadrant pain attributed to hepatobiliary tract

Imaging of choice to evaluate acute cholecystitis

Intra/extrahepatic biliary duct dilatation

Right hydronephrosis, calculi

RUQ US LIMITATIONS (1)

Recent meal (within 4-6 hours) will contract

gallbladder, therefore :
Limiting evaluation for gallstones
May lead to 'false-postive' thickening of gallbladder
wall
Recent morphine will contract gallbladder and mask the
presence of sonographic Murphy's sign

Limited evaluation in patients with :

Obesity (poor ultrasound beam penetration)

Fatty liver (obscuring liver pathology)

Significant bowel gas (obscuring pancreas)

Low sensitivity to detect CBD stones (CBD often

cannot be visualized in its entirety)

RENAL ULTRASOUND

Evaluation of kidneys and bladder

Acute indications :

Hydronephrosis

Renal infection (pyelonephritis is not an imaging diagnosis

altough US can occasionally suggest the diagnosis)

ABDOMINAL ULTRASOUND

Evaluation of hepatobiliary tract, both kidneys, spleen,

+/- aorta and IVC

Acute indications :

Patients contraindicated or unable to undergo CT or MR

imaging

Pregnant patients with trauma

Pediatric patients with abdominal pain

LIMITED ULTRASOUND

Ultrasound performed at specific anatomic location(s)

according to clinical suspicion

Free fluid in trauma patients (FAST)

Suspected appendicitis

Suspected intussusception in pediatric patients

COMPUTED TOMOGRAPHY (CT)

Evaluation of the whole abdomen and pelvis is required

Options :

Without oral or IV contrast (urinary tract stone,

retroperitoneal hematoma)

With oral and without IV contrast (cannot receive IV

contrast)

With both oral and IV contrast (most indications)

With rectal contrast (appendicitis, colonic pathology i.e.

penetrating trauma)

Indications

Contraindications :

Inappropriate use

History of severe contrast reaction (CECT)

Renal insufficiency (CECT)

Concerns

Use of iodinated contrast medium : nephrotoxicity, adverse

reactions

Radiation exposure

VALUE OF CT IN ACUTE ABDOMEN

Changes leading diagnosis

Changes were shown to be as high as 1/3 of all cases ini
prospective investigations
Increases physician's diagnosis certainty
CT doubled diagnosis certainty of ED physicians,
particularly in elderly

Changes patient management plan

CT influenced disposition in up to 60% of cases

CT INTRAVENOUS CONTRAST

Often required in acute abdomen imaging

Iodinated contrast medium enhances visibility of
vascular structures and organs
Characters

Water-based

Non-ionic (mostly used at present) vs ionic

Less osmolality decreases adverse reactions and side

effects

More hydrophilic less tendency to cross cell membranes

CT IV CONTRAST REACTIONS

Can range from minimal (e.g. hives) to anaphylactoid

reactions; mostly idiosyncratic (unpredictable, not dosedependent)
Acute or delayed
Delayed reaction = 1 hour to 7 days after injection;
usually mild
Incidence

Mild reactions up to 3% (LOCM), 15% (HOCM)

Severe reactions 0.04% (LOCM), 0.22% (HOCM)

Fatal reactions exceedingly rare in both (1:170,000)

CT RADIATION EXPOSURE

CT accounts for 5% of radiologic examinations but

contributes 34% of collective radiation dose, worldwide

Risk of radiation exposures

Deterministic effect : cell death; threshold level secified

when effect would occur; rarely seen with diagnostic x-ray
and CT

Stochastic effect : cancer, genetic effects; linear, nonthreshold model generally believed; seen with diagnostic xray and CT

Effective radiation dose of one abdominal-pelvic CT

scan equals to

10 mSv, comparable to 3 years of natural background

radiation
100 chest radiograph

Estimated risk of cancer death for those undergoing CT

is 12.5/10,000 population for each pass of the CT scan
through the abdomen.
Any efforts to reduce radiation dose from CT should be
done

MR IMAGING

Advantages over CT

High contrast resolution (good for imaging of pelvis,

hepatobiliary tract and pancreas)

No ionizing radiation

Can be performed in pregnancy

Total exam time usually <30 minutes. No contrast needed in

many cases

Limitations
Contraindications for MR : pacemaker, claustrophobia,
etc
Critically ill patients require MR-compatible life supprt
equipments

Scientific evidence for MRI in acute abdomen still is not

extensive
Clinical applications

Suspected acute appendicitis (particularly during pregnancy,

and in children). Note that gadolinium-based contrast agent
cannot be used in pregnant women.

Good results shown for MRI in sigmoid diverticulitis,

common bile duct stone, acute cholecystitis, pancreatitis

SCINTIGRAPHY

Major drawback is limited availability in acute setting;

requires efforts to gather a team off-hours; and limited
resolution
Clinical applications

Acute cholecystitis : hepatobiliary scintigraphy

Higher accuracy and specificity than ultrasound

Reserved for patients whom diagnosis is unclear after

ultrasound

Acute pulmonary embolism : ventilation-perfusion

(V/Q) scan
Considered V/Q scan in patients with a normal chest
radiograph suspected of having PE when there is a
contraindication to CT scan (renal impariment, severe
contrast reaction)

CONCLUSIONS

Imaging plays an increasingly important role in

diagnosis of etiology of abdominal pain

CT is widely used in abdominal indications; along with

ultrasound and MR imaging
Limitations of each imaging method and
appropriateness criteria should be considered before
selecting an imaging test for a particular patient