A site specific approach to radiologic diagnosis

1. Abdominal pain A site specific approach to radiologic diagnosis Dr. Ahmed Refaey MBBCh, MS, FRCR Consultant Radiologist Department of Radiology Riyadh Militry Hospital

2. Locations of abdominal pain • Right upper quadrant RUQ • Left upper quadrant LUQ • Right Lower quadrant RLQ • Left lower quadrant LLQ • Midepigastric

4. Acute RUQ pain • Acute cholecystitis – most common • DD - PUD - acute hepatitis - liver abscess - RLL pneumonia

5. RUQ pain imaging evaluation • Ultrasound • Acute cholecystitis – most common • DD - PUD - acute hepatitis - liver abscess - RLL pneumonia

6. US in acute cholecystitis • Gall stones with ….. …. ( sonographic Murphy’s sign ) • distended gall bladder • Pericholecystic fluid collection • Obstructing stone in GB neck or in cystic duct • gall bladder wall thickening (> 3 mm )

8. LUQ pain

9. LUQ pain • Peptic ulcer disease • Splenic infarct • LLL pneumonia

10. Diagnostic tests • Plain X-ray chest -- pneumonia • US - splenic infarct • UGI - peptic ulcer disease

13. RLQ pain

14. RLQ pain • Acute appendicitis • Mesenteric adenitis • Diverticulitis • Urinary tract calculi • Gynacologic disease

15. Diagnostic imaging • US • CT • Exceptions for CT * children * pregnant women • Acute appendicitis • Mesenteric adenitis • Diverticulitis • Urinary tract calculi • Gynacologic disease

16. CT findings in acute appendicitis • Dilated appendix ( > 6 mm ) • Non filling of the appendix with contrast • Peri-appendiceal inflammatory changes • Increased enhancement of the wall • Appendicolith • Accuracy of CT is 94-98 %

21. US findings in acute appendicitis • Non-compressible • Dilated appendix ( > 6 mm ) • Hyperemic thick wall • Appendicolith • Surrounded by omentum • Peri-appendiceal fluid collection

27. Mesenteric adenitis • Clinical presentation similar to appendicitis • inflammatory / infectious process • Children > adults • Most common alternative condition identified at surgery with removal of normal appendix

30. Mesenteric adenitis vs appendicitis • Both may have lymphadenopathy and ileal wall thickening. • Appendix is normal in mesenteric adenitis.

31. Rt side diverticulitis

32. Uretric stone

33. LLQ pain

34. LLQ pain • Divericulitis • Epiploicappendagitis • Perforated colon cancer • Urinary tract calculi • Gynacologic disease

35. Diagnostic imaging • CT: best overall examination • US : better for females

36. CT in diverticulitis • Diverticulosis • Wall thickening • Inflammatory changes in pericolonic fat • Extraluminal air or abscess • Soft tissue inflammatory mass ( phlegmon) • Evidence of colovesical fistula

40. Epiploicappendagitis • Epiploic appendages * small fatty protrusions * 2-5 cm long * serosal surface of colon

42. Epiploicappendagitis • Torsion of epiploic appendages • Clinical presentation similar to diverticulitis * localized abdominal pain, fever and elevated WBCs * typically no nausea and vomiting

43. CT in epiploicappendagitis • Low density mass ( fat ). • Surrounding hyperdense rim • May have central dot ( thrombosed vessel)

47. Left uretric stone

48. Qynacologic causes of LQ/pelvic pain • PID • Ruptured ovarian cyst • Hemorrhagic ovarian cyst • Adenexal torsion • Ectopic pregnancy

49. Diagnostic imaging • US is the primary imaging modality

50. Midepigastric pain