Imaging Pearls ❯ Small Bowel ❯ Abdominal Pain
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- “Mucinous neoplasms of the appendix are mucin-producing epithelial tumors classified into four types: adenoma, low-grade appendiceal mucinous neoplasm (LAMN), high-grade appendiceal mucinous neoplasm (HAMN), and mucinous adenocarcinoma. The peak prevalence is in middle-aged adults, with a slight female predominance. These tumors are typically asymptomatic and discovered incidentally at imaging, but occasionally patients present with acute appendicitis or other nonspecific abdominal symptoms related to peritoneal spread.”
Approach to Cystic Lesions in the Abdomen and Pelvis, with Radiologic-Pathologic Correlation.
Yacoub JH, Clark JA, Paal EE, Manning MA.
Radiographics. 2021 Sep-Oct;41(5):1368-1386. - “These neoplasms commonly appear as an appendiceal mucocele, a macroscopic description of an appendix abnormally distended with mucin Appendiceal mucoceles can be caused by nonneoplastic entities or by mucin-secreting epithelial neoplasms of the appendix. Non-neoplastic entities are most commonly mucous retention cysts caused by luminal obstruction and tend to be smaller than mucinous neoplasms. “
Approach to Cystic Lesions in the Abdomen and Pelvis, with Radiologic-Pathologic Correlation.
Yacoub JH, Clark JA, Paal EE, Manning MA.
Radiographics. 2021 Sep-Oct;41(5):1368-1386.
- KEY POINTS
-Non-invasive imaging with whole-body computed tomography (WBCT) is an excellent tool for the prompt screening, diagnosis, management, and surveillance of potentially life-threatening trauma related injuries in the significantly or severely injured patient; however, its role in those without obvious injury is debatable.
- WBCT may be used to identify unexpected critical injuries and incidental findings that may affect mortality and morbidity, thereby making it appropriate despite associated costs and radiation exposure. -The decision to utilize WBCT in trauma is ultimately that of the managing medical/surgical team.
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “Multiple studies have shown that WB-CT has sensitivity greater than 95% and a negative predictive value approaching 100% to identify treatable polytrauma injuries. It can be used to detect unexpected injuries in approximately 22% of patients, and to identify additional traumatic findings that may lead to change in management in up to 34% of patients. There is also questionable evidence demonstrating the beneficial effect on the survival of polytrauma patients evaluated by immediate WB-CT in all such cases, and there are data showing shorter time to treatment and length of stay for polytrauma patients who underwent assessment with WBCT.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - Perienteric findings associated with small bowel CD include perienteric edema or fat stranding, which are present in more severe disease. Engorged vasa recta, also known as the “comb sign,” results from current or previous bowel inflammation. Findings of chronicity include sacculations and fibrofatty proliferation. Sacculations result from shortening along the mesenteric border with ballooning along the antimesenteric border. Fibrofatty proliferation is hypertrophy of the mesenteric fat adjacent to diseased bowel segments due to repeated inflammation. Mesenteric venous thrombosis or occlusion has been described in CD. It is important to distinguish between acute mesenteric thrombosis and chronic mesenteric vein thrombosis. Chronic peripheral mesenteric vein occlusion has been shown to anatomically correspond with small bowel segments with active or prior CD inflammation.
Evidence-Based Review of Current Cross-Sectional Imaging of Inflammatory Bowel Disease
Jesi Kim, MDa,b,c, Bari Dane, MDc
Radiol Clin N Am 62 (2024) 1025–1034
- “Acute nonclotted blood appears as a high-density fluid with 30-45 Hounsfield units (HU) and clotted blood shows higher attenuation, 45-70 HU. Multiphase CT can provide additional information on the source of the bleeding. Active bleeding appears as contrast extravasation in arterial and/or delayed phases of the imaging, depending on bleeding source. Blood density can be helpful in detecting the site of bleeding as the highest attenuation area is closest to the bleeding source (“sentinel clot” sign).”
Imaging of abdominopelvic oncologic emergencies.
Pooyan A, Mansoori B, Wang C.
Abdom Radiol (NY). 2023 Nov 28. doi: 10.1007/s00261-023-04112-8. Epub ahead of print. PMID: 38017112. - Tumor rupture can be spontaneous, iatrogenic or happen because of trauma. The rupture of a malignant tumor is a serious emergency, and, in some cases, it can cause up to 75% mortality. Several mechanisms have been proposed to explain the spontaneous rupture of a tumor. Disruption of the tumor surface due to rapid growth, neovascularization, tear in a feeding artery or increased intratumoral pressure as a result of venous occlusion by tumor cells are some of the theories. Tumor rupture happens more frequently in tumors with higher vascularity like hepatocellular carcinoma (HCC) and renal cell carcinoma (RCC).
Imaging of abdominopelvic oncologic emergencies.
Pooyan A, Mansoori B, Wang C.
Abdom Radiol (NY). 2023 Nov 28. doi: 10.1007/s00261-023-04112-8. Epub ahead of print. PMID: 38017112. - “Spontaneous rupture of HCC complicates up to 15% of the cases. Larger HCCs (>5cm) and lesions that are located in the peripheral or subcapsular location have a higher risk of rupture. Other known risk factors include hypertension and post treatment settings like after transarterial chemoembolization (TACE). In the case of an acutely ruptured HCC, US shows an echogenic/cirrhotic liver and adjacent free fluid/hemoperitoneum (usually heterogenous echogenicity). CT shows areas of high attenuation hematoma (45-70 HU) in the vicinity of the organ. Several studies show that both hypo- and hypervascular liver metastasis could bleed spontaneously.”
Imaging of abdominopelvic oncologic emergencies.
Pooyan A, Mansoori B, Wang C.
Abdom Radiol (NY). 2023 Nov 28. doi: 10.1007/s00261-023-04112-8. Epub ahead of print. PMID: 38017112. - “Trousseau syndrome is a paraneoplastic syndrome primarily triggered by adenocarcinomas most commonly of the stomach, pancreas, and lungs. It leads to recurrent, migratory thrombophlebitis which typically occurs in lower limbs but can migrate to different areas including the abdominal and thoracic wall, abdominal vessels, upper limbs, and neck. While its exact pathophysiology is not fully understood, it is believed that mucin compounds from adenocarcinomas interact with selectin adhesion molecules, causing thrombocyte activation and aggregation . This often causes thrombi detachment and distant embolization, primarily pulmonary thromboembolism.”
Imaging of abdominopelvic oncologic emergencies.
Pooyan A, Mansoori B, Wang C.
Abdom Radiol (NY). 2023 Nov 28. doi: 10.1007/s00261-023-04112-8. Epub ahead of print. PMID: 38017112.
- “Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - "Cancer complications may be directly related to the tumor due to its local effect, or may be an indirect consequence related to its systemic manifestations including immune suppression, paraneoplastic syndromes or disorders of hemostasis. Cancer treatment including surgery, chemotherapy and/ or radiotherapy can also be associated with significant com- plications.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
- Small bowel obstruction
- Large bowel obstruction
- Bowel ischemia
- Bowel perforation
- Enteritis (chemotherapy, radiation enteritis)
- Thyphlitis - “Neutropenic enterocolitis or typhlitis is an acute life- threatening intestinal inflammation typically affecting the immunocompromised patients such as those with myeloproliferative disorders or those receiving myelo- suppressive therapy such as paclitaxel, idarubicin, fluorouracil, and carboplatin. It is most commonly associated with the treatment of acute leukemia. Patients usually present with fever, abdominal pain, and neutropenia. Although neutropenic enterocolitis may occur anytime during the course of the disease, it usually occurs 5–17 days after therapy initiation, often at the nadir of neutropenia, which is a later presentation compared to chemotherapy-induced ischemic enterocolitis.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - "Although abdominal oncologic emergencies are uncommon, their number are increasing, particularly so with advance- ments in oncologic management. Prompt detection and assessment are crucial for improving quality of life and survival. Various abdominal emergencies may occur in cancer patients and these can sometimes be due to benign or unrelated causes, in addition to expected malignant etiopathophysiology. Although imaging recognition could be a challenge, identification of key imaging findings with an awareness of the clinical scenario permits not only a timely diagnosis but also accurate management planning.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
- Pancreatitis
- Graft versus host disease
- Pseudomembranous colitis
- Treatment-induced enteritis
- Acute liver failure - Genitourinary Etiology of the Acute Abdomen in Oncology Patients
- Urinary obstruction
- Acute pyelonephritis
- Bladder perforation - Vascular Etiology of the Acute Abdomen in Oncology Patients
- Vascular thrombosis and thromboembolic complications
- Budd-Chiari syndrome (BCS) and Hepatic veno-occlusive disease
- “Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - "Cancer complications may be directly related to the tumor due to its local effect, or may be an indirect consequence related to its systemic manifestations including immune suppression, paraneoplastic syndromes or disorders of hemostasis. Cancer treatment including surgery, chemotherapy and/ or radiotherapy can also be associated with significant com- plications.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
- Small bowel obstruction
- Large bowel obstruction
- Bowel ischemia
- Bowel perforation
- Enteritis (chemotherapy, radiation enteritis)
- Thyphlitis - “Neutropenic enterocolitis or typhlitis is an acute life- threatening intestinal inflammation typically affecting the immunocompromised patients such as those with myeloproliferative disorders or those receiving myelo- suppressive therapy such as paclitaxel, idarubicin, fluorouracil, and carboplatin. It is most commonly associated with the treatment of acute leukemia. Patients usually present with fever, abdominal pain, and neutropenia. Although neutropenic enterocolitis may occur anytime during the course of the disease, it usually occurs 5–17 days after therapy initiation, often at the nadir of neutropenia, which is a later presentation compared to chemotherapy-induced ischemic enterocolitis.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - "Although abdominal oncologic emergencies are uncommon, their number are increasing, particularly so with advance- ments in oncologic management. Prompt detection and assessment are crucial for improving quality of life and survival. Various abdominal emergencies may occur in cancer patients and these can sometimes be due to benign or unrelated causes, in addition to expected malignant etiopathophysiology. Although imaging recognition could be a challenge, identification of key imaging findings with an awareness of the clinical scenario permits not only a timely diagnosis but also accurate management planning.”
Imaging of acute abdomen in cancer patients
Morani AC et al.
Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5 - Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
- Pancreatitis
- Graft versus host disease
- Pseudomembranous colitis
- Treatment-induced enteritis
- Acute liver failure - Genitourinary Etiology of the Acute Abdomen in Oncology Patients
- Urinary obstruction
- Acute pyelonephritis
- Bladder perforation - Vascular Etiology of the Acute Abdomen in Oncology Patients
- Vascular thrombosis and thromboembolic complications
- Budd-Chiari syndrome (BCS) and Hepatic veno-occlusive disease
- “ In addition to diagnosis and follow-up assessment of disease response, the radiologist should be familiar with the imaging findings of acute conditions affecting the oncologic patient to optimize patient care.”
Cross-sectional imaging of acute abdominal conditions in the oncologic patient
Heller MT, Khanna V
Emerg Radiol (2011) 18;417-428 - “ In addition to the commonly encountered acute conditions found in the general population, the oncologic patient is at increased risk to develop an acute condition due to local effects of the primary tumor and metastases, untoward effects of treatment, and potential altered immune response.”
Cross-sectional imaging of acute abdominal conditions in the oncologic patient
Heller MT, Khanna V
Emerg Radiol (2011) 18;417-428 - Tumor Related Complications
- Acute vascular complications
- Gastrointestinal complications
- Hepatobiliary complications
- Genitourinary complications - Tumor Related Complications
- Acute vascular complications
- Vessel invasion or occlusion (Budd Chiari syndrome)
- Organ infarction due to vessel invasion (splenic infarction)
- Organ abscess (splenic abscess)
- Spontaneous hemorrhage (renal cell carcinoma) - Tumors with Spontaneous Hemorrhage
- Hepatoma
- Renal cell carcinoma
- Melanoma - Tumor Related Complications
Gastrointestinal complications
- Obstruction
- Perforation
- Intussusception
- Ischemia - Treatment Related Complications
Complications of immunosuppression include
- Typhlitis
- Acute graft versus host disease
- infection - Treatment Related Complications
Complications of TACE include
- Mild post procedure symptoms like abdominal pain, nausea and vomiting, increased LFTs and leukocytopenia
- Hepatic artery spasm or occlusion
- Tumor rupture
- Duodenal perforation
- Acute cholecystitis
- Liver abscess
- Biliary necrosis
- Right Lower Quadrant Pain: Differential Diagnosis
- Ileum
- Cecum
- Genitourinary cause
- Perivisceral structures - Right Lower Quadrant Pain: Differential Diagnosis
- Ileum
- IBD (crohns)
- Infectious ileitis
- Obstruction
- Diverticulitis
- Meckel’s diverticulum
- Intussusception - Imaging of acute right lower quadrant abdominal pain: differential diagnoses beyond appendicitis
Heller MT, Hattoum A
Emerg Radiol (2012) 19:61-73 - Right Lower Quadrant Pain: Differential Diagnosis
- Cecum
- IBD
- Diverticulitis
- Ischemia
- Neoplasia
- Thphlitis
- Volvulus - Imaging of acute right lower quadrant abdominal pain: differential diagnoses beyond appendicitis
Heller MT, Hattoum A
Emerg Radiol (2012) 19:61-73 - Right Lower Quadrant Pain: Differential Diagnosis
- Perivisceral structures
- Epiploic appendagitis
- Omental infarction
- Mesenteric adenitis
- Body wall lesions
- Endometrioma
- metastases - Imaging of acute right lower quadrant abdominal pain: differential diagnoses beyond appendicitis
Heller MT, Hattoum A
Emerg Radiol (2012) 19:61-73 - “The purpose of this review is to list an anatomy based, encompassing differential diagnosis in addition to acute appendicitis for right lower quadrant pain; demonstrate the key imaging findings of numerous differential considerations; and describe helpful imaging and clinical features useful in narrowing the differential diagnosis.”
Imaging of acute right lower quadrant abdominal pain: differential diagnoses beyond appendicitis
Heller MT, Hattoum A
Emerg Radiol (2012) 19:61-73