Abdomen Flashcards
indications for a KUB
i. Bowel gas pattern
ii. Foreign bodies (especially things up the butt)
iii. Calcifications,
iv. Tube placement
KUB stands for
kidney abdomen bladder
need to see the entire abdomen and the diaphragm
when would you get a KUB ubright and CXR
is you suspect a bowel obstruction
if you suspect a perf
1. Upright film –>look for air-fluid levels &/or free air
if you are looking for air fluid levels with images would you want
upright horizontal to the floor or lying down but the beam needs to be placed at the side
this is a sign of obstruction
what muscle should be visible bilaterally in a KUB
psoas
Has valvulae conniventes
small or large bowl?
small
Has haustra
small or large bowl?
large bowel
characteristics of haustra
- Don’t traverse the entire lumen
- Widely spaced
diameter and wall thickness of large bowel
< 5 cm diameter
< 3 mm wall thickness
how much air do we usually see in the small bowel
Little air in lumen (2-3 loops max)
diameter and wall thickness of small bowel
< 2.5 cm diameter
< 3 mm wall thickness
characteristics of valvulae conniventes
Traverse the entire lumen
-Spaced closer together compared to haustra
air fluid levels in the colon normal or nah?
NO
no air fluid levels in the colon NOT NORMAL
when the bowel stops progressing it is known as a
ilieus
can you have air in the rectum with a small bowle obstruction?
yes~
what is the difference between a complete and partial small bowel obstruction
Complete –>no air distal to obstruction (sigmoid, rectum)
- Partial —> some air distal to obstruction
what is the relationship between obstruction proximity in the small bowel and loops of air seen on film
More proximal the obstruction, the fewer bowel loops are seen
what would you expect to see on a supine (KUB)
of a small bowl obstruction
Dilated loops, centrally located
- “Stack of coins,”
“bent finger sign”
what would you expect to see on a upright film of a pt with a small bowel obstruction
Air-fluid levels, may look like a “step-ladder”
- “String of pearls” (air trapped in successive valvulae conniventes)
types of large bowel obstructions
Can be mechanical (mass, twist)
- Can be from fecal impaction or inflammation
- Few or no air-fluid levels are typical in the BO
LBO
Volvulus
special type of LBO where it twists like a Jesus fish
Coffee bean sign
. Sigmoid volvulus
and axis of bean points to LLQ)
- “embryo sign”
. Cecal volvulus
feet of embryo point to RLQ
. Toxic megacolon aka
Ischemic colitis
what is toxic megacolon
what is the sign called on plain film
Bowel wall edema (“thumbprinting sign” along lumen of colon)
when bowel twists on itself and dies
volvulus
MC valvulus in bedbound seniors who take anticholinergics
Ogilive’s syndrome
physiological mechanism behind Ogilive’s syndrome
how does the pt present
usually in elderly where they lose peristalsis, colon dilates
pt is usually on anticholinergic medications
come in with an extended abdomen that looks like an obstruction (surgical diagnosis)
thumb-printing casued by
colitis
toxic megacolon
sigmoid volvulus goes from which quadrant where
LLG–>RLQ
which direction does cecal volvulus run?
RLQ upward
highest risk for SBO
having had one before
risk factors for SBO
Post-surgical adhesions (MCC!)
- Malignancy
- Hernia
- Intussusception (bowel telescopes in on itself)
- Inflammatory Bowel Dz
- Hx of prior SBO (very strong risk!!)
MCC of LBO
Malignancy (MCC!)
Causes of LBO
- Hernia
- Volvulus
- Nobody knows precisely why these happen
- Diverticulitis
- Intussusception
- fecal impaction
Single or few dilated loops (usually SB) that stop moving (not due to an obstruction) is known as a
Functional Ileus
- Inflammatory Bowel Dz CC of SBO or LBO
SBO
Diverticulitis can cause SBO or LBO
LBO
best imaging study for toxic megacolon
CT
sentinel loops
loop of small bowel cause by inflammation from another process
fix the process–> will act normally
Ileus
caused by renal stone, appy, pancreatitis, diverticulitis
Generalized (‘adynamic”) Ileus
Entire bowel dilated (LB and SB loops)
localized Ileus usually occurs in the
SB
causes of generalized Ileus
Causes: Post surgical, e-lyte problems, DKA, meds
how do you diagnose stones
ULS
but can be see on plain film
laminar means
stones with a border
tract like calcifications are seen as
follow some sort of vasculature or anatomy
vas deferens
amorphous calcifications
don’t have a border
Rim like calcification
seen as the whole organ
porcelain gallbladder
phlebolith
stone in the vessels
“Track-like “
best views for plain films pneumoperitoneum
i. Lateral CXR is sensitive for small ones (seen under L hemidiaphragm first!)
gold standard for pneumoperitoneum
CT overall best test!!
necrotizing infection of the bowel seen in children
pneumatosis intestanales
nectrotizing enterocolitis
gas producing bacteria in the bowel
adults get it too it’s is called ischemic bowel
Makes bowel loops appear like loofa sponges
Called “double wall sign” on CT
name for it on plain film is
Rigler’s sign
pneumoperitoneum sign
Air in biliary system
what is it called and what causes it
pneumobilia
ii. Cause: gas-forming bacteria
pneumobilia seen as
Tube-like lucencies in RUQ
Retroperitoneal air
look for black around retroperitoneal structures (kidneys, aorta, psoas, bladder)
CT is the best but can be visualized on plain film
three signs of a pnuemoperitoneum and what type pf plain film you’d see them on
free air under the diaphragm on PA CXR
RIGLER’s sign- seen btoh sides of the bowl wall large amt, KUB and upright
visualized falciform ligament on KUB
what is the double wall sign
seen on CT for pneumoperitoneum
it is the visualization of the falciform ligament (liver to diaphragm)
CC of pneumoperitoneum
trauma perforation, infxn, surgery (normal for 5-7d)
techniques for viewing the esophagus
usually use endoscopy (for a thing)
Biphasic Esophagogram (barium studies/fluoroscopy) can also be used
(for a function)
indications for a biphasic edophagogram (barium study)
dysphagia, perforation (only in small), FB, stricture motility problems malignancy
will fill the space and ignore the mass
“i feel like i can’t pass food:”
normal
- Aortic arch
- Left mainstem bronchus
- Esophago-gastric junction
specific conditions in which you would want to use a barium study/contrast to view the esophagus
Zenker’s
Barrett’s (precancerous chronic GERD)
esophagitis
hiatal hernia
apple core lesion indicates
malignancy
masses on the side of the esophagus
a birds beak or rat tail with barium is indicative of
achalasia
or seen as the esophagus dilated like a sausage ABOVE the obstruction
lights up poop
a. CT + oral contrast
i. Less used these days
b. CT + IV contrast lights up
lights up vessel, kidneys, bladder
i. CONTRAST + CREATININE
shaggy-looking, indicate inflammation (often surrounds a sick structure)
a. Fat stranding
b. Free fluid is seen as
seen as black on CT
dx of skip lesions
Crohn’s
seen in the terminal ileum most commonly
also seen as skip lesions and cobbles-stoning
initial test for painless rectal bleeding
colonoscopy
braium enemas are used for
Crohn's UC diverticular dz malignancy and fistula formation
if you are looking for a mass inside the bowel
Colonoscopy!!!
CT IS NOT THE FIRST TEST
what are the indications for a endoscopy of the esophagus
same as barium
biopsy possibly during procedure
esophagitis
malignancy
UGI bleeds, mallory, varices, boerhaave’s
boerhaave’s
transmural perforation of the esophagus to be distinguished from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting.
why would you do a endoscopy of the stomach
gastritis gastric ulcers
gastric tumors
gastic outlet obstruction
post surgical
capsule video best for
better for small bowel
when do you get a colonoscopy
after 50 for malignancy
or indications
rectal bleeding
abnormalities
Hx LBO
colitis
indications for ABD ULS
a. Biliary system (best initial test!)
b. Bladder - urinary retention; post-void residual
c. Kidneys - hydronephrosis; cystic masses; parenchyma
d. Liver & ascites - free fluid in abdomen; liver parenchyma
e. Aorta - aneurysm
f. Trauma - FAST (free abd fluid)
LATBBK
best imaging for dx Ulcerative colitis
CT (+ oral or IV contrast); colonoscopy
best study for dx Duodenal/gastric ulcer
b. Duodenal/gastric ulcer –> endoscopy
best study for dx diverticular disease
CT + oral or IV con
Dx appendicitis with what
Kids, thin adult, or pregnant person = ultrasound
All other adults = CT + IV con
dx appendicitis in a child
Edema, inflammation, fat stranding
Dilated appy (>6mm)
DX appendicitis in an adult
CT
Wall thickness >6mm
Non-compressible appendix
best tx for dx pancreatitis
CT (+ oral or IV contrast)
best tx for dx bowel obstruction (secondary to mass
plain film CT + IV con
best tx for dx bowel ischemia
CT + oral or IV con
Ascites/Free fluid in the abdomen (traumatic or non-traumatic)
i. Non-traumatic –>CT if it’s their first time with ascites; US otherwise
ii. Traumatic—>FAST exam; follow with CT + IV con if stable
best test for biliary dz
Ultrasound is best for biliary dz
Dx criteria for cholecystitis (4)
gallbladder wall thickening
peri-cholecystic fluid (black stripe)
sonographic murphy’s sign (probe up there and get slapped)
common bile duct dilation >6mm
acalculous cholecystitis
no stone cholecystitis seen commonly in the elderly
ampulla of vater
goes past sphincter of oddi
where you get the die put in
where you light of the biliary tree
looking for things that don’t pick up contrast and they will appear dark
infected gallbladder that causes jaundice encephalis
cholangitis
MRCP
no contrast need with MRI
Just flip over to the T2
HIDA scan
what are the indications
nuclear medicine used to image biliary system
helps look at the integrity of the tree
acute cholecystitis chronic tract disease congenital disease post operative bile leak/fistula assess liver transplant
best test for a renal stone
CT no contrast
DO NOT ORDER A PLANE FILM
IVP
intravenous pyelogram
plain KUB series after contrast
helps evaluate patency/efficiency
Retrograde urethrogram is used for
fluoroscopy
urethra strictures trauma
Besides ULS what other tests can be use for biliary dx
ERCP: endoscopy w/ fluoroscopy
biliary stones
malignancy
cholagitis
MRCP: MRI same indications and lessin
indications for a bladder ULS
Bladder masses
urinary retention
FAST
obstruction in the urethra leads to
hydronephrosis
how do you confirm hydronephrosis
ULS
Target sign is seen on what type of imaging
a. When an inflamed bowel loop is seen END-ON it looks like a target
what is best for finding the exact location of an obstruction
CT
Target sign ddx
Crohn’s
UC
ischemic bowl
intussuception
pancreatitis is caused by what?
ETOH drugs viruses
gallstones (MC)
CT oral and IV is best test but usually you just see CT with IV contrast
alcoholic that comes in with epigastric pain and vomitting
get an ULS to look for gallstone pancreatitis
CT to confirm but ULS if suspected
ERCP/MRCP can be done but ERCP precipitate by blocking spincter of ODI
if hypotensive with AAA
means it is leaking NOT GOOD
elderly person can be seen with first time back pain (retroperitoneal structure)
why would you want to do a CT for the biliary system
emphysematous cholecystitis
because this is an air around the gallbladder necrotizing and BAD
AIR IS THE ENEMY OF ULS
severe abd pain
what imaging is best for hydroureter
CT
sequele of the stones
of a certain size that causes problems
when can you see a pregnancy transabdominallys`
after 12 weeks
which type of ULS do you need a full bladder for
transabdominal as a landmark
body of the uterus is known as the
MYOMETRIUM
in most people when can you identify a IUP
7 weeks transvaginal
can see 5-6 weeks best for
which view do you need in a transabdominal in order to visualize the cervix
longitudinal
best ULS for ID ectopic pregnancy
transvaginal
most reliable sign for a viable pregnancy
fetal heart beat
in ED we also look for
clear IUP
dates match size
4-5 weeks with IUP seen as
gestational sac visible
double decidual sac
5-6 weeks with IUP seen as
gestational sac plus yok sac
possible fetal pole
6-8 weeks seen as
gestational sac plus yoc and fetal pole
7-8 weeks
fetal pole and cardiac activity
pregnancy in more than one place is known as
heterotopic pregnancy
IUP does not rule out an ectopic
what length measurement would you take earliest in pregnancy
7-13 weeks
CRL
Crown rump length
measurements you would make at 13 weeks
biparietal diameter BPD and CRL
AND head circumfrance
parietal bones
when can you measure the femur of the fetus
after 14 weeks
2nd trimester
what is the latest measurement you can make for the fetus
Late pregnancy use abdominal circumference (AC)
size and weight
