Abdominal imaging - masterclass

Question 1

What is diffuse abdominal pain?

Answer 1

Pain occurring throughout the whole abdominal area.

Question 2

Some causes of diffuse abdominal pain?

Answer 2

Acute pancreatitis
Diabetic ketoacidosis
Mesenteric ischaemia (a blockage in an artery cuts off blood flow to a portion of the intestine).

Question 3

Causes of left upper quadrant pain?

Answer 3

Splenic disorders (ruptures, abscesses)
Gastritis (inflammation of stomach lining).

Question 4

Causes of right upper quadrant pain?

Answer 4

Perforated duodenal ulcer
Hepatitis or hepatic abscess

Question 5

Causes of left lower quadrant pain?

Answer 5

Sigmoid diverticulitis

Question 6

Causes of right lower quadrant pain?

Answer 6

Appendicitis
Meckel’s diverticulitis
Mesenteric adenitis

Question 7

Causes of both right or left upper quadrant pain?

Answer 7

Acute pancreatitis
Herpes zoster
Lower lobe pneumonia

Question 8

Causes of both right or left lower quadrant pain?

Answer 8

Abdominal or psoas abscess
IBD
Renal stone
Ruptured abdominal aortic aneurysm

Question 9

Primary imaging tools of the abdomen?

Answer 9

X-ray
CT
USS (ultrasound scan)

Question 10

Secondary imaging tools of the abdomen?

Answer 10

MRI
(Fluoroscopy)

Question 11

Pros of x-ray?

Answer 11

Widely available
Supine AXR - Assessing for bowel obstruction
Erect CXR - Assessing for hollow viscus perforation
Quick
Well Tolerated
Inexpensive

Question 12

Cons of x-ray?

Answer 12

Overall sensitivity low
Rarely changes management
Ionising radiation

Question 13

Pros of ultrasound scan?

Answer 13

Easy, safe (no ionising radation)
Clear visualization of solid organs, free fluid, aorta, female pelvic organs
Bowel – occasionally helpful
Correlate imaging with tenderness

Question 14

Cons of ultrasound scan?

Answer 14

Operator and patient dependant
Challenging in obese and/or immobile patients

Question 15

Pros of CT scan?

Answer 15

Quick
Relatively widely available and tolerated
Accurate
Sensitivity CT vs USS – 89% vs 70%
Allows multiple structures to be imaged simultaneously
Allows better planning of surgery or intervention

Question 16

Cons of CT scan?

Answer 16

Radiation exposure – risk of complications increases as the dose increases.
Contrast induced nephropathy
Contrast allergy

Question 17

What is MRI used as second line for?

Answer 17

Hepato-Biliary
Small bowel
pelvis

Question 18

Where does acute appendicitis pain present?

Answer 18

RIF (right iliac fossa)

Question 19

X-ray can be used for acute appendicitis. true/false?

Answer 19

False

CT and USS are important tools
Confirm Diagnosis
Detect alternative pathologies
Ideally, use USS first, then CT if this is inconclusive

No role for x-ray in this

Question 20

Appearance of acute appendicitis in USS?

Answer 20

target appearance (axial section)
peri appendiceal fluid collection

Question 21

Appearance of acute appendicitis in CT?

Answer 21

appendiceal dilatation (>6 mm diameter)
wall thickening (>3 mm) and enhancement

Question 22

Pain associated with right ureteric calculus?

Answer 22

Right “loin to groin” pain

Question 23

What is gold standard for ureteric stone imaging?

Answer 23

Non-contrast CT (CT KUB) is the gold standard for imaging ureteric stones, with the vast majority (99%) being radiodense

Question 24

Stones more >1mm are visualised. true/false?

Answer 24

True

Show up on non-contrast CT

Question 25

Where does acute diverticulitis pain present?

Answer 25

LIF (left iliac fossa)

Question 26

Who is most likely to get acute diverticulitis?

Answer 26

elderly patients most at risk
80% of 80-year-olds have diverticula
4% go on to develop diverticulosis

Question 27

Presentation of acute diverticulitis?

Answer 27

left iliac fossa pain
unremitting pain with associated tenderness
possibly, an ill-defined mass
as the disease progresses, symptoms become more generalised

Question 28

Investigation of choice for acute diverticulitis?

Answer 28

CT with IV contrast

CXR can possibly look for perforation

Question 29

Reasons for imaging in acute diverticulitis?

Answer 29

confirmation of diverticula
confirmation of active inflammation around diverticula
assess for complications, e.g. perforation, abscess
look specifically for fistula, e.g. with bladder
identify other potential causes of symptoms

Question 30

How to tell which way a CT or MRI scan is done?

Answer 30

Radiologists view CT and MR as if they are looking from the feet upward (the right image is the left side of the patient).

Question 31

4 main potential diagnoses for epigastric and RUQ pain?

Answer 31

Biliary colic
Cholecystitis
Pancreatitis
Perforation

Question 32

Acute Cholecystitis (gallbladder inflammation) is always secondary to gallstones. true/false?

Answer 32

True

Question 33

Almost always CTs ordered should be ordered “with” OR “without’ only – NOT BOTH. true/false?

Answer 33

True

Question 34

When is contrast CT used?

Answer 34

CT of the abdomen and pelvis (with the exception of a CT stone study and CT angiography) will receive an oral contrast prep.

So non-contrast CT is only used usually used for CT of ureteric stones and CT angiography (lymph or blood vessels).

Question 35

What common indications do not require use of IV contrast?

Answer 35

flank pain
evaluating for urinary tract calculus hernia

Question 36

When should CT contrast be used?

Answer 36

Abdomen pain
Pancreatitis
Painless jaundice
Abdominal mass
To rule out Small Bowel Obstruction
Staging Colorectal Carcinoma
To assess vascular pathology
Assess for abscess

Question 37

Oral CT contrast vs IV CT contrast?

Answer 37

IV contrast improves tissue contrast, the parameter that distinguishes one organ from the next) and greatly aids in identifying masses or inflammatory/infectious processes.

oral contrast is used for most abdominal and pelvic CT scans unless there is no suspicion of bowel pathology