Female with RLQ pain Imaging

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28-y-o female with RLQ pain, nausea, low-grade
fever, WBC Zissin R, Head of CT Meir Medical
center

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Ac abd. pain - a diagnostic challenge

• RLQ - DD
• Acute appendicitis (AA)
• Epiploic appendagiitis / Omental infarction -
  non-surgical mimicker of AA
• GI related Crohns disease (CD), Rt-sided
  diverticulitis, Inf. enteritis (Yersinia),
  Perforated cecal ca
• Mesenteric lymphadenitis
• Acute GUT pathologyAc Pyelonephritis
• Renal colicGynecologic etiology

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Acute appendicitis

• The most common cause of RLQ pain and 28 of ac.
  abdominal pain
• Treated surgically !!! Perforation rate 20,
  (more common lt9y and gt60y)
• The most common emergency in children and
  pregnant women.
• 6 chance during lifetime for each person
• Classic history periumbilical pain migrating to
  RLQ only in 50, atypical presentation mainly
  children, women 20-40y, elderly

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Imaging modalities in acute abdomen

• Plain abdominal films supine erect LIMITED
  INDICATIONS
• US non invasive, no radiation
• CT semi invasive, radiation !
• Contrast media studies imaging of bowel only
  (barium, gastrografin) radiation

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Plain abdominal films - Indications

• 1. Detection of free air Common causes
  perforation of hollow viscus, post-operation,
  peritoneal dialysis
• 2. Gas (air) distribution intestinal
  obstruction dilated loops, air/fluid
  levelsdisplaced loops a secondary sign of
  mass effect
• 3. Detection of pathological calcificationsMost
  common calculi (20 of gallstones 80
  urolithiasis), vascular,
  intra-abdominal radiopaque foreign bodies
• Usually insensitive in AA but can suggest an
  alternative diagnosis

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Ultrasound

• Advantages - Lack of radiation, non-expensive
  and availability
• - Aids in diagnosing alternative causes
• Disadvantages - Operator dependent !!
• - Sen 85-90, Spec 92-96, As NPP is too low
  CT
• Mainly in children childbearing age women

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• Aperistaltic, noncompressible, blind-ended,
  fluid-filled, tubular structure with distinct
  wall layers arising from the cecal base
• Outer diameter gt 6 mm
• Appendicolith
• Periappendiceal fluid collection

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Computed Tomography - CT

• Radiation! (excludes pregnancy, consider
  benefit versus radiation risk)
• Semi invasive exam. IV injection of CM

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2005

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Type of CT examinations

• Diagnostic study
• Interventional procedure- F. N. A (fine needle
  aspiration)- Diagnostic puncture
  (bacteriological evaluation)- Drainage of
  abscess, fluid collections
• Screening - Virtual colonoscopy- Cardiac CT-
  Low dose chest CT

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Radiation on CT

• Abd CT ( 500 CXR)(BE-350 CXR, Upper GIT-150
  CXR)
• Typical effective dose 10mSv (time provide for
  equivalent effective dose from background
  radiation 3.3y)
• Malignancy risk 5/1Sv 1 to 2000

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Technical notes Abdominal CT

• Optimal technique OralIV Contrast Media - Oral
  (for maximum GIT opacification)
• -IV (semi-invasive) 120cc 2,5-4cc/sec
• Optional
• - Rectal
• - Cysto CT
• Delayed scan as necessary

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5 tissues densities
ca
air
fat
soft tissue
fluid
Everything should be made as simple as possible,
but not simpler. Albert
Einshtein
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Acute Appendicitis

• CT diagnosis depends on combined appendicular
  and periappendicular signsCT sens. 94-97 spec.
  97-99 accuracy 93-98 NPV PPV 94-98
• Appendicular signs distended (gt6mm),
  unopacified thickened wall (gt2mm) app.
  appendicolith
• Periappendicular signs pericecal fat
  strandingscecal mural thickening-arrowhead

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Periap. Abscess Conservative therapy P.C.
abscess drainage gt 3cm
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Epiploic appendagitis

• Torsion of EA-infarction and sec. inflammatory
  changes
• Clinical presentation L/RLQ signs of
  peritonitis, mimicking ac. diverticulitis/
  appendicitis
• Benign, self-limited course

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An oval-shaped fat density with a rim of
soft-tissue density juxtaposed to the serosal
colonic surface
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Crohns Disease (CD) - terminal ileitis

• Diarrhea- most common presentation
• Gradual, progressive RLQ pain - 45-95
• Role of CTIn known cases - for detection of-
  complications (abscess, enterovesical fistula,
  perianal disease)- alternative diagnosis (look
  for the appendix) CD may be first diagnosed on
  CT in pts. presented with acute abdomen RLQ
  pain

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CT in CD

• Direct imaging of the bowel wall (normal lt3mm)
• Secondary signs in surrounding mesentery-mesente
  ric vascular engorgement-fluid within the
  mesenteric root-peri-bowel fat stranding,
  creeping fat-mesenteric adenopathy
• To guide P.C. interventional procedures

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Stones and Obstruction

• Non contrast scan
• Determine the level of obstruction calculi, and
  associated parenchymal changes

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GOOD LUCK