Perspective Sonography and the Acute Abdomen

Perspective Sonography

and the Acute

Abdomen:

Practical

Considerations Julien

B. C. M. Puylaert1,

O

Friso M. van der Zant1, Arie M. Rijke2

ver the past 10 years, has gained acceptance

. .

patients

ing

with

sonography for examin-

acute

of

abdominal

27%;

and

into three

and low

abdomen

rapid,

inexpensive,

clinical

limited

in obese patients;

suspicion have an

cannot

penetrate

and readily accessible; it has some serious drawbacks. Use is

however,

more

than

other

the ultrasound

radiologic

and

ator-dependent

techniques,

requires

skill,

and experience. In this perspective,

several

of

on

using

include

pain

are

the choice

is oper-

practical

patients

puncture,

graphic

findings,

appendix

highlighted. These aspects between sonography and CT

value

the

significance

of normal

and,

commu-

on

nication

with the clinician.

a sonogram,

finally,

the threshold

for

diagnostic

sono-

negative ill-advised surgical

laparotomy

delay.

inside

prospective

study

appendicitis

showed

accepted

the

Nonetheless, hospital

of patients a negative

a high

the risks of

rate to avoid

surgical delay

have

with

A

of sonography

rate

Received June 1, 1995; accepted after revision July 23, 1

of Radiology.

AJR 1997;168:179-186

AJR:168, January

Health Sciences

0361-803X/97/1681-179

1997

be

using were

sonography, 13%,

surgical

13%,

delay.

all patients are

patients

as

in cases

of

rejected.

on clinical

man-

abdomen

is

of all

at our abdominal

abdominal

sonographic

institution, pain has

and nationbecome the

Sonography

or CT as Initial

Several

for radiologists are on call.

when

acute

easily

detected

gram.

They

abdominal

include

a ruptured

hepatic

abscesses.

provide

better results in obese retrocecal appendicitis,

institution,

in unnecesvirtually

abscess,

deeply

sematous enced

referred

for

a sonogram,

including

reliably

definitely

tions

In addition,

located

bowel

aneurysm, rupture,

CT scans

sigmoid

obstruction,

cholecystitis. hands,

diagnose in most

most

patients

acute

usually

who appendiceal

diverticulitis, gastrointestinal and emphy-

However,

the sonograrn

a an and

patients

to the retropetitoneum,

perforation

abdominal

seems

internal

closed-loop

aortic

acute pancreatitis, hernia, and perirenal

incarcerated

laparotomy

more

on a sono-

an

sig-

respectively,

are

than

an esophageal

sus-

7%,

Technique?

conditions

on a CT scan

aneurysm,

have

to go in

they

dissection,

mycotic

or subacute surgery

perpain

reason

acute

whom

25%

prac-

abdominal

of acute

most frequent to the hospital

with for

up

the acute

routine

Sonography

with

reduction

In our

institutions.

possi2).

of

findings

negative and

makes

1 and

affected

on indication

an aortic

changed the therapeutic management of patients [4]. In three independent

in experi-

can still be used abdominal

[4]. Therefore,

to

condia reason-

1996.

Department of Radiology, Westeinde Hospital. Ujnbaan 32, 2512 VA The Hague, the Netherlands.

2Department

only

sonographic

[4-61 with a concomitant

pain

a suspected

laparotomy

of sonography used

is and should

rates

studies

imaging

concept

doubt

sary

serious

is common.

diagnoand that

The impact

studies surgeons

a

is unreliable

agement of patients with an acute impressive. In a study of patients

Indications

with

that the clinical

tool

pected appendicitis,

examinations wide, acute

with a remote (Figs.

sonography

in many

had

an

surgery

has markedly

formed

treatment was of misdiagnosis

radiologic

should be low. The a helpful

nificantly in 26% Traditionally,

show abdomen

tice

as patients

surprisingly,

did not of the

In 30 patients

6 hr because

figures

Not

in the high-

group

aneurysm,

than

sis of an acute

clinical

the

findings

of indirect

of

even

of the patients whereas 5%

[2].

aortic more

[3]. These

acute

that

in the low-suspicion

ruptured

aspects

with

equivocal,

showed

group, 35% appendicitis,

inflamed

dedication,

(high,

suspicion)

patients

as an initial examining technique, the timing the sonographic examination, sonographically guided

categories

delayed

sonography

abdominal

beam

or gas; and sonography,

bone

as well

required

bility ofrequiring

Sonography

noninvasive,

therapeutic

surgery patients

pain.

is dynamic,

serious

concomitant

delay in 14% of patients who needed [1]. Another prospective study dividing

Center, University

of Virginia.

Lee St, Charlottesville,

Address

correspondence

to J. B. C. M. Puylaert

VA 22908.

© American Roentgen Ray Society

179

Puylaert

et al. Fig. 1-68-year-old

man with acute appendicitis had 2-day history of constipation and uncomfortable sensation in lower abdomen. No local or rebound tenderness and no fever were present Erythrocyte sedimentation rate was 32 mm! hr with normal leukocyte count Proposed management was conservative. A and B, Sonography showed inflamed appendix in longitudinal (A) and transverse (B) plane. Appendix was subsequently removed.

able course

of action

is to begin

with

the least

ticular

patient.

expensive and least invasive technique and proceed to a CT scan only in cases of an inconclu-

radiologist

sive sonogram.

the Technique

abdominal

patient

of all

pain is more

abdominal

organs.

involves

a sonographically

approach

to the clinical

findings.

sonographic

communication cific

than

a routine

The

examination

guided.

problem

survey

rational

of that

par-

findings

and.

sonographic Similarly.

linked

may

to

(Fig.

feature sonographic

with physical

on

palpable

mass. For example.

spe-

questions

provided

a search

corresponds

requires because

specific

information lead

structure

symptom-

patient

raise

nation

all

depending This

the

the

consider

examination

with

conversely, may

examination,

diagnoses

sonographic

Examination of the entire abdomen, from the axilla to the groin. in patients with acute

the

continuously

differential

possible

directed Examination

During should

for

by the

a specific

3).

tender

sonography cologic moid Asking

region

is closely

A dual exami-

when

may

help

conditions

to

pelvis,

in detecting in diagnosing

appendicitis

point

can be especially

out

the

important

cause localized

omental

organ

infarction

the

vaginal gynesig-

[8] (Fig. 4). most

tender

in conditions

tenderness

sonographic

or

area or

if in women

also

171or

diverticulitis patients

what

not only but

not have conspicuous mental

identifying

to the most painful is deep in the

region

that typically

examination

examination.

most

is helpful

but

19].

do

Seg-

features.

epiploic

Fig. 2-24-year-old previously healthy man was admitted with classical presentation of acute appendicitis. No diarrhea was present WBC was 16,500!mm3. Immediate appendectomy was proposed. AD, Sonography shows mucosal inflammation ofterminal 1eum in transverse (A) and longitudinal (B) planes as well as enlarged mesenteric lymph nodes (C). Appendix (arrows) was small and measured 2.1 mm during compression. Surgery was cancelled. Three days later, Salmonella paratyphi B (D) was cultured from stool. a = iliac artery , v = iliac vein.

180

AJR:168,

January

1997

Sonography

appendagitis

10), an incarcerated

f

epiga.stric

hernia,

or sigmoid

a small

On the other

hand.

at a considerable

tender

region.

with

[I I],

lower

abdomen,

track

maximum

pain

(Fig.

ureter may present the biliary

system

down

indicate

metastases

a

may

air in

obstniction

ileus,

or

liver

an underlying

with

an

malig-

appendiceal

all emphasize

the

mass. importance

of examining the entire abdomen. If the anatomy is aberrant. especially case of

an inflamed

the

point

normally marked (Fig.

appendix

where

made.

the

The

on the

skin

abdomen

compression transducer

an indelible

shortens

the

to the abnormal

to compress

bowel.

thereby

also involves

and its surrounding For instance, of gallbladder

compression

If. despite the can

positioned this manner.

extent

ventrally

the lateral

wall and the liver.

effect

of

an

Timing

with over

of

(Fig.

9).

be applied

pain.

the

to the

transducer the flank.

acute

tendency

organ

gas continues examination,

of the Sonographic

Many

identification

always

located

abdominal

It is also

as assessment

to minimize

be scanned

or gas-containing (Fig. 10). With the

decubitus position, free be looked for between

mittent

posterolaterally

bowel loops can be avoided

patient in a left lateral air should specifically

however,

compression. sonographic

hamper

the

fluid-filled abscesses

can be compressed.

should

manner

14).

Compression

appendicitis

in

urinary tract infec-

A, Sonography showed thickened small-bowel loops (b) with interloop fistula (black arrows). Adjacent bladder wall was locally irregular (white arrows). B, Small amount of air was found in dome of bladder (arrowhead). Only on specific questioning did patient recall episode of urinating air. She was diagnosed with Crohns disease with fistulization to bladder.

allows as well

rigidity

in a graded

patient

tissues

hydrops

appendiceal Finally,

images.

compression

of recurrent

gas-containing

the disturbing the

[

from

and allows

probe.

determining

graded

palpation

distance structure

gas on the sonographic

an acute

with

or displace

reducing

is

be

woman with 10-year history of abdominal pain complained

tions.

pencil

with

performed

the use of a high-frequency used

incision

should

to gentle

similar

Compression

Fig. 3-67-year-old in the removed

gridiron

in patients be

should

far

appendix with

8). Sonography

the distal

pain,

bowel

gallstone

indicate

nancy in patients These examples

from in the

flank

small

pare-

may cause

distance

with only

because

the right

7), a stone

with

ulcer

pain

obstruction

at a marked

of obstruction

be

a patient

duodenal

quadrant

small-bowel

can

the pain is some-

lower

contents

colic gutter.

signs

from the most

a perforated

right

the gastric

diagnostic distance

in the

that causes

from

Abdomen

or

hematoma

In appendicitis.

times diffuse may present

may

Acute

(Figs. 5 and 6).

found

site

the

[ I 2, 13j are a few such

diverticulitis

conditions

spigelian

rectus

and

toward

gas in partially

may

symptoms

toms

resolve.

recurs,

the symptoms

This

and

scenario disease.

recur

a

the

Inter-

are pre-

obstruction. the sympobstruction

reappear.

is seen

in

appendicitis. hernia,

later. pain

cases of is relieved, when

show

resolution;

of abdominal

dominantly seen in When the obstruction

stone

Examination conditions

spontaneous

episodes

incarcerated In

abdominal

and

biliary

and

urinary

intussusception, small-bowel

obstruc-

tion from adhesions. Sonographic findings during an episode of pain may differ significantly

Fig. 4.-25-year-old woman complained of lower abdominal pain in pelvic region for 1 day. Transabdominal sonography

was normal.

Transvaginal

sonography

revealed inflamed appendix (arrow).

Fig. 5.-Infarcted epiploic appendix. 40-year-old man had severe pain on pressure in left lower quadrant, suspect for sigmoid diverticulitis. Erythrocyte sedimentation rate was 36 mm!hr. A, At point of maximum tenderness, sonography showed 2.5-cm ovoid area of inflamed fat (arrowheads). B, CT scan confirmed diagnosis of infarcted epiploic appendix

(arrowheads).

AJR:168,

January

1997

181

Puylaert

et al. Fig. 6.-Otherwise healthy middle-aged woman presented with severe localized pain in right lower quadrant. She was suspected of having appendicitis. A, Sonography showed small, impalpable rectus hematoma (arrowheads). B, Rectus hematoma (arrowheads) was confirmed by CT scan. Appendectomy was cancelled.

Fig. 1.-Incarcerated obturator hernia. 86-year-old woman presented with small-bowel obstruction. A, Left-sided groin sonography revealed small, impalpable herniated bowel loop (asterisk) behind pectineus muscle. B, T2-weighted MR imaging confirms incarcerated obturator hernia (asterisk). Also note contralateral asymptomatic

Fig. 8.-Inflamed appendix in unusually high position. A, Sonogram shows inflamed appendix in right upper quadrant. B. In view of its unusual position, location of appendix was drawn C. This location influenced site, size, and direction of incision.

182

on skin with indelible

hernia.

a

=

femoral

artery,

v

=

femoral

vein.

pencil.

AJR:168, January

1997

Sonography from

findings

sode

and

immediately

such

an episode.

from

For

examined

during

sonogram

may show

gallbladder

after

the findings an

wall,

such

several

instance, episode

and

the

Acute

Abdomen

an epi-

days

after

if a patient is of biliary colic, a

hydrops,

thickening

a sonographic

of the

Murphy’s

sign,

and an impacted stone. A few days later, when the symptoms have subsided, all that is found is a morphologically ing

a

should

normal

mobile

stone.

gallbladder

be correlated

always

contain-

Sonographic with

findings the course

appendix may the obstruction.

quickly However, the

disappear

associated

changes

tion

often

days

or weeks

long

since

remain

appendicitis

of obstrucvisible

when

cally in a patient the sonogram

the symptoms

These

residual

impressive

can

or

sonographically

subsided. an

bowel,

after relief of inflammatory

with the process

even

why

explain

of

due to an

the symptoms in time. Dilatation obstruction ofthe gallbladder, kidney,

for

have changes

cholecystitis

be documented free ofsymptoms

or

sonographiat the time of

16](Fig. I 1).

Preferably, the examination should be done during an episode of pain for two reasons. Not only is the chance of a diagnostic sonographic finding greater but it also guarantees optimal timing of possible surgery. In case of intennirtent episodes ofpain, the patient should be warned to seek immediate medical attention during the next episode so that sonography, and possibly surgery, can be performed without delay (Fig. 12).

Sonographically In patients

with

Guided

Puncture

an acute

abdomen,

Fig. 9.-Acute gallbladder hydrops. A and B, On compression of gallbladder, in longitudinal (A) and transverse (B) plane mild bulging (arrowheads) of anterior abdominal wall was noted, indicating hydrops with high pressure in lumen. No gallstones were visualized. At surgery, 3-mm obstructing stone in distal cystic duct was found.

Indirect fluid,

however,

cally

guided

a small

blood, tory

pus,

malignant

Fig. 10.-Small-bowel obstruction with partially gas-filled loops. A and B, Ventral scanning yielded only air(A), whereas posterolateral

January

1997

carries

rapid

differentiation

and

investigation

between

gastric ascites

be helpful.

puncture

risk and allows

amount of free fluid may occur in both surgical and nonsurgical conditions and, as such, is nonspecific. Identifying the nature of the

AJR:168,

can

bile,

and can

fluid, (Fig.

Sonographivirtually

additional distinguish

pancreatic 13).

Many no

between laborafurther fluid,

and

scanning clearly showed dilated loops (B).

Sonographic sonographic

dicitis, renal straightfoaward

findings

such as appen-

colic, or cholecystitis and can be made

dence. However, tion is not well, sonography.

Findings diagnoses

are fairly with confi-

sometimes the primary condior not at all, recognizable by

In such

cases,

indirect

sonographic

may be of help.

Fig. 11.-50-year-oldwomanwith classic signs of cholecystitis 2 days earlier was completely free of symptoms when this sonogram was obtained. Gallbladder still showed considerable residual changes. 183

Puylaert

et al.

primary

bowel

ocolitis.

Crohn’s

wall diseases disease,

as infectious

ile-

I 15).

or ischemia

Other useful indirect findings are associated with abscesses, which occur when a gastrointestinal sealed

perforation

off.

Often

appendicitis,

is not

the

diverticulitis,

a malignancy-can be cases of large, gas-containing may

abscessogram

done

neous

cause-

Crohn’s

disease,

determined. abscesses,

or

determination

effectively

underlying

be difficult

In this

I 16, 17). An

some days after percutaand a repeated sonogram

drainage

may, as yet, reveal

the underlying

condition.

Another indirect sonographic sign related to free perforation. If the process sealing

has been completely

the bowel

fective and the bowel contents into the peritoneal cavity. first then Fig. 12.-Over 3 months, 59-year-old woman suffered from severe colicky attacks lasting 1-2 hr. Two earlier sonographic examinations performed during symptom-free intervals showed no abnormalities. Present examination, performed during attack, revealed intussusception.

a generalized

ileus

will

fluid-filled

peritonitis

ensue.

The

bowel

loops

sis is an important

clue

inef-

are spilling a local and with

presence with

paralytic of

dilated

absent

and.

peristal-

in most

cases,

indicates a gastrointestinal perforation ing surgical treatment (Fig. 15). The most helpful to gastrointestinal occur in appendicitis, ease,

peptic

indirect findings are related pertration. such as may diverticulitis.

all of these conditions,

omentum, site

of

attempt

contents

inesenteiy, imminent to seal

offand

protective and bowel

perThration prevent

into the peritoneal

ing, inflamed fatty mesentery recognized as amorphous choic,

noncompressible

fat is usually

Crohn’s

ulcer disease, and bowel

concentrated

of howel

The

around

migrat-

omentum

are

of hypere-

This

inflamed

the diseased

feature

of inflamed

intermittent

graded

compression fat,

Inflamed

attenuating

streaky

by applying with the trans-

especially

in advanced

on a CT scan as hyper-

(dirty)

areas

in the abdomi-

nal fat(dirtyfat)(Fig. 14). Secondary

boring citis,

bowel is another

be confusing

mural

thickening

loops,

such

indirect

and

may

Normal

of

as seen

sign.

This

be interpreted

Sonographic

It is not

fat is its noncom-

is best observed

is well recognized

can easily

The most con-

which

cases,

in

prominent,

pressibility, ducer.

masses tissue.

spicuous

an

spillage

and

In

often

on a sonogram.

be overlooked

migration of loops to the occurs

cavity.

dis-

cancer.

organ and, although

unusual

abnormalities acute

sonographic

occurs

as such

sonographic

with

requiring

with

an

a low clinical

surgery, can

a negabe

usually

taken as confirmation that no condition requiring surgery exists. lf however, clinical findings

finding

can

no

in patients

examination

and laboratory tests ity, further workup

neigh-

find

In patients

in appendi-

the

to

of disease

suspicion tive

requir-

Findings

whatsoever

abdomen.

is of

frequently

appendicitis

suggest

a serious

is required. in young

women

must be differentiated

abnormal-

This

problem in

whom

from adnexi-

Fig. 13.-61-year-old woman was admitted with rapidly increasing pain over entire abdomen. She had suffered no trauma. A and B, Sonograms show free fluid around liver and inhomogeneous spleen. C, Sonography-guided puncture yielded blood. Surgery confirmed spontaneously ruptured spleen.

184

AJR:168, January

1997

Sonography

and

the

Acute

Abdomen

unnecessary

laparotomy.

may provide

ney

Two

other and

creatitis

is usually

amylase

in

by

both

ischemia,

urine

in a patient

upper

quadrant

severe

symptoms, cause

of pulmonary

the first embolism

If,

in

be fluid

consolidation

or early

pneumonia with

both

findings

should

a patient

symptoms,

study

patient

(Fig.

normal.

the most

is

a

is obese

phy in other

CT

useful

scan,

with

between

Understandably,

ogy has

c&tsed

Radiologist

role of the erythrocyte

sedimentation

rate must

be present

be emphasized, because in adnexitis it is usually high at the time of admission. If the etythrocyte sedimentation

rate

is

markedly

young and not too obese woman sonographic findings. adnexitis favored. erythrocyte

The reasoning sedimentation

AJR:168, January

1997

is as follows:

elevated

with is

in

normal strongly

if the high

rate had been

caused

that would

during sonography. Another condition a

not have

gone

in which

no sonographic

in the presence

however,

is usually

cal presentation. a condition

rate

It can, however,

requiting

surgery

ofa

lead

as

to an

good

communica-

should speak such

as

acorn-

“phlegmon”,

“walled-offperforation”,

and

“pseudoa-

mean differentthings

a radiologist

a morphologic

should

In

difficult

to

cases,

of the intni-

description

be avoided.

ln such

ings

cases,

the radiolo-

to be present

at the

sonographic

find-

examination.

In the

on clini-

masquerade and

and

and “ileus”can

sonographic

is pyelonephritis;

made

a good relarelationship starts have

A good

gisi should ask the surgeon

high

ad-

and

abdominal situation based on the sonographic findings should be given, and a single-term diagnosis

abnormalities are found erythrocyte sedimentation this diagnosis

unnoticed

the

and confusion

must

Tenns

“perforation”,

therefore,

would

man-

abdomen.

viewed

excitement

and surgeon

language.

mon

a surgeon extensive

acute

have

radiologists

tionship with surgeons. with mutual confidence

neulysm”,

and

an

in this field with caution

both

[20}; therefore,

changes

in their

conservative

and

surgeons

been

have

impression

even some distrust. The realization that astuteness is being challenged by technol-

perhaps

clinical

conspicuous

surgeons

with

vance ofsonography

tion.

the

the Clinician

surgery

of patients

agement

if

for sonogra-

respects.

to rely on their clinical

decision

periappendiceal

be is

complemen-

especially

For mote than a century, taught

appendicitis,

16). abdominal laboratory

a psychogenic

or is not suitable

Communication

inflammatory

be

of pulmonary

or functional bowel disorder should suspected. If the sonographic examination not conclusive,

by

or a

cause

tary

sonographic findings do not exclude or adnexitis. In this context, the

con-

may

severe and

sonographic

are repeatedly

or inf-

of pleural

to the diagnosis

clue

are

epigastric

a myocardial

A subtle amount

region

tis. Normal appendicitis

serum.

be a diag-

can

abnormalities

with

or a pulmonary

sidered.

Fig. 15.-i 1-year-old girl presented with right lower quadrant pain. A and B, Sonograms show dilated fluid-filled bowel loops over entire abdomen with complete absence of penstalsis during 10 mm of examination. No other abnormality was shown. Surgery by median incision showed generalized purulent peritonitis from perforated appendicitis.

Pan-

elevated

and

however,

no sonographic

found arction

B

an

nightmare.

When

A

are pan[19).

ischemia

diagnosed

level

Mesenteric

Fig. 14.-Inflamed fat in sigmoid diverticulitis. A, Sonogram shows wall thickening of contracted sigmoid (5) and diverticulum surrounded by large areas of hyperechoic, noncompressible tissue (asterisks). B, This tissue represents fatty mesentery and migrated omentum, which was confirmed by CT scan.

findings

mesenteric

pye-

[ I 8J. do not give

that initially

sonographic

creatitis

nostic

ofthe

over the kid-

to the diagnosis

clues

diseases

to abnormal

rise

Thickening

wall and local tenderness

localiceal

final

should

report, be

history,

physical

as well

as the

integrated signs,

results

the

with

and

the

patient’s

laboratory

of a possible

data CT

scan

185

Puylaert

et al. Fig. 16.-2O-year-old woman presented with severe right upper quadrant pain and marked leukocytosis. Patient was suspected of having cholecystitis or generalized pelvic inflammatory disease. A, Sonographically.

abdomen

was normal.

Only abnormalities observed were some echolucent areas above diaphragm. B, On lateral chest radiograph, small posterobasal consolidation wasfound. Final diagnosis was right-sided basal pneumonia.

and other radiologic examinations. Liberal use and a clinical approach are the key points in sonography of the acute abdomen. Sonography

is

a valuable

tool

to

lower

both

number of unnecessary laparotomies technique related to surgical delay.

and

the the

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