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The lecture illustrates the different patterns of abnormal gas in abdominal plain X-rays.
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Abnormal Gas..Basic Abnormal Gas..Basic conceptsconcepts
Dr/Ahmed BahnassyDr/Ahmed BahnassyConsultant RadiologistConsultant Radiologist
MBCHB-MD-FRCRMBCHB-MD-FRCRE-mail:[email protected]:[email protected]
Where is the gas ?Where is the gas ? IPIP RPRP BWBW GBGB ABAB
IntraperitonealIntraperitoneal RetroperitonealRetroperitoneal Bowel wall Bowel wall Gall bladder and Gall bladder and
biliarybiliary AbscessAbscess
PNEUMOPERITONEUMPNEUMOPERITONEUM
FREE AIR FREE AIR SENSITIVITY OF IMAGING STUDIESSENSITIVITY OF IMAGING STUDIES
COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY 99%99%
LATERAL UPRIGHT CHEST RADIOGRAPH LATERAL UPRIGHT CHEST RADIOGRAPH 98%98%
AP UPRIGHT CHEST RADIOGRAPH AP UPRIGHT CHEST RADIOGRAPH 80 - 90%80 - 90%
SUPINE ABDOMEN RADIOGRAPHSUPINE ABDOMEN RADIOGRAPH ? ?
PNEUMOPERITONEUM PNEUMOPERITONEUM SENSITIVITY OF IMAGING STUDIESSENSITIVITY OF IMAGING STUDIES
RADIOLOGIC DEMONSTRATION DEPENDS ON:RADIOLOGIC DEMONSTRATION DEPENDS ON:– VOLUME OF FREE AIRVOLUME OF FREE AIR– TIME INTERVAL BEFORE IMAGINGTIME INTERVAL BEFORE IMAGING– TYPE OF IMAGINGTYPE OF IMAGING– CONDUCT OF IMAGING EXAMINATIONCONDUCT OF IMAGING EXAMINATION
AS LITTLE AS ONE CC CAN BE DEMONSTRATEDAS LITTLE AS ONE CC CAN BE DEMONSTRATED
10% OF PATIENTS WITH PERFORATED ULCERS 10% OF PATIENTS WITH PERFORATED ULCERS DO NOT DEMONSTRATE PNEUMOPERITONEUMDO NOT DEMONSTRATE PNEUMOPERITONEUM
UPRIGHT CHEST UPRIGHT CHEST
PNEUMOPERITONEUMPNEUMOPERITONEUMUPRIGHT RADIOGRAPHSUPRIGHT RADIOGRAPHS
UNDER RIGHT HEMIDIAPHRAGMUPRIGHT ABD CENTRAL TENDON
AND HEMIDIAPHRAGM
FREE AIR…….DECUBITUS VIEWFREE AIR…….DECUBITUS VIEWGAS BETWEEN LIVER AND BODY WALLGAS BETWEEN LIVER AND BODY WALL
BUT MAY ALSO BE IN BUT MAY ALSO BE IN OR ONLY INOR ONLY IN THE PELVIS THE PELVIS
FREE AIRFREE AIRCENTRAL TENDONCENTRAL TENDON
FREE AIRFREE AIRCENTRAL TENDONCENTRAL TENDON
RIGLER’S SIGNRIGLER’S SIGNBOTH SIDES OF BOWEL WALL VISIBLEBOTH SIDES OF BOWEL WALL VISIBLE
DOUBLE WALL SIGN
MASSIVE PNEUMOPERITONEUMMASSIVE PNEUMOPERITONEUMFOOTBALL SIGNFOOTBALL SIGN
FALCIFORM LIGAMENTFALCIFORM LIGAMENTGAS BUBBLE OVER LIVERGAS BUBBLE OVER LIVER
FALCIFORM LIGAMENTFALCIFORM LIGAMENT
PNEUMOPERITONEUMPNEUMOPERITONEUMSUBHEPATIC GAS BUBBLESUBHEPATIC GAS BUBBLE
DIVERTICULITIS DIVERTICULITIS PNEUMOPERITONEUMPNEUMOPERITONEUM
ANTERIOR ABDOMINAL WALLANTERIOR ABDOMINAL WALLANATOMIC FOLDSANATOMIC FOLDS
FREE AIRFREE AIRINFERIOR EPIGASTRIC VESSELSINFERIOR EPIGASTRIC VESSELS
(LATERAL UMBILICAL LIGAMENTS)(LATERAL UMBILICAL LIGAMENTS)
PSEUDO-PSEUDO-PNEUMOPERITONEUMPNEUMOPERITONEUM
CENTRAL TENDON GASCENTRAL TENDON GAS
YES, BUT JUST THE STOMACH
GAS UNDER THE RIGHT HEMIDIAPHRAGMGAS UNDER THE RIGHT HEMIDIAPHRAGM
HEPATIC FLEXURE ANTERIOR-SUPERIOR TO LIVER
SUBDIAPHRAGMATIC FATSUBDIAPHRAGMATIC FATSIMULATING FREE AIRSIMULATING FREE AIR
FREE AIR OR NOT FREE AIR?FREE AIR OR NOT FREE AIR?THAT IS THE QUESTIONTHAT IS THE QUESTION
PNEUMOTHORAX SIMULATES FREE AIR
RETROPERITONEAL GASRETROPERITONEAL GASSIMULATES FREE AIRSIMULATES FREE AIR
RETROPERITONEAL GASRETROPERITONEAL GAS
IATROGENICIATROGENIC– SURGERYSURGERY– DIAGNOSTIC PROCEDUREDIAGNOSTIC PROCEDURE
TRAUMATRAUMA– PENETRATINGPENETRATING– RUPTURED VISCUSRUPTURED VISCUS
RETROPERITONEAL DUODENUM, COLON, RECTUMRETROPERITONEAL DUODENUM, COLON, RECTUM
PERFORATED BOWELPERFORATED BOWEL SECONDARY TO TUMOR, INFECTION, OBSTRUCTION, NECROSISSECONDARY TO TUMOR, INFECTION, OBSTRUCTION, NECROSIS
CAUDAL EXTENSION OF PNEUMOMEDIASTINUMCAUDAL EXTENSION OF PNEUMOMEDIASTINUM
GAS WITHIN ABSCESSGAS WITHIN ABSCESS
RETROPERITONEAL GASRETROPERITONEAL GASCAUSESCAUSES
LITTLE CHANGE IN POSITION OR SHAPE WHEN LITTLE CHANGE IN POSITION OR SHAPE WHEN COMPARING SUPINE, UPRIGHT, DECUB COMPARING SUPINE, UPRIGHT, DECUB RADIOGRAPHSRADIOGRAPHS
BUT FREE INTRAPERITONEAL GAS IS FREELY MOBILE BUT FREE INTRAPERITONEAL GAS IS FREELY MOBILE
TENDS TO STAY IN ONE RETROPERITONEAL TENDS TO STAY IN ONE RETROPERITONEAL COMPARTMENTCOMPARTMENT
DUODENAL PERFORATION…..RUQ ANTERIOR PARARENAL DUODENAL PERFORATION…..RUQ ANTERIOR PARARENAL SPACESPACE
SIGMOID DIVERTICULITIS….. LLQ SIGMOID DIVERTICULITIS….. LLQ PERIRENAL ABSCESS…………. PERINEPHRIC SPACEPERIRENAL ABSCESS…………. PERINEPHRIC SPACE
OFTEN FORMS LINEAR, CURVILINEAR GAS COLLECTIONSOFTEN FORMS LINEAR, CURVILINEAR GAS COLLECTIONS
RETROPERITONEAL GAS RETROPERITONEAL GAS IMAGINGIMAGING
Severe dysuria-left flank painSevere dysuria-left flank pain
BENEATH DIAPHRAGM CAN SIMULATE BENEATH DIAPHRAGM CAN SIMULATE PNEUMOTHORAXPNEUMOTHORAX
LARGE VOLUME OF GAS CAN OUTLINE LARGE VOLUME OF GAS CAN OUTLINE RETROPERITONEAL STRUCTURESRETROPERITONEAL STRUCTURES
KIDNEY, LIVER MARGIN, PSOAS, FLANK STRIPEKIDNEY, LIVER MARGIN, PSOAS, FLANK STRIPE
RETROPERITONEAL GAS CAN EXTENDRETROPERITONEAL GAS CAN EXTEND CEPHALAD TO MEDIASTINUMCEPHALAD TO MEDIASTINUM FASCIAL PLANES OF BODY WALL AND EXTREMITIESFASCIAL PLANES OF BODY WALL AND EXTREMITIES INTO PERITONEAL CAVITYINTO PERITONEAL CAVITY
RETROPERITONEAL GAS RETROPERITONEAL GAS IMAGINGIMAGING
RETROPERITONEAL GASRETROPERITONEAL GAS
13-YEAR-OLD GIRL WITH CROHN’S DISEASE 13-YEAR-OLD GIRL WITH CROHN’S DISEASE
HAS SUBACUTE FEVER AND ABD PAINHAS SUBACUTE FEVER AND ABD PAIN
RETROPERITONEAL GASRETROPERITONEAL GASEXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT EXTENDS TO POSTERIOR PARARENAL SPACE & THEN PROPERITONEAL FAT
AFTER COLONOSCOPY AND AFTER COLONOSCOPY AND BIOPSYBIOPSY
EXTENSIVE RETROPERITONEAL GAS
BAROTRAUMABAROTRAUMAMEDIASTINUM – RETROPERITONEUM – FREE AIRMEDIASTINUM – RETROPERITONEUM – FREE AIR
BOWEL WALL GASBOWEL WALL GAS
PNEUMATOSIS OF COLONPNEUMATOSIS OF COLON INFANTINFANT ADULTADULT
NECROTIZING ENTEROCOLITIS
ISCHEMIC COLITIS
WHAT IS THE ABNORMALITY WHAT IS THE ABNORMALITY HERE? HERE?
USE LUNG WINDOWS TO LOOK FOR GAS
72-YEAR-OLD WOMAN WITH DIARREHA72-YEAR-OLD WOMAN WITH DIARREHA
58-YEAR-OLD WOMAN58-YEAR-OLD WOMANMILD ABDOMINAL PAIN FOR 2 DAYSMILD ABDOMINAL PAIN FOR 2 DAYS
SCLERODERMA, GAS IN COLON WALL
PNEUMATOSIS 2 DAYS AFTER SEGMENTAL SB RESECTIONPNEUMATOSIS 2 DAYS AFTER SEGMENTAL SB RESECTION
RESOLVED SPONTANEOUSLYRESOLVED SPONTANEOUSLY
ASYMPTOMATIC 40-YEAR-OLD MANASYMPTOMATIC 40-YEAR-OLD MAN
BENIGN STEADY STATE PNEUMATOSIS
ISCHEMIC BOWELISCHEMIC BOWEL
ISCHEMIC BOWELISCHEMIC BOWELIMAGING SIGNSIMAGING SIGNS
– DILATIONDILATION PSEUDOOBSTRUCTIONPSEUDOOBSTRUCTION
– BOWEL WALLBOWEL WALL THICKENEDTHICKENED PNEUMATOSISPNEUMATOSIS UNENHANCINGUNENHANCING
– GAS IN VESSELSGAS IN VESSELS MESENTERIC, SMV, PORTAL VEINSMESENTERIC, SMV, PORTAL VEINS
– OBSTRUCTED VESSELSOBSTRUCTED VESSELSSMA, SMVSMA, SMV
– HIGH DENSITY CLOT ON UNENHANCED CTHIGH DENSITY CLOT ON UNENHANCED CT– FILLING DEFECTS ON CT WITH IV CONTRASTFILLING DEFECTS ON CT WITH IV CONTRAST
– ASCITES, FREE AIR AFTER PERFORATIONASCITES, FREE AIR AFTER PERFORATION
ACUTE ONSET OF ABDOMINAL PAINACUTE ONSET OF ABDOMINAL PAIN
SMA EMBOLIS
ThumprintingThumprinting
SBOSBOISCHEMIC BOWELISCHEMIC BOWEL
AT SURGERY: SB TWISTED UNDERADHESION
ISCHEMIC SMALL BOWELISCHEMIC SMALL BOWELETIOLOGY ? ETIOLOGY ?
SMV CLOT
Gall bladder and Biliary GASGall bladder and Biliary GAS
BILE DUCT GASBILE DUCT GAS IATROGENICIATROGENIC
– BILE DUCT SURGERYBILE DUCT SURGERY– SPHINCTEROTOMYSPHINCTEROTOMY
BILIARY FISTULABILIARY FISTULA– GALLSTONE ERODING INTO BOWELGALLSTONE ERODING INTO BOWEL– DUODENAL ULCERDUODENAL ULCER– UPPER ABDOMINAL MALIGNANCYUPPER ABDOMINAL MALIGNANCY– TRAUMATRAUMA
CHOLANGITISCHOLANGITIS– GAS FORMING ORGANISMGAS FORMING ORGANISM
BILE DUCT GASBILE DUCT GAS
BILE DUCT GAS CHUNKY AND CENTRAL
BILE DUCT GAS AND SBOBILE DUCT GAS AND SBO
SBO GALLSTONE ILEUSSBO GALLSTONE ILEUS
GALLSTONE ILEUSGALLSTONE ILEUS
GALLSTONE ILEUSGALLSTONE ILEUSBILE DUCT GAS, SBO, STONEBILE DUCT GAS, SBO, STONE
GALLBLADDER GASGALLBLADDER GAS
GALLBLADDER LUMENGALLBLADDER LUMEN– GALLBLADDER-BOWEL FISTULAGALLBLADDER-BOWEL FISTULA– GALLSTONE ILEUSGALLSTONE ILEUS– EMPHYSEMATOUS CHOLECYSTITISEMPHYSEMATOUS CHOLECYSTITIS
GALLBLADDER WALL GASGALLBLADDER WALL GAS– EMPHYSEMATOUS CHOLECYSTITISEMPHYSEMATOUS CHOLECYSTITIS
EMPHYSEMATOUS CHOLECYSTITISEMPHYSEMATOUS CHOLECYSTITIS
PORTAL VEIN GASPORTAL VEIN GAS
SMALL BOWEL ISCHEMIASMALL BOWEL ISCHEMIAGAS IN MESENTERIC AND PORTAL VEINSGAS IN MESENTERIC AND PORTAL VEINS
48 SubPhrenic Abs CT
65-YEAR-OLD MAN65-YEAR-OLD MANABDOMINAL PAIN ABDOMINAL PAIN
PORTAL VEIN GAS DELICATE AND PERIPHERAL
36-YEAR-OLD MAN36-YEAR-OLD MANMULTIPLE CONGENITAL ANOMALIESMULTIPLE CONGENITAL ANOMALIES
FEVER , WBC 17.8, 15 BANDSFEVER , WBC 17.8, 15 BANDS
ISCHEMIA OF SB AND STOMACH
ABSCESSABSCESS
ABSCESSABSCESS
SUSPECT AN ABSCESS WHEN RADIOGRAPHS SUSPECT AN ABSCESS WHEN RADIOGRAPHS SHOW A GAS COLLECTION THAT IS ABNORMAL SHOW A GAS COLLECTION THAT IS ABNORMAL BECAUSE OF PERSISTENCE ON MULTIPLE BECAUSE OF PERSISTENCE ON MULTIPLE VIEWSVIEWS
GET HISTORY, PX, LAB DATA BY CONSULTATION GET HISTORY, PX, LAB DATA BY CONSULTATION WITH ORDERING MD.WITH ORDERING MD.
CONFIRM WITH CROSS-SECTIONAL IMAGINGCONFIRM WITH CROSS-SECTIONAL IMAGING
APPENDICEAL ABSCESSAPPENDICEAL ABSCESSRETROCECAL APPENDIXRETROCECAL APPENDIX
ABNORMAL GAS… UNCHANGED ON MULTIPLE VIEWS
SIGMOID DIVERTICULITISSIGMOID DIVERTICULITISGAS FILLED “DIVERTICULUM!!GAS FILLED “DIVERTICULUM!!
Huge Abscess !Huge Abscess !
FEVER 10 DAYS AFTER FEVER 10 DAYS AFTER ABDOMINAL SURGERYABDOMINAL SURGERY
CROHN’S DISEASE WITH ABSCESSCROHN’S DISEASE WITH ABSCESS
PANCREATIC ABSCESSPANCREATIC ABSCESS
PANCREATIC GASPANCREATIC GAS-only 3 causes-only 3 causes
GAS IN PANCREATIC BEDGAS IN PANCREATIC BED– ABSCESSABSCESS
– POST PANCREATIC DRAINAGE PROCEDUREPOST PANCREATIC DRAINAGE PROCEDURE PERCUTANEOUS OR SURGICALPERCUTANEOUS OR SURGICAL
– PUESTOW PROCEDUREPUESTOW PROCEDURE– PSEUDOCYST PSEUDOCYST
– PANCREATIC FISTULA PANCREATIC FISTULA
PANCREATITIS WITH ABSCESSPANCREATITIS WITH ABSCESS
LESSER SAC ABSCESS
GAS IN PANCREATIC ABSCESS
PANCREAS-COLON FISTULA
PANCREAS-GAS BUT NO ABSCESS
LESSER SACLESSER SAC
GAS IN LESSER SACGAS IN LESSER SACPERFORATED GASTRIC ULCERPERFORATED GASTRIC ULCER
GASTRIC ULCER GASTRIC ULCER PERFORATION INTO LESSER SACPERFORATION INTO LESSER SAC
Pancreatic Abscess.Pancreatic Abscess.
SummarySummary
IPIPRPRPBWBWGBGBABAB