CT of the Acute Abdomen

458 Pages·2011·29 MB·English

by  Mustapha Sebbane

Medical Radiology
Diagnostic Imaging
Series Editors
Albert L. Baert
Maximilian F. Reiser
Hedvig Hricak
Michael Knauth
Editorial Board
Andy Adam, London
Fred Avni, Brussels
Richard L. Baron, Chicago
Carlo Bartolozzi, Pisa
George S. Bisset, Durham
A. Mark Davies, Birmingham
William P. Dillon, San Francisco
D. David Dershaw, New York
Sam Sanjiv Gambhir, Stanford
Nicolas Grenier, Bordeaux
Gertraud Heinz-Peer, Vienna
Robert Hermans, Leuven
Hans-Ulrich Kauczor, Heidelberg
Theresa McLoud, Boston
Konstantin Nikolaou, Munich
Caroline Reinhold, Montreal
Donald Resnick, San Diego
Rüdiger Schulz-Wendtland, Erlangen
Stephen Solomon, New York
Richard D. White, Columbus
For furthervolumes:
http://www.springer.com/series/4354
Patrice Taourel
Editors
CT of the Acute Abdomen
Foreword by
Albert L. Baert
123
Editor
Prof.Dr. Patrice Taourel
Imagerie Médicale
Hôpital Lapeyronie
avenueduDoyen GastonGiraud 371
34295Montpellier CX 5
France
e-mail: [email protected]
ISSN 0942-5373
ISBN 978-3-540-89231-1 e-ISBN978-3-540-89232-8
DOI 10.1007/978-3-540-89232-8
SpringerHeidelbergDordrechtLondonNewYork
LibraryofCongressControlNumber: 2011935932
(cid:2)Springer-VerlagBerlinHeidelberg2011
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Foreword
Radiological imaging plays a key role in the correct differential diagnosis and
the decision-making for medical or surgical treatment of acute abdominal
conditions.
FormanydecadesanduntiltheadventofCT,standardradiographywasthe
main imaging tool to guide clinicians towards the correct management of the
patients. Notwithstanding the sophisticated rules and guidelines that were
inventedanddevelopedovertheyearsbymanyhighlytalentedradiologists,for
the Optimal interpretation of the standard radiogram of the abdomen; the
important limitations of this diagnostic tool, which could mostly provide only
indirect evidence for the cause or the site of the lesions, remained painfully
evident in our daily practice.
The introduction of CT, especially the multislice technology and the multi-
planar reconstructions, have opened immense new opportunities and possibil-
itiesfortherapidandexactdiagnosisaswellasfortheevaluationoftheextent
oflesionsinthepatientwithanacuteabdominalconditionandhasprofoundly
changed the diagnostic approach of these patients.
This volume offers a comprehensive and detailed description of the optimal
useofCTinacuteabdomenandofthewiderangeofitsclinicalapplicationsin
this large group of patients. The text is supported by numerous, high-quality
images, well-chosen to illustrate the key-CT findings in a Broad Spectrum of
traumatic and non-traumatic acute abdomen.
I am indebted to the editor, P. Taourel, an internationally well known
abdominal radiologist, with a long experience in abdominal CT for his out-
standingeditorialcoordinationandforhispersonalcontributionstothiswork.
I am also very grateful for the high-level contributions from a large group of
other recognised experts in the field.
Thisexcellentvolumewillgreatlyappealtonotonlythegeneral,abdominal
aswellasemergencyradiologistsbutalsotogastroenterologistsandabdominal
surgeons, who will find this book a great help for the better management of
their patients.
Iamconvincedthatitwillmeetgreatinterestofthereadershipforourseries:
Medical Radiology.
Albert L. Baert
v
Contents
Part I Epidemiological Data and Clinical Findings
Epidemiology of Acute Abdominal Pain in Adults in the Emergency
Department Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Mustapha Sebbane, Richard Dumont, Riad Jreige,
and Jean-Jacques Eledjam
Epidemiology of Abdominal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Françoise Guillon
Part II Elementary CT Findings
Key CT Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Eric Delabrousse
Part III CT Techniques
Volume CT of Acute Abdomen: Acquisition and Reconstruction
Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Samuel Me´rigeaud, Ingrid Millet, Fernanda Curros-Doyon,
and Patrice Taourel
Part IV CT Diagnosis in Non Traumatic Abdomen
Acute Liver Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Vale´rie Vilgrain and François Durand
Biliary Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Yves Menu, Julien Cazejust, Ana Ruiz, Louisa Azizi, and Lionel Arrivé
Acute Splenic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Eric Delabrousse
Acute Pancreatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Catherine Ridereau-Zins and Christophe Aubé
vii
viii Contents
Acute Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Samuel Me´rigeaud, Ingrid Millet, and Patrice Taourel
Ischemia (Acute Mesenteric Ischemia and Ischemic Colitis) . . . . . . . . . 183
Stefania Romano and Luigia Romano
Diverticulitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Jean-Michel Bruel and Patrice Taourel
Nonischemic Colitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Philippe Soyer, Mourad Boudiaf, Youcef Guerrache, Christine Hoeffel,
Xavier Dray, and Patrice Taourel
Acute Gastritis and Enteritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Denis Re´gent, Valerie Croise´-Laurent, Julien Mathias, Aurélia Fairise,
Hélène Ropion-Michaux, and Clément Proust
Bowel Obstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Patrice Taourel, Denis Hoa, and Jean-Michel Bruel
Bowel Perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Patrice Taourel, Joseph Pujol, and Emma Pages-Bouic
Acute Gastrointestinal Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Benoit Paul Gallix
Intra- and Retroperitoneal Hemorrhages. . . . . . . . . . . . . . . . . . . . . . . 343
Philippe Otal, Julien Auriol, Marie-Charlotte Delchier,
Marie-Agnès Marachet, and Herve´ Rousseau
Urological Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Patrice Taourel and Rodolphe Thuret
Gynecologic Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Patrice Taourel, Fernanda Curros Doyon, and Ingrid Millet
Acute Diseases Related to Intra-abdominal Fat in Adults . . . . . . . . . . . 393
Etienne Danse
Acute Disease of the Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . 399
Catherine Cyteval
Complications of Abdominal Surgery (Abdominal, Urologic
and Gynecologic Emergencies). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Marc Zins and Isabelle Boulay-Coletta
Contents ix
Part V CT Diagnosis in Traumatic Abdomen
Abdominal Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Ingrid Millet and Patrice Taourel
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Epidemiology of Acute Abdominal Pain
in Adults in the Emergency Department
Setting
Mustapha Sebbane, Richard Dumont, Riad Jreige,
and Jean-Jacques Eledjam
Contents
Abstract
Managingacuteabdominalpainisagreatchallenge
1 Introduction.............................................................. 3 for the emergency physician. The diagnostic
approachforacuteabdominalpainisoneofthemost
2 AcuteAbdominalPainBasedonAge................... 4
2.1 ClinicalPresentationofAbdominalPainBased difficultforaphysician.Thisisprimarilyduetothe
onAge........................................................................ 4 largeextentoftheclinicalmanifestationsforabdom-
2.2 EtiologyofAbdominalPainBasedonAge............. 5
inalpain,aswellastothesubjectivityofthepatient’s
3 AbdominalPainBasedonGender........................ 7 feelings when it comes to clearly expressing the
symptoms.Accuratemeasurementoftheprevalence
4 AbdominalPainBasedonPainLocation............. 7
4.1 SurgicalAbdominalPain.......................................... 7 oftheoriginofacuteabdominalpainisdifficult.The
4.2 NonsurgicalAbdominalPain.................................... 8 causeofthesepainsisindeedwide-ranging,includ-
5 AbdominalPainBasedonPainFeatures............. 9 ingverydifferentclinicalsituations,extendingfroma
viralgastroenteritistoabdominalaneurysmcompli-
6 PopulationatRiskofSeverity............................... 9
cations,throughnonspecificabdominalpain.
6.1 AbdominalPainintheSeropositivePatient............ 10
7 AbdominalPainBasedonSeveritySigns............ 10
7.1 TwoDisordersMustBePrimarilyConsidered
BecauseoftheRiskofSuddenDeath...................... 10
7.2 CausesAssociatedwithRisksofSeverity............... 10
1 Introduction
8 GeneralManagement.............................................. 11
9 Conclusion................................................................ 11
Acute abdominal pain classically refers to pain pro-
References.......................................................................... 12 jectingontotheabdomenthathasevolvedforlessthan
1 week at the time of consultation. It can reflect
intra-abdominal conditions, including gastrointestinal
(GI), urogenital, or vascular disorders, as well as a
symptom revealing extra-abdominal conditions,
includingcardiac,pulmonary,endocrinal,ormetabolic
disorders.
Itisoneofthemostfrequentreasonsforadmission
of an adult to the emergency department, ranging
from 4 to 10% of all admissions. Physical examina-
M.Sebbane(&)(cid:2)R.Dumont(cid:2)R.Jreige(cid:2)J.-J.Eledjam tion, especially the interview, remains one of the key
ServicedesUrgences,HôpitalLapeyronie, elements of the diagnostic approach for acute
371avenueduDoyenGastonGiraud,
abdominal pain conditions. However, the success of
34295Montpellier,France
e-mail:[email protected] physicalexaminationtoaccuratelydiagnosethecause
P.Taourel(ed.),CToftheAcuteAbdomen,MedicalRadiology.DiagnosticImaging, 3
DOI:10.1007/174_2010_135,(cid:2)Springer-VerlagBerlinHeidelberg2011
4 M.Sebbaneetal.
is no greater than 50%. Physical examination along Table1 Causes of main acute abdominal disorders and their
with simple laboratory tests improve the diagnosis prevalence(BouillotandBresler2004)
accuracy in 60% of cases (Nagurney et al. 2003), Causeofacuteabdominalpain Prevalence(%)
because of the highly variable cause and clinical Nonspecific 34.8
pattern with age, sex, type, and location of pain or
Cholecystitis 6.1
severity signs. With the population aging, reasoning
Appendicitis 7.5
by range of ages becomes a determining element in
Intestinalobstruction 6.7
thediagnosticapproach.Withthevariableprevalence
Renaloruretericcolic 11
of the different diagnoses, the older the patient, the
more organic and surgical the condition. Acutepancreatitis 4.3
These orientating epidemiologic elements will Diverticulardisease 3.8
allow the diagnostic strategy to be improved in most Hernia 3.4
patients. However, radiologic explorations, including Gynecologicdisorder 6.1
ultrasonography and tomodensitometry, may be nec-
Otherdiagnoses 6
essary to confirm the diagnosis (Stoker et al. 2009;
de Dombal 1979).
A totally standardized and articulated manage-
ment, essentially based on the physical examination 2 Acute Abdominal Pain Based
along with, when required, additional laboratory on Age
and morphological tests, will support or allow one to
rule out a diagnosis, with the aim to optimize the 2.1 Clinical Presentation of Abdominal
intervention delays, and facilitate the patient’s Pain Based on Age
orientation.
Abdominal emergency can be defined as a condi- Clinical presentation varies with age. Patients over
tion to be medically or surgically treated within 6 h. 50 yearsoldaccountforaboutaquarterofemergency
It represents about 40% of all emergency surgical admissions. The clinical presentation of acute
operations. Overacute abdominal emergency or life- abdominal pain in patients over 50 years old may
threatening emergency only concerns 1% of acute differ from that of younger patients (Ahmed et al.
abdominal pain cases in the emergency setting. 2005; Samaras et al. 2010; Laurell et al. 2006). The
Acuteabdominalpainisasourceofanxiety,andis most common causes of abdominal conditions and
often associated with emotional stress suffered either their prevalence are reported in Table 1.
by the patient or by the patient’s relatives, which The risk of misdiagnoses and delay in diagnosis
could interfere with an objective evaluation. To help canbedetrimental.Specificdiagnosticchallengesare
thedecision-making,managementmustbesimpleand encountered intheelderly,especiallyinpatientsover
obey a predefined algorithm. If the digestive sur- 75 years old. Besides an often, long medical history,
geon’s evaluation is frequently sought, then the and heavy medication, these patients present with
emergency physician often faces challenging deci- nonspecific symptoms, and a certain delay between
sion-makingwhenitcomes toorientating the patient, the onset of symptoms and admission. Often a wider
especially for discharging the patient from hospital. range of differential diagnoses must be considered
Theemergencyphysicianmustresolvethereasonfor (Marco et al. 1998). The most common causes of
the admission. He therefore has to work out an abdominal conditions and their prevalence in the
appropriate cognitive approach, to differentiate over- elderly are reported in Tables 2 and 3.
acute from acute or subacute abdominal pain. Potential challenges to the clinical assessment in
He must seek criteria which will ensure he can assess the elderly are history taking and clinical assess-
the level of emergency. From that time on, immedi- ment. They include altered mentation from fever
atelyaftertheinitialclinicalexamination,thedecision or electrolyte abnormalities, cognitive impairment,
strategy should set up the patient’s clinical course, to decreased mentation from drugs (e.g., opiates, ben-
thefirstminute,hour,and24 h,andeventuallyprevent zodiazepines) dementia, hearing difficulties, intoxi-
mid-term and long-term complications. cation, language barriers, psychiatric disorders, the