Diagnostic Imaging of the Acute Abdomen: A Clinico-Radiologic Approach

463 Pages·1988·27.66 MB·English

by  Professor Dr. Dieter Beyer

Dieter Beyer Ulrich Madder
Diagnostic Imaging
of the
Acute Abdomen
A Clinico-Radiologic Approach
With Contributions by
G.Benz-Bohm W.Gross-Fengels A.E.Horwitz G.P.Krestin
R. Lorenz K. F. R. Neufang P. E. Peters H. Pichlmaier
W. Steinbrich F. E. Zanella
With a Foreword by H. Pichlmaier
With 250 Figures Containing 680 Separate Illustrations
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo
Professor Dr. Dieter Beyer
Department of Radiology
Krankenhaus Porz am Rhein
Urbacher Weg 19
D-5000 Cologne 90
Professor Dr. Ulrich Modder
Department of Radiology
University of Dusseldorf Medical School
MoorenstraBe 5
D-4000 Dusseldorf 1
Translator:
Terry C. Telger, 6112 Waco Way, Ft. Worth, TX 67133, USA
Title of the German Edition
Diagnostik des akuten Abdomens mit bildgebenden Verfahren
ISBN-13: 978-3-642-71886-1
ISBN-13: 978-3-642-71886-1 e-ISBN-13: 978-3-642-71884-7
DOl: 10.1007/978-3-642-71884-7
Library of Congress Cataloging-in-Publication Data
Diagnostic imagmg of the acute abdomen: a clinico-radiologic approach / [edited by] Dieter Beyer, Ulrich
MOdder ; with contributions by G.Benz-Bohm ... let al.] ; with a foreword by H.Pichlmaier.
p. cm.
Includes index.
ISBN-13 978-3-642-71886-1 (U. S.)
1. Acute abdomen-Diagnosis. 2. Acute abdomen-Radiography. 3. Abdomen-Imaging. I. Beyer, Dieter,
1946- . II. MOdder, Ulrich, 1945- . III. Benz-Bohm, G.(Gabriele) RD540.D52 1988
617'.550757-dc19 88-28157
This work is subject to copyright. All rights are reserved, whether the whole or part of the material ist con
cerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, repro
duction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts
thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its
version of June 24,1985, and a copyright fee must always be paid. Violations fall under the prosecution act
of the German Copyright Law.
© Springer-Verlag Berlin Heidelberg 1988
Softcover reprint of the hardcover 1st edition 1988
The use of registered names, trademarks, etc. in the publication does not imply, even in the absence of a
specific statement, that such names are exempt from the relevant protective laws and regulations and there
fore free for general use.
Product Liability: The publisher can give no guarantee for information about drug dosage and application
thereof contained in this book. In every individual case the respective user must check its accuracy by con
sulting other pharmaceutical literature.
2121/3145-543210 - Printed on acid-free paper
We dedicate this manual with appreciation to
Gerd Friedmann, Cologne, and Bernhard Swart, Neuss,
for their inspiration, guidance, and friendship.
Foreword
That radiologists and surgeons work in close cooperation is in the nature of
things, as it is the surgeon who is in the best position to verify radiographic
findings or reveal errors. At the same time, the surgeon depends more than
anyone else on precise diagnosis, accurate preoperative details of topogra
phy and pathology, clear description of the relative positions of neighbor
ing organs and structures, and evaluations of function, e. g., by angiogra
phy. It was these considerations that gave rise to the idea of this book.
The aim is to outline the applications of imaging techniques in examination
of the acute abdomen, structured around key words, to give the student and
the practising radiologist a conceptual framework for everyday use. This
seemed to us all the more necessary in that imaging techniques are in a pro
cess of rapid technological development: new ground is broken and new
elements are added every year. Appropriate and rational application of
these techniques is essential, if only because of the multitude of possibili
ties available. The correct choice of techniques and the sequence in which
they are used is becoming increasingly significant both to the well-being of
the patient and to the economics of patient care.
Cologne, June 1988 H. Pichlmaier
VII
Preface
Altes Fundament ehrt man,
darf aber das Recht nicht
aufgeben, irgendwo wi~der
einmal von vom zu griindenJ
J. W von Goethe
The acute abdomen ist one of the most frequent, most dangerous, and most
difficult ailments a diagnostic radiologist has to examine and diagnose. It is
an everyday, recurring problem for the private practitioner and an interdis
ciplinary diagnostic and therapeutic challenge for physicians in the hospi
tal setting.
The potential causes range from extra- or intra-abdominal disorders amen
able to conservative, nonsurgical treatment to highly acute abdominal con
ditions after a prompt diagnosis demanding immediate surgical interven
tion. The outcome of many acute abdominal disorders is decided in a
matter of hours, and often diagnosis can be a matter of extreme urgency.
Today the attending physician has to choose from a wide range of diagnos
tic procedures, because no other field of medicine has changed as dynami
cally during recent years as diagnostic radiology. An inexperienced physi
cian on call - most patients with acute abdomen are first seen in the
evening or at night, even if the symptoms start in the daytime - may find it
especially difficult to determine the most suitable sequence of imaging mo
dalities for a given patient ("tailored approach"). Because of their special
ized training, it is the radiologists' role to guide the referring physician to
the appropriate available examinations, reducing the time needed to estab
lish a diagnosis and decreasing the number of examinations required.
This book, which was designed to serve as a quick reference aid in daily
practice, draws on the 1974 publication of Swart and Meyer on plain radi
ography of the acute abdomen. However, the concept of plain abdominal
radiography has undergone marked changes in the last decade, and we
wish to show that the newer imaging techniques, most notably ultrasonog
raphy and computed tomography, now enable many conditions to be diag
nosed earlier, more accurately, and less invasively, with a consequent re
duction in the mortality rate. The new imaging modalities and intervention
al radiology have already greatly changed methods of diagnosis and
therapy of a number of acute abdominal conditions and undoubtedly will
lead to further changes in the future.
The material and case studies presented are designed to show the current
status of diagnostic radiology in the investigation of the acute abdomen.
The success of more sophisticated procedures, however, should not make
us forget the simpler and less costly method of plain abdominal
radiography. It would be unfortunate if this mainstay were to decline due
to lack of practice in plain film interpretation, since plain radiographs have
not at all been replaced by the newer imaging techniques. This is borne in
mind in the staged approach to the diagnostic imaging of the acute
abdomen that is presented in this book.
To keep this text within a reasonable length we have followed a pragmatic
lOne reveres ancient foundations, but must not surrender the right to begin building
elsewhere anew
IX
PREFACE
ULTRASOUND?
eT?
CHOl..e~FlAP~f(?
-
DIAGNOSTIC DILEMMA 1988
approach, giving short and clear presentations and emphasizing the most
relevant symptoms and clinical problems. Overlap and repetitions between
chapters were, however, necessary so that the various chapters, arranged
according to methods, symptoms, and diseases, would each form a
complete unit.
The importance of interdisciplinary consultation between the attending
physician, the surgeon, and the radiologist is repeatedly emphasized
throughout the text. The many years of close cooperation between the
Departments of Surgery and Radiology of the University of Cologne
Medical School provide an important basis for this. Daily consultations on
patient selection and postoperative feedback have produced a continuing
follow-up on the results of diagnostic imaging and have provided a
mechanism for their improvement. For this we are particularly indebted to
Prof. Dr. Dr. H. Pichlmaier and his colleagues.
We wish to express our appreciation to Mr. F. Textoris for his advice on
photographic matters and for the processing of illustrations. We are also
grateful to Mrs. Schreiber for providing the diagrams, and to Mrs. Milo for
typing the manuscripts. Thanks also to the translators, Terry C. Telger,
Walter Gross-Fengels and Hans Herlinger. We also thank Springer-Verlag,
and especially Mr. B. Lewerich, Dr. U. Heilmann, and Mr. J. Sydor, for their
courtesy and personal efforts in the preparation of this book.
We will be grateful if errors and omissions are brought to our attention.
Cologne, June 1988 Dieter Beyer
Ulrich Madder
x
Table of Contents
1 Clinical Examination and Symptoms
H. PiCHLMAIER. • • • •• 1
2 Imaging Techniques and Systematic Image Analysis
(in Adults). . . . .. 8
2.1 Plain Abdominal Radiography
D.BEYER, w.GRoss-FENGELS. .• • 8
2.2 Real-Time Ultrasonography
D.BEYER. . • • •• 12
2.3 Computed Tomography
U.MODDER. • • • •• 16
2.4 Angiography
K. F. R. NEUFANG, P. E. PETERS. 19
3 Radiographic, Sonographic, and Computed Tomographic
Findings. . . . .. 24
3.1 Pathologic Gaseous Distension of the Intestinal
Tract. . . . .. 24
3.1.1 Pathologic Gastric Distension
D.BEYER. • • • •• 25
3.1.2 Duodenal Distension
D.BEYER. • • • •• 31
3.1.3 Distension Limited to the Small Bowel
D.BEYER, W.GRoss-FENGELS. • • • •• 37
3.1.4 Distension Limited to the Colon
D.BEYER. • • • •• 47
3.1.5 Combined Distension of the Small and Large Bowel
D.BEYER. • • • •• 57
3.2 Pathologic Thickening of the Bowel Wall - Separation of
Gas-Filled Bowel Loops - Mucosal Alterations
D. BEYER, U. MOODER. • • • •• 66
3.3 Intraperitoneal Fluid Collections
G.P.KRESTIN, D.BEYER. • • • •• 76
3.4 Extraperitoneal Fluid Collections
F.E.ZANELLA, D.BEYER, R.LoRENZ. • • . 85
3.5 Pathologic Gas Collections. . . . .. 96
3.5.1 Free Intraperitoneal Gas (Pneumoperitoneum)
D. BEYER, G. P. KRESTIN. • • • •. 96
XI
TABLE OF CONTENTS
3.5.2 Extraperitoneal Gas Collections
G. P. KRESTIN, D. BEYER, U. MOODER. • 106
3.5.3 Pathologic Gas Collections in Organ Parenchyma
U. MOODER, G. P. KRESTIN, D. BEYER. • • • •. 114
3.5.4 Intraluminal and Intramural Gas Collections in Canalicular
Structures and Hollow Viscera
D. BEYER, U. MOODER. • • •• 126
3.6 Intra-abdominal Masses
G. P. KRESTIN, D. BEYER. . .... 144
3.7 Calcifications
R. LORENZ, D. BEYER, U. MOODER. 155
3.8 Foreign Bodies
D. BEYER, U. MOODER. • • • • • 178
4 Major Diseases Associated with Acute Abdomen and Their
Accessibility to Diagnostic Imaging. . . 195
4.1 Acute Inflammatory Abdominal Diseases. 195
4.1.1 Acute Cholecystitis
195
D.BEYER, RLoRENZ. •
4.1.2 Acute Pancreatitis
U. MOODER, D. BEYER. • • 202
4.1.3 Diffuse Peritonitis
D. BEYER, W. STEINBRICH • . . . . . 216
4.1.4 Acute Appendicitis
D. BEYER, G. P. KRESTIN • 219
4.1.5 Abscesses ...... 233
4.1.5.1 Intraperitoneal Abscesses
233
G. P. KRESTIN, D. BEYER, W. STEINBRICH •
4.1.5.2 Extraperitoneal Abscesses
245
G. P. KRESTIN, D. BEYER, W. STEINBRICH •
4.2 Acute Bowel Diseases. . . . .. 255
4.2.1 Mechanical Obstruction of the Small Bowel
255
D.BEYER. . • • ••
4.2.2 Mechanical Obstruction of the Large Bowel
275
D.BEYER, RLoRENZ. • • • .•
4.2.3 Intestinal Pseudo-Obstruction (Atonic, Adynamic, Paralytic,
Functional Ileus)
286
D.BEYER, K.F.RNEUFANG. • • • ••
4.2.4 Acute Intestinal Ischemia - Mesenteric Infarction
290
D.BEYER, w.GRoss-FENGELS. • • • ••
4.2.5 Toxic Megacolon
D. BEYER. • • • •. 305
4.3 Acute Hemorrhage. . . 309
4.3.1 Upper Gastrointestinal Hemorrhage
K. F. R NEUFANG, D. BEYER, P. E. PETERS. • • 309
4.3.2 Lower Gastrointestinal Hemorrhage
K. F. R. NEUFANG, D. BEYER, P. E. PETERS. • • 314
XII
TABLE OF CONTENTS
4.3.3 Intramural Intestinal Hemorrhage
R. LoRENZ, D. BEYER. • • • •• 322
4.3.4 Acute Intraperitoneal Hemorrhage (of Nontraumatic Cause)
K.F.RNEUFANG, D.BEYER, P. E. PETERS • • • 331
4.4 Acute Retroperitoneal Disorders
R LoRENZ, D. BEYER, U. MOODER. • • • 338
4.5 Acute Abdominal Trauma
347
RLoRENZ, D.BEYER. • • • ••
4.6 Soft-Tissue Lesions of the Abdominal Wall and Back That Produce
Acute Symptoms
376
RLoRENZ, D.BEYER. • • • ••
4.7 Acute Diseases of the Lesser Pelvis
D. BEYER, W. STEINBRICH. • • • •• 383
4.8 Acute Abdomen Following Operative and Diagnostic Procedures
P. E. PETERS, D. BEYER. • • • •• 390
5 Special Features of Acute Abdominal Disorders in Children
G.BENZ-BoHM, A. E. HORWITZ • • • • •• 404
5.1 Acute Abdomen in Newborns. . . . .. 404
5.1.1 High Intestinal Obstruction. . . . .. 408
5.1.2 Low Intestinal Obstruction. . . . .. 414
5.1.3 Intestinal Pneumatosis. . . . .. 420
5.1.4 Pneumoperitoneum. . . . .. 422
5.1.5 Intra-abdominal Calcifications. . . . .. 422
5.1.6 Fluid Collections. . . . .. 424
5.1.7 Rare Causes of Acute Abdomen in Newborns. . . . .. 424
5.2 Acute Abdomen in Infants. . . . .. 425
5.2.1 Paralytic Ileus. . . . .. 425
5.2.2 Mechanical Bowel Obstruction. . . . .. 425
5.3 Acute Abdomen in Small and School-Age Children. . . . .. 437
5.3.1 Acute Appendicitis. . . . .. 437
5.3.2 Mechanical Bowel Obstruction. . . . .. 440
5.3.3 Other Causes of Abdominal Complaints. . 441
5.3.4 Recurring Abdominal Pain. . . . .. 441
6 Evaluation of Imaging Procedures in the Diagnosis of Acute
Abdomen
D. BEYER, U. MOODER, H. PICHLMAIER. • • • •• 443
7 Subject Index. . . . .. 447
XIII