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Tailored Helical CT Evaluation of Acute Abdomen¹

(CME available in print version and on RSNA Link)

¹ From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287. Received March 8, 1999; revision requested May 5 and received June 3; accepted June 8. Address reprint requests to B.A.U. (e-mail: burban@jhmi.edu).

View larger version (153K): [in a new window]   Figure 1.   Glandular enlargement in a 49-year-old woman with acute pancreatitis. Axial CT scan obtained with intravenous contrast material shows a moderate amount of inflammatory fluid (arrows) surrounding a minimally enlarged pancreas (p). The pancreas demonstrates normal attenuation without evidence of necrosis.

View larger version (154K): [in a new window]   Figure 2.   Pancreatic abscess in a 38-year-old man with acute pancreatitis. Axial CT scan obtained with rapid bolus administration of intravenous contrast material shows an air-fluid level (A) in the lesser sac anterior to the underlying pancreas (arrow), whose enhancement implies viability.

View larger version (144K): [in a new window]   Figure 3.   Hemorrhagic pancreatic pseudocyst in a 44-year-old man who presented with acute abdominal pain. Axial CT scan obtained with intravenous contrast material demonstrates calcifications from chronic pancreatitis in the head of the pancreas. A high-attenuation focus of blood (arrow) is seen within the low-attenuation pseudocyst, a finding that is consistent with hemorrhage.

View larger version (140K): [in a new window]   Figure 4.   Acute cholecystitis in a 40-year-old man. Axial CT scan obtained with intravenous contrast material demonstrates the classic features of acute cholecystitis: distention of the gallbladder (gb), wall thickening with enhancement, and focal pericholecystic fluid and inflammation. Surgery revealed acute cholecystitis with a xanthogranulomatous component.

View larger version (157K): [in a new window]   Figure 5.   Emphysematous cholecystitis in a 66-year-old man. Axial CT scan obtained with intravenous contrast material shows air filling the distended gallbladder lumen (gb) and wall (arrow). Pathologic analysis revealed extensive necrosis with adherence to the adjacent liver.

View larger version (154K): [in a new window]   Figure 6.   Infectious cholangitis in an 82-year-old woman with acute cholecystitis. Axial CT scan obtained with intravenous contrast material demonstrates multiple hepatic abscesses (arrows), which were a complication of cholecystitis in this case.

View larger version (147K): [in a new window]   Figure 7.   Gallbladder perforation in a 59-year-old woman with acute cholecystitis. Axial CT scan obtained after bolus injection of intravenous contrast material demonstrates a liver abscess with heterogeneous attenuation (A) adjacent to the distended gallbladder (gb). Continuity is demonstrated between the gallbladder and the abscess, indicating the site of rupture (arrow). Aspiration yielded frank pus.

View larger version (143K): [in a new window]   Figure 8a.   Biliary obstruction from an impacted common bile duct stone in an 81-year-old woman with choledocholithiasis. (a) On an axial CT scan obtained with intravenous contrast material, the common bile duct (cbd) is moderately dilated and tortuous. (b) CT scan obtained inferior to a shows an impacted high-attenuation nidus from a gallstone at the ampulla (arrow).

View larger version (132K): [in a new window]   Figure 8b.   Biliary obstruction from an impacted common bile duct stone in an 81-year-old woman with choledocholithiasis. (a) On an axial CT scan obtained with intravenous contrast material, the common bile duct (cbd) is moderately dilated and tortuous. (b) CT scan obtained inferior to a shows an impacted high-attenuation nidus from a gallstone at the ampulla (arrow).

View larger version (168K): [in a new window]   Figure 9.   Gallstones in a 75-year-old man with choledocholithiasis and pancreatitis. Axial CT scan obtained with intravenous contrast material shows very subtle gallstones within the gallbladder lumen (white arrow) and common bile duct (black arrow). Stranding is seen in the peripancreatic fat.

View larger version (175K): [in a new window]   Figure 10.   Splenic infarction in a 41-year-old woman. Axial CT scan obtained with intravenous contrast material demonstrates multiple infarcts in an enlarged spleen (arrows). Most splenic abnormalities, including infarcts, can be differentiated from normal inhomogeneous splenic enhancement.

View larger version (179K): [in a new window]   Figure 11.   Global splenic infarction in a 32-year-old man with human immunodeficiency virus (HIV) infection who presented with severe left upper quadrant pain. Axial CT scan obtained with intravenous contrast material demonstrates an enlarged, infarcted spleen (S) resulting from portal vein thrombosis. The spleen appears similar to a large abscess.

View larger version (136K): [in a new window]   Figure 12.   Acute bilateral pyelonephritis in a 34-year-old woman. Axial CT scan obtained with intravenous contrast material demonstrates patchy, striated nephrograms.

View larger version (150K): [in a new window]   Figure 13.   Acute pyelonephritis in a 69-year-old man. Axial nephrographic-phase CT scan obtained with intravenous contrast material reveals patchy enhancement of the left kidney. The kidney is minimally enlarged with perinephric stranding, secondary findings that also suggest infection.

View larger version (153K): [in a new window]   Figure 14.   Abdominal aortic aneurysm and renal infarction in a 67-year-old man. On an axial arterial-phase CT scan obtained with intravenous contrast material, the lateral aspect of the left kidney demonstrates the characteristic appearance of renal infarction (arrow).

View larger version (156K): [in a new window]   Figure 15.   Global infarction in a 67-year-old man with aortic dissection. The patient presented with acute left flank pain. Axial CT scan obtained with intravenous contrast material reveals a dissection flap occluding the left renal artery (arrow). Flow to the left kidney is obstructed.

View larger version (149K): [in a new window]   Figure 16a.   Obstructing ureteral calculus in a 51-year-old woman. (a) Axial unenhanced CT scan demonstrates right hydronephrosis. (b) CT scan obtained inferior to a clearly depicts an obstructing calculus in the midureter (arrow).

View larger version (139K): [in a new window]   Figure 16b.   Obstructing ureteral calculus in a 51-year-old woman. (a) Axial unenhanced CT scan demonstrates right hydronephrosis. (b) CT scan obtained inferior to a clearly depicts an obstructing calculus in the midureter (arrow).

View larger version (152K): [in a new window]   Figure 17.   Ureteral calculus in a 24-year-old man. Axial unenhanced CT scan shows focal stranding around the middle of the right ureter, a finding that helps localize a subtle calculus (arrow).

View larger version (168K): [in a new window]   Figure 18.   Tubo-ovarian abscess and pyosalpinx in a 41-year-old woman. On a CT scan obtained with intravenous contrast material, the left fallopian tube is dilated and filled with fluid. Subtle tubular enhancement is also seen (arrows).

View larger version (155K): [in a new window]   Figure 19a.   Acute appendicitis. Axial CT scans obtained with intravenous contrast material in a 27-year-old woman (a) and a 62-year-old man (b) show a minimally distended appendix with an enhancing wall (arrow). Stranding is seen in the periappendiceal fat. These findings are pathognomonic for acute appendicitis.

View larger version (148K): [in a new window]   Figure 19b.   Acute appendicitis. Axial CT scans obtained with intravenous contrast material in a 27-year-old woman (a) and a 62-year-old man (b) show a minimally distended appendix with an enhancing wall (arrow). Stranding is seen in the periappendiceal fat. These findings are pathognomonic for acute appendicitis.

View larger version (141K): [in a new window]   Figure 20a.   Perforating appendicitis in a 44-year-old man. (a) Axial CT scan obtained with intravenous contrast material demonstrates subtle findings of a minimally enhancing, tortuously dilated appendix (arrowheads). This finding was initially misinterpreted as the normal terminal ileum. (b) CT scan obtained inferior to a demonstrates minimal fluid in the pelvis (arrow). B  = bladder. In this case, use of oral contrast material would likely have aided in making the correct diagnosis. Although reported sensitivities for detecting acute appendicitis are similar with any combination of oral, intravenous, and rectal contrast material (or with none of the three), we prefer using a combination of the first two whenever possible.

View larger version (142K): [in a new window]   Figure 20b.   Perforating appendicitis in a 44-year-old man. (a) Axial CT scan obtained with intravenous contrast material demonstrates subtle findings of a minimally enhancing, tortuously dilated appendix (arrowheads). This finding was initially misinterpreted as the normal terminal ileum. (b) CT scan obtained inferior to a demonstrates minimal fluid in the pelvis (arrow). B  = bladder. In this case, use of oral contrast material would likely have aided in making the correct diagnosis. Although reported sensitivities for detecting acute appendicitis are similar with any combination of oral, intravenous, and rectal contrast material (or with none of the three), we prefer using a combination of the first two whenever possible.

View larger version (122K): [in a new window]   Figure 21.   Crohn disease mimicking acute appendicitis in an 18-year-old woman. Axial CT scan obtained with intravenous contrast material shows minimal thickening of the distal terminal ileum (white arrow). Focal abscesses in the right lower quadrant (black arrows) mimic perforating appendicitis.

View larger version (136K): [in a new window]   Figure 22.   Acute diverticulitis in a 62-year-old man. Axial CT scan obtained with intravenous contrast material demonstrates focal thickening and pericolonic stranding (arrow), both of which are classic features of acute diverticulitis.

View larger version (134K): [in a new window]   Figure 23.   Diverticular abscess in a 49-year-old man. Axial CT scan obtained with intravenous contrast material shows a small abscess adjacent to an abnormally thickened sigmoid colon (arrow). The rim enhancement of the fluid collection implies infection.

View larger version (153K): [in a new window]   Figure 24.   Duodenitis in a 72-year-old man. The patient presented with postoperative nausea, vomiting, and abdominal pain. Axial CT scan obtained with intravenous contrast material shows moderate duodenal thickening (arrowheads).

View larger version (138K): [in a new window]   Figure 25.   Perforated duodenal ulcer in a 62-year-old man. Axial CT scan obtained with intravenous contrast material demonstrates stranding in the right anterior pararenal space (arrow), a common location for the traversal of fluid in patients with perforated ulcer. Surgery confirmed the presence of a large perforated ulcer.

View larger version (139K): [in a new window]   Figure 26a.   Small bowel obstruction from inguinal hernia in a 55-year-old man. (a) Axial CT scan obtained with intravenous contrast material shows moderately dilated small bowel loops with minimal mural thickening and enhancement. (b) CT scan obtained inferior to a shows a transition point at the site of an incarcerated right inguinal hernia (arrow).

View larger version (117K): [in a new window]   Figure 26b.   Small bowel obstruction from inguinal hernia in a 55-year-old man. (a) Axial CT scan obtained with intravenous contrast material shows moderately dilated small bowel loops with minimal mural thickening and enhancement. (b) CT scan obtained inferior to a shows a transition point at the site of an incarcerated right inguinal hernia (arrow).

View larger version (156K): [in a new window]   Figure 27.   Small bowel obstruction from metastatic gastric cancer in a 68-year-old man. Axial CT scan obtained with bolus administration of intravenous contrast material demonstrates a markedly distended small bowel with air-fluid levels. An enhancing serosal implant is seen involving a bowel loop in the midabdomen (arrow).

View larger version (159K): [in a new window]   Figure 28.   Small bowel obstruction from adhesions in a 61-year-old man who had undergone renal transplantation. Axial CT scan obtained with intravenous contrast material shows a moderately dilated proximal small bowel. Collapsed small bowel loops are seen in the right lower quadrant (arrowheads). No discrete mass is seen in the region of transition in the lower abdomen, and there is no evidence of hernia or intussusception.

View larger version (141K): [in a new window]   Figure 29.   Closed-loop small bowel obstruction from adhesions in a 44-year-old woman. Axial CT scan obtained with intravenous contrast material shows distended small bowel loops in the left midabdomen with collapsed loops in the right lower quadrant. Strangulated obstruction is suggested by the bowel wall thickening with mesenteric edema radiating toward the point of strangulation (arrow). Surgery revealed extensive transmural ischemia with mucosal and submucosal hemorrhage.

View larger version (142K): [in a new window]   Figure 30a.   Diffuse bowel ischemia in a 49-year-old woman. The patient presented with recurrent pancreatic cancer and had a history of Whipple disease. (a) Axial CT scan obtained with intravenous contrast material reveals a tumor surrounding the pancreas and mesenteric vessels (white arrowheads). The superior mesenteric artery is patent (straight arrow), but the superior mesenteric vein is thrombosed (curved arrow). Infarcts are seen in the left kidney (black arrowheads). (b) On a CT scan obtained inferior to a, minimal bowel wall thickening is seen in both the small and large intestine (arrows). Surgery revealed diffuse ischemia.

View larger version (120K): [in a new window]   Figure 30b.   Diffuse bowel ischemia in a 49-year-old woman. The patient presented with recurrent pancreatic cancer and had a history of Whipple disease. (a) Axial CT scan obtained with intravenous contrast material reveals a tumor surrounding the pancreas and mesenteric vessels (white arrowheads). The superior mesenteric artery is patent (straight arrow), but the superior mesenteric vein is thrombosed (curved arrow). Infarcts are seen in the left kidney (black arrowheads). (b) On a CT scan obtained inferior to a, minimal bowel wall thickening is seen in both the small and large intestine (arrows). Surgery revealed diffuse ischemia.

View larger version (155K): [in a new window]   Figure 31.   Intussusception and secondary bowel ischemia in an 80-year-old woman. Axial CT scan obtained with intravenous contrast material shows a colocolic intussusception (black arrow). There is no evidence for a lead point. Low-attenuation bowel wall ischemia is also seen (white arrow) and was confirmed at surgery.

View larger version (161K): [in a new window]   Figure 32.   Ischemic colitis in a 79-year-old man. Axial CT scan obtained with intravenous contrast material reveals a focal low-attenuation area representing thickening in the transverse colon (arrowheads). Focal stranding is seen in the pericolonic fat.

View larger version (123K): [in a new window]   Figure 33.   Ischemic small bowel and pneumatosis intestinalis in a 41-year-old woman. The patient presented with acute thrombosis of multiple vessels including the superior mesenteric artery. Unenhanced CT scan reveals air within the bowel wall (arrow). Pneumatosis is often best appreciated with a lung window setting.

View larger version (138K): [in a new window]   Figure 34.   Bowel necrosis and mesenteric air in a 53-year-old woman. Unenhanced CT scan demonstrates air within the mesenteric vessels (arrowheads). Surgery revealed transmural necrosis of the distal ileum, cecum, and sigmoid colon.

View larger version (138K): [in a new window]   Figure 35.   Perforating gastric cancer in a 61-year-old man who had undergone endoscopy. Axial CT scan obtained with intravenous contrast material demonstrates extensive extraluminal air, predominantly in the retroperitoneum. The exact site of perforation can be difficult to determine if there is a large amount of air, especially in patients with iatrogenic perforation.

View larger version (142K): [in a new window]   Figure 36.   Perforated benign gastric ulcer in an elderly man. Axial CT scan obtained with intravenous contrast material demonstrates free air anterior to the liver (black arrow) as well as focal extraluminal oral contrast material (white arrow), which helped localize the perforation in the stomach.

View larger version (140K): [in a new window]   Figure 37.   Ruptured abdominal aortic aneurysm in a 69-year-old man. Axial CT scan obtained with intravenous contrast material demonstrates massive extravasation of contrast material. Intraoperative repair was unsuccessful, and the patient died.

View larger version (140K): [in a new window]   Figure 38.   Ruptured abdominal aortic aneurysm in an elderly man. Axial CT scan obtained with intravenous contrast material demonstrates acute extravasation of contrast material from an aneurysm leak (black arrow). Note the interruption of intimal calcifications at the site of rupture (white arrow).

View larger version (151K): [in a new window]   Figure 39.   Aortic dissection in a 54-year-old man. Axial CT scan obtained with intravenous contrast material clearly depicts an intimal flap caused by aortic dissection (arrowhead).

View larger version (139K): [in a new window]   Figure 40.   Bleeding Meckel diverticulum in a 25-year-old man. Axial CT scan obtained with intravenous contrast material demonstrates bleeding from ectopic gastric mucosa within the diverticulum (arrow).

View larger version (146K): [in a new window]   Figure 41.   Peritoneal hemorrhage in a 33-year-old man who had undergone paracentesis. Axial CT scan obtained with intravenous contrast material demonstrates hemorrhagic ascites throughout the abdomen. A bleeding vessel is identified near the site of recent needle insertion (arrow).

View larger version (144K): [in a new window]   Figure 42.   Small bowel hematoma in a 68-year-old man who was undergoing anticoagulation therapy. The patient presented 7 days after undergoing heart surgery. Unenhanced CT scan demonstrates a high-attenuation hematoma in the proximal small bowel (arrows).

View larger version (133K): [in a new window]   Figure 43.   Hematoma in a 38-year-old man with hemophilia who presented with acute abdominal pain. Axial CT scan obtained with intravenous contrast material demonstrates bilateral hematomas with heterogeneous attenuation causing minimal enlargement of the psoas muscles (arrows).

View larger version (172K): [in a new window]   Figure 44.   Renal cell carcinoma in a 74-year-old man. Axial CT scan obtained after rapid intravenous administration of contrast material demonstrates hemorrhage in the right kidney (arrow). Surgery revealed hemorrhagic cystic degeneration from renal cell carcinoma.