Abnormal Gas..Basic Abnormal Gas..Basic conceptsconcepts

Dr/Ahmed BahnassyDr/Ahmed BahnassyConsultant RadiologistConsultant Radiologist

MBCHB-MD-FRCRMBCHB-MD-FRCRE-mail:aatteya2001@yahoo.comE-mail:aatteya2001@yahoo.com

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