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MDCT of Patients with Acute Abdominal Pain: A New Perspective Using Coronal Reformations from Submillimeter Isotropic Voxels

¹ All authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.

View larger version (93K): [in a new window]   Fig. 1A. —36-year-old woman with diffuse abdominal pain. Axial MDCT scan obtained with IV and oral contrast agents shows thickened appendix (arrow) medial to cecum. There is minimal adjacent inflammation.

View larger version (107K): [in a new window]   Fig. 1B. —36-year-old woman with diffuse abdominal pain. Coronal reformation of MDCT scan shows entire length of thickened appendix (arrows) arising from cecum and extending into pelvis. Coronal image provides confidence in suspected diagnosis of acute appendicitis, which was confirmed surgically.

View larger version (94K): [in a new window]   Fig. 2A. —19-year-old woman who presented in emergency department reporting 10 hr of increasing cramping pain radiating to right lower quadrant. Axial MDCT scan obtained with IV and oral contrast agents shows collapsed loops of small bowel and colon in pelvis. It is difficult to identify appendix with confidence.

View larger version (144K): [in a new window]   Fig. 2B. —19-year-old woman who presented in emergency department reporting 10 hr of increasing cramping pain radiating to right lower quadrant. Coronal reformation of MDCT scan shows portion of normal contrast-filled appendix (arrows), adjacent to gas-filled sigmoid colon. Appendix has no wall thickening or adjacent inflammation. In this patient, coronal reformations aided in identification of normal appendix, and acute appendicitis could be ruled out with high degree of confidence.

View larger version (169K): [in a new window]   Fig. 3A. —20-year-old woman with right lower quadrant pain and fever 1 day after uncomplicated vaginal delivery. Ut = uterus. Axial MDCT scan obtained with IV and oral contrast agents shows gas- and fluid-filled structure (arrows) medial to cecum with surrounding fluid and inflammation. On this image, it is difficult to differentiate distended appendix with perforation from fluid-filled small bowel and to determine whether rounded high-attenuation structure (arrowhead) represented oral contrast material or appendicolith. Dome of postpartum uterus is identified at midline.

View larger version (165K): [in a new window]   Fig. 3B. —20-year-old woman with right lower quadrant pain and fever 1 day after uncomplicated vaginal delivery. Ut = uterus. Coronal reformation of MDCT scan shows tubular structure (arrows) medial to cecum in different perspective. High-attenuation structure (arrowhead) clearly represents appendicolith. At surgery, gangrenous appendicitis with an appendicolith and perforation were identified.

View larger version (135K): [in a new window]   Fig. 4A. —48-year-old man with periumbilical pain who was referred to rule out acute appendicitis. Axial MDCT scan obtained with IV and oral contrast agents shows impressive thickening of cecum (arrows) with adjacent inflammatory changes.

View larger version (158K): [in a new window]   Fig. 4B. —48-year-old man with periumbilical pain who was referred to rule out acute appendicitis. Coronal CT reformation of MDCT scan clearly depicts inflammatory mass (arrows) medial to cecum as well as inflammatory changes. Portion of appendix (arrowheads) is well visualized and appears normal. At surgery, inflammatory mass proved to be contained perforation from diverticulitis. Appendix was normal.

View larger version (88K): [in a new window]   Fig. 5A. —31-year-old woman with periumbilical pain and fever. Axial MDCT scan obtained with IV and oral contrast agents shows thickening of cecum (arrows) and cluster of enhancing lymph nodes (arrowheads) in adjacent mesentery.

View larger version (155K): [in a new window]   Fig. 5B. —31-year-old woman with periumbilical pain and fever. Coronal CT reformation of MDCT scan reveals enlarged lymph nodes (arrowheads) along ileocolic veins that are more conspicuous in coronal than in axial plane. Note thickened ascending colon (white arrow). On colonoscopy, acute colitis was identified, which was likely cause of adenitis. Note respiratory motion artifact (black arrows) along both sides of diaphragm.

View larger version (111K): [in a new window]   Fig. 6A. —91-year-old woman with 3-day history of crampy abdominal pain, nausea, and vomiting. Axial MDCT scan obtained with IV and oral contrast agents shows dilated small bowel (white arrows) and collapsed colon (arrowheads). Note dilated bowel in region of inguinal canal (black arrow).

View larger version (170K): [in a new window]   Fig. 6B. —91-year-old woman with 3-day history of crampy abdominal pain, nausea, and vomiting. Coronal CT reformation of MDCT scan shows bowel dilatation throughout abdomen. "Knuckle" of bowel (arrows) passes through right femoral canal where there is abrupt change in caliber. At surgery, incarcerated bowel within femoral hernia was reduced. Note streak artifact (arrowheads) coursing through abdomen caused by metallic hardware in lower thoracic and lumbar spine (not shown).

View larger version (142K): [in a new window]   Fig. 7A. —57-year-old-woman who presented with nausea, vomiting, abdominal pain, and no bowel movement for 1 week. Axial MDCT scan obtained with IV and oral contrast agents shows dilatation of hepatic flexure of colon (arrows) due to obstructing mass (arrowheads) in splenic flexure.

View larger version (155K): [in a new window]   Fig. 7B. —57-year-old-woman who presented with nausea, vomiting, abdominal pain, and no bowel movement for 1 week. Coronal CT reformation of MDCT scan shows dilated small bowel and colon up to leading edge of splenic flexure mass (arrow) described in A. Note enlarged lymph nodes (arrowheads) in gastrocolic ligament. At colonoscopy, an obstructing adenocarcinoma was identified.

View larger version (129K): [in a new window]   Fig. 8A. —58-year-old man with remote history of testicular cancer and radiation therapy who presented with pain and diarrhea and who was referred to rule out bowel obstruction. On axial MDCT scan obtained with IV and oral contrast agents, it is unclear whether central fluid-attenuation structures (arrows) are dilated loops of bowel or loculated fluid suggesting abscess.

View larger version (181K): [in a new window]   Fig. 8B. —58-year-old man with remote history of testicular cancer and radiation therapy who presented with pain and diarrhea and who was referred to rule out bowel obstruction. Coronal CT reformation of MDCT scan clarifies presence of fluid collection (arrows) with enhancing pseudocapsule. Subsequent percutaneous drainage yielded 125 mL of purulent material. Cultures grew Klebsiella pneumoniae and Bacteroides fragilis organisms.

View larger version (128K): [in a new window]   Fig. 9. —50-year-old woman with nonbilious emesis and colicky abdominal pain. Coronal reformation of MDCT scan obtained with oral contrast material shows dilated and thick-walled bowel (arrows) in mid abdomen. Other loops of bowel are normal and filled with contrast material. Note loculated right subphrenic fluid (arrowheads). At exploratory laparotomy, ischemic bowel (caused by closed-loop obstruction from volvulus) was resected.

View larger version (174K): [in a new window]   Fig. 10. —36-year-old woman with right lower quadrant pain. Coronal reformation of MDCT scan obtained with IV and oral contrast material shows tubular fluid-filled structure (black arrows) in right adnexa. Inflammation (arrowheads) is present in fatty tissue in right lower quadrant. Note appendix (white arrow) is normal and opacified with oral contrast material. At laparoscopy, tubular structure in right adnexa proved to represent pyosalpinx.

View larger version (168K): [in a new window]   Fig. 11. —23-year-old woman who presented with abdominal pain after undergoing heart transplantation for peripartum cardiomyopathy. Coronal reformation of MDCT scan obtained with IV and oral contrast material shows free intraperitoneal fluid, pneumatosis coli (arrows), and gas (arrowheads) in peripheral portal vein branches. Findings are consistent with colonic ischemia. These findings were also evident on axial MDCT scans (not shown).

View larger version (121K): [in a new window]   Fig. 12A. —48-year-old woman with bloody diarrhea. Axial MDCT scan obtained with IV and oral contrast agents shows thickening of ascending and descending colon (arrows).

View larger version (192K): [in a new window]   Fig. 12B. —48-year-old woman with bloody diarrhea. Coronal CT reformation of MDCT scan shows thickening of descending colon (arrows). Note excellent visualization of vasa recta (arrowheads) medial to sigmoid colon. On colonoscopy, ischemic colitis was identified.

View larger version (143K): [in a new window]   Fig. 13. —36-year-old man with periumbilical pain referred to rule out acute appendicitis. Coronal CT reformation of MDCT scan obtained with IV and oral contrast agents shows left-sided pelvicaliectasis (arrow). Dilated ureter can be traced to 4-mm obstructing calculus (arrowhead).

View larger version (164K): [in a new window]   Fig. 14. —35-year-old man with right lower quadrant pain. Coronal CT reformation of MDCT scan shows small amount of intraperitoneal fluid (arrow) adjacent to small bowel. Note excellent visualization of mesenteric vessels (white arrowhead) and small lymph nodes (black arrowhead).

View larger version (108K): [in a new window]   Fig. 15A. —47-year-old woman with ovarian cancer and abdominal pain. Axial MDCT scan obtained with IV and oral contrast agents shows questionable soft-tissue abnormality (arrows) anterior to ascending colon.

View larger version (157K): [in a new window]   Fig. 15B. —47-year-old woman with ovarian cancer and abdominal pain. Coronal CT reformation of MDCT scan clearly shows peritoneal-based soft-tissue thickening (arrows) along ascending colon and inferior liver capsule. Note nodular capsular-based implants (arrowheads) along liver dome, consistent with peritoneal carcinomatosis.

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