Acute abdomen in pediatric radiology. / Das akute Abdomen in der Kinderradiologie.

BACKGROUND: Imaging is a common part of the workup for acute abdomen in childhood and adolescence. Rapid diagnosis is crucial for adequate therapy, especially in young children. METHOD: This review is intended to provide an overview of the typical causes of acute abdomen in children and adolescents and is specifically aimed at radiologists who do not regularly work in pediatric radiology. RESULTS AND CONCLUSION: Age-specific peculiarities make a division into three age groups useful: Newborns, infants and toddlers, and schoolchildren. Possible causes of acute abdomen in children range from congenital lesions, particularly in newborns, to entities well known in adult radiology, more commonly in school-aged children. Since younger children have a higher sensitivity to radiation and often a limited ability to cooperate, sonography and conventional X-ray are the primary imaging modalities used. Decisive advantages of sonography, especially in younger children, include its widespread availability, the lack of need for sedation, and the possibility of bedside examination. Supplementary cross-sectional imaging, usually MRI, is reserved for special clinical questions. Close interdisciplinary cooperation between attending clinicians and radiologists is essential for efficient diagnostics in this patient group. KEY POINTS: · Age-specific features must be observed. · Sonography and radiography are the most important modalities. · Both congenital and acquired pathologies play a role. · Good interdisciplinary cooperation is essential in this patient group. CITATION FORMAT: · Lochbühler N, Bölle P, Müller-Abt P. Acute abdomen in pediatric radiology. Fortschr Röntgenstr 2024; 196: 451 - 462.

Epiploic appendagitis: a commonly undiagnosed non-surgical acute abdominal emergency.

Epiploic appendagitis is a rare cause of acute abdomen and is diagnostically challenging as it mimics common causes of acute abdomen. However, advancements in computerised tomography/Ultrasound imaging have improved the frequency and confidence of diagnosing epiploic appendagitis, preventing unnecessary surgeries. We present a case of an acute abdomen who had to undergo laparoscopy before being diagnosed with epiploic appendagitis, underscoring the difficulty in diagnosis.

Diagnosing the acute abdomen during a global contrast shortage: a single centre experience.

BACKGROUND: The COVID-19 pandemic led to a global shortage of iodinated contrast media (ICM) in early 2022. ICM is used in more than half of the computed tomography of the abdomen and pelvis (CTAP) performed to diagnose an acute abdomen (AA). In response to the shortage, the RANZCR published contrast-conserving recommendations. This study aimed to compare AA diagnostic outcomes of non-contrast CTs performed before and during the shortage. METHODS: A single-centre retrospective observational cohort study of all adult patients presenting with an AA who underwent a CTAP was conducted during the contrast shortage period from May to July 2022. The pre-shortage control comparison group was from January to March 2022; key demographics, imaging modality indication and diagnostic outcomes were collected and analysed using SPSS v27. RESULTS: Nine hundred and sixty-two cases met the inclusion criteria, of which n = 502, 52.2% were in the shortage period group. There was a significant increase of 464% in the number of non-contrast CTAPs performed during the shortage period (P < 0.001). For the six AA pathologies, only n = 3, 1.8% of non-contrast CTAPs had equivocal findings requiring further imaging with a contrast CTAP. Of the total CTs performed, n = 464, 48.2% were negative. CONCLUSION: This study showed that when non-contrast CTs are selected appropriately, they appear to be non-inferior to contrast-enhanced CTAPs in diagnosing acute appendicitis, colitis, diverticulitis, hernia, collection, and obstruction. This study highlights the need for further research into utilizing non-contrast scans for assessing the AA to minimize contrast-associated complications.

Tummy pain is not often what we think - Imaging findings in uncommon causes of abdominal pain in children and adolescents - A case series.

Acute abdominal pain is a common complaint in children. We came across several unusual causes of acute abdomen including jejunal haematoma, perforation and abdominal abscess following hydrostatic intussusception reduction, twisting of mesenteric cyst, perforation of sigmoid colon and Meckel's diverticulum presenting with intussusception. In this article, we aim to present imaging features of these entities so that paediatric surgeons, radiologists and other health-care providers are aware of these unusual manifestations of acute abdomen.

Infarcts and ischemia in the abdomen: an imaging perspective with an emphasis on cross-sectional imaging findings.

Infarcts and ischemia of abdominal organs may present with acute abdominal pain, and early diagnosis is crucial to prevent morbidity and mortality. Unfortunately, some of these patients present in poor clinical conditions to the emergency department, and imaging specialists are crucial for optimal outcomes. Although the radiological diagnosis of abdominal infarcts is often straightforward, it is vital to use the appropriate imaging modalities and correct imaging techniques for their detection. Additionally, some non-infarct-related abdominal pathologies may mimic infarcts, cause diagnostic confusion, and result in delayed diagnosis or misdiagnosis. In this article, we aimed to outline the general imaging approach, present cross-sectional imaging findings of infarcts and ischemia in several abdominal organs, including but not limited to, liver, spleen, kidneys, adrenals, omentum, and intestinal segments with relevant vascular anatomy, discuss possible differential diagnoses and emphasize important clinical/radiological clues that may assist radiologists in the diagnostic process.

Omental infarction mimicking acute appendicitis with negative radiological findings.

A male in his 30s presented to the emergency department with a 1-day history of supra-umbilical pain migrating to the right iliac fossa. On examination, his abdomen was soft but tender with localised guarding in the right iliac fossa and a positive Rovsing's sign. The patient was admitted under a presumptive diagnosis of acute appendicitis. A CT scan and ultrasound scan of the abdomen and pelvis showed no acute intra-abdominal pathology. He stayed in hospital for 2 days for observation without improvement of symptoms. A diagnostic laparoscopy was therefore performed that revealed an infarcted omentum adherent to the abdominal wall and ascending colon causing congestion of the appendix. The infarcted omentum was resected, and the appendix was removed. The CT images were reviewed by multiple consultant radiologists, but no positive findings were appreciated. This case report demonstrates the potential difficulty in diagnosing omental infarction clinically and radiologically.

Primary Epiploic Appendagitis: Not Rare But Rarely Diagnosed Pathology.

OBJECTIVE: The aim of this study is to determine the clinical and laboratory parameters which may be suggestive of or even pathognomonic for primary epiploic appendagitis (PEA) and to discuss the diagnostic efficacy of ultrasound (US) compared to computed tomography (CT) in patients with PEA. MATERIALS AND METHODS: For this retrospective study, 92 patients diagnosed with PEA using US, CT or both modalities were included. All patient symptoms, clinical findings and laboratory parameters were reviewed. The CT and US images of the PEA were evaluated for lesion size and location, the relationship of the lesion to the colon and the distance of the lesion to the skin. RESULTS: There were 16 female and 76 male patients in the study group. The mean age was 35 years (range: 38-79 years). Well-localized abdominal pain was the primary symptom in all patients. The mean leukocyte count was 7857±1326 mm-3. The most frequent localization of PEA was sigmoiddescending colon junction (79/92). In patients who were examined by both US and CT, the size of the fatty central core was between 15-48 mm (mean:28.10 mm) and 9-22 mm (mean:15.07 mm) in its long-axis and short-axis diameter, respectively on US, whilst that by CT was between 15-46 mm (mean:26.88 mm) and 9-21 mm (mean:14.40 mm) in its long-axis and short-axis diameter, respectively. In patients who were examined by both US and CT, the mean distance of the lesions to the skin was 20.80 mm and 33.97 mm, respectively. All patients were treated conservatively with complete resolution of symptoms within a week of presentation. CONCLUSION: PEA is an unrare self-limiting condition that should be considered in the differential diagnosis of acute abdomen. To support clinicians and radiologists regarding PEA and its clinical, laboratory and radiological findings, targeted sonographic examination - which is radiation and contrast agent-free - could be highly sufficient for the diagnosis of PEA and may prevent unnecessary further imaging and mistreatment.

Inguinal hernia leading to omental torsion: Role of CT in differentiating from other clinical mimics - a case report and literature review.

Omental torsion is a very rare cause of acute abdomen. Clinically, it mimics other common pathologies such as acute appendicitis, acute diverticulitis and acute cholecystitis. It is therefore no surprise, that it was rarely diagnosed pre operatively before the advent and easy availability of modern imaging techniques. CT scan, in particular, can diagnose omental torsion with confidence pre operatively. This can make conservative treatment possible in cases of primary omental torsion and guide regarding the appropriate treatment in cases of secondary torsion. We present a case of a young male patient who presented to Emergency department with symptoms of acute abdomen. Clinical and laboratory findings were non-specific for any specific cause of acute abdomen. CT scan, however, showed omental fat stranding with whirlpool sign representing omental torsion which was seen to be secondary to left inguinal hernia. Patient was operated in emergency and necrotic omentum was resected and hernia repaired. Post-operative recovery was uneventful.

Causes of acute abdomen, preferred imaging methods, and prognoses in geriatric patients presenting to the emergency department with abdominal pain.

OBJECTIVE: Abdominal pain is one of the most common reasons for admission to the emergency department in the geriatric population. The aim of this study was to investigate the diseases frequently detected in elderly patients diagnosed with acute abdomen in the emergency department, the imaging methods used in the diagnostic processes of these diseases, and the prognosis of the patients. METHODS: In all, 175 patients who visited the emergency department due to abdominal pain and were hospitalized with a diagnosis of acute abdomen were evaluated. The patients were categorized into seven groups according to their diagnosis as biliary diseases, pancreatitis, appendicitis, gastrointestinal system perforation, ileus, mesenteric ischemia, and atypical causes. RESULTS: The mean age of the patients was 76.3±7.7 years (range 65-93), and 96 (54.9%) were women. The most common causes of acute abdomen were biliary diseases and pancreatitis. Ultrasonography (88.6%) was the most frequently preferred imaging method in the emergency department, and it was most frequently used for biliary diseases. Notably, 20 (11.4%) patients were treated in the intensive care unit, and 9 (5.1%) patients died. CONCLUSION: The most common causes of acute abdomen in the geriatric population were biliary diseases and pancreatitis, and ultrasonography imaging was the most common choice for the diagnosis of these diseases. In elderly patients with abdominal pain, rapid and accurate diagnosis and selection of the correct imaging method are extremely important.

Non-traumatic adult acute abdomen with high-attenuation lesions or materials in the gastrointestinal tract on unenhanced computed tomography.

Computed tomography (CT) is an imaging modality that provides otherwise unobtainable information in the diagnostic workup for acute abdomen. The patient's clinical history, physical examination, and laboratory findings are essential for a correct diagnosis; however, some diagnoses are difficult to establish. Although contrast-enhanced CT is the preferred diagnostic tool and provides invaluable information, using only post-contrast images can lead to misdiagnoses. Unenhanced CT images are more useful than post-contrast images for detecting high-attenuation lesions or materials because surrounding tissues also show high attenuation on post-contrast images. Unenhanced CT often provides key imaging findings for a correct diagnosis; hence, the purpose of this article is to describe CT findings in acute abdomen with high-attenuation lesions in the gastrointestinal tract.

Clinical Value of Abdominal Ultrasonography in the Diagnosis of Acute Abdomen in Children.

In order to study the practical application value of abdominal ultrasonography in the diagnosis and treatment of acute abdomen in children, this study uses the method of collecting clinical actual cases and scientific analysis to estimate the clinical diagnostic value of high-frequency ultrasound and low-frequency ultrasound. In order to further clarify its curative effect and treatment advantages, a retrospective analysis of medical records was conducted, and 95 children with acute abdominal pain and suspected appendicitis who were admitted to a hospital from September 2021 to November 2021 were reviewed. ATIL HD15000 color Doppler ultrasound was used for diagnosis. The results are as follows: the sensitivity, specificity, positive predictive value, and negative predictive value of low-frequency probe in the diagnosis of intussusception in children were 83.61%, 73.33%, 92.73%, and 52.38%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of mesenteric lymphadenitis were 80.00%, 81.97%, 52.17%, and 94.34%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of high-frequency probe in the diagnosis of intussusception in children were 93.44%, 80.00%, 95.00%, and 75.00%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of mesenteric lymphadenitis were 93.33%, 95.08%, 82.35%, and 98.31%, respectively. Among the children with appendicitis confirmed by operation and pathology, 69 cases were detected by high-frequency ultrasound and 4 cases were missed (including 3 cases of acute simple appendicitis and 1 case of perforated appendicitis). The false negative was 4%, there was no false positive, and the sensitivity, specificity and accuracy were 95%, 100%, and 96%. In the same cases, 28 cases were detected by low-frequency ultrasound, 45 cases were missed, the false negative was 61%, and there was no false positive. The sensitivity, specificity, and accuracy were 39%, 100%, and 53%. The sensitivity, accuracy, and false negative of high-frequency ultrasound in the diagnosis of acute appendicitis were significantly higher than that of low-frequency ultrasound. This study shows that ultrasound has high accuracy, sensitivity, and specificity in the diagnosis of acute appendicitis. Low-frequency ultrasound can show the whole picture of the disease and the situation in the abdominal cavity, which can better guide the clinical treatment. Color Doppler hemodynamics is a useful supplement to two-dimensional ultrasound, and ultrasound also plays a positive role in the differential diagnosis of acute appendicitis in children.

Evaluation of community-based CT abdomen for acute abdominal pain during COVID-19.

AIM: The purpose of this study was to determine the utility of community-based imaging to reduce use of inpatient surgical resources and enforce social distancing at the outset of the COVID-19 pandemic. METHOD: A prospective evaluation of community-based CT for patients presenting to Christchurch general practitioners with acute abdominal pain from April to November 2020. Eligible patients were discussed with the on-call general surgical team, and then referred for CT abdomen rather than hospital assessment. The positivity rate of CT scans, the 30-day all-cause hospital admission rate, and the proportion of patients where community scanning altered management setting and the number of incidental findings, were all assessed. RESULTS: Of 131 included patients, 67 (51%) patients had a positive CT scan. Thirty-nine (30%) patients were admitted to hospital within 30 days, 34 (87%) of whom had a positive CT scan and were admitted under a surgical specialty. Ninety-two (70%) patients did not require hospital admission for their acute abdominal pain, thirty-three (35%) of whom had a positive CT scan. There were three deaths within 30 days of the community CT, and the setting of the community CT did not contribute to the death of any of the cases. Forty patients (30%) had incidental findings on CT, 10 (25%) of which were significant and were referred for further investigation. CONCLUSION: Community based abdominal CT scanning is a feasible option in the management of acute abdominal pain. While trialed in response to the initial nationwide COVID-19 lockdown in New Zealand, there may be utility for acute community-based CT scanning in regular practice.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI.

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

Obstructed hemivagina with ipsilateral renal and urinary tract anomaly presenting as an unusual cause of acute abdomen: a radiologic perspective.

Obstructed hemivagina with ipsilateral renal anomaly (OHVIRA) is a rare congenital genitourinary defect with a triad of unilateral vaginal obstruction, uterine anomaly and ipsilateral renal agenesis. This paper reports an unusual presentation of OHVIRA, with our patient experiencing severe abdominal pain from a left tubo-ovarian abscess that is contralateral to the side of the vaginal outflow obstruction. Another reportable finding is our patient's rare association of a trifid ureter that fuses distally before inserting ectopically in her vaginal canal. Lastly, this case report also emphasises the importance of radiologists' expertise in suspecting the diagnosis early on and in contributing to the preoperative evaluation of patients with OHVIRA, thereby providing adequate management for these patients.

MR imaging of acute abdominal pain in pregnancy.

Abdominal pain in pregnancy is a diagnostic challenge with many potential aetiologies. Diagnostic imaging is a valuable tool in the assessment of these patients, with ultrasound commonly employed first line. MRI is an excellent problem-solving adjunct to ultrasound and has many advantages in terms of improved spatial resolution and soft tissue characterisation. This pictorial review aims to outline the role of MRI in the work up of acute abdominal pain in pregnancy and provide imaging examples of pathologies which may be encountered.