22

DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 22.1 Air swallowing. There is slight gaseous distension of both small and large bowel, but this extends down to the rectum. A 7-year-old girl admitted to hospital with abdominal pain and distension following a single episode of vomiting. At the time of admission she was distressed and crying. Shortly after admission her bowels were opened normally and the abdominal distension and pain disappeared.

• Fig. 22.2 Pneumoperitoneum. Erect chest film. Free intra-abdominal gas is clearly demonstrated under the right hemidiaphragm. Under the left hemidiaphragm a small triangular collection of free gas can be identified between loops of gas-filled bowel (arrow).

• Fig. 22.3 Pneumoperitoneum. Abdomen, supine. A triangular collection of free gas is demonstrated in the subhepatic region (arrows). The falciform ligament is also outlined (arrowheads).

• Fig. 22.4 Pneumoperitoneum. Abdomen, supine. Visualisation of both sides of the bowel wall (Rigler's sign). Both the inside and outside wall of multiple loops of small bowel can be clearly identified.

• Fig. 22.5 Free intraperitoneal gas. (A) On abdominal windows the free gas is not well seen anteriorly. (B) On wide window settings, the free gas is much more obvious.

• Fig. 22.6 Pseudopneumoperitoneum. A band of curvilinear pulmonary collapse (arrows) with a crescent of normal lung beneath it simulates a pneumoperitoneum almost exactly.

• Fig. 22.7 Pneumoperitoneum without peritonitis. Small-bowel pneumatosis. Free gas is readily identified under the left hemidiaphragm and there is a thin crescent of gas under the right hemidiaphragm. The typical cysts of pneumatosis can be identified in the small bowel under the right hemidiaphragm. A 69- year-old man admitted with haematemesis. (Courtesy of Dr A. R. Carter.)

• Fig. 22.8 Acute gastric dilatation. Abdomen, supine. A 38-year-old woman admitted in diabetic precoma.

• Fig. 22.9 Small-bowel obstruction: (A) supine; (B) erect. Multiple dilated loops of both gas-filled and fluid-filled small bowel are readily identified. There is little or no gas in the large bowel. Multiple fluid levels are noted on erect film. A 77-year-old woman with a past history of several abdominal operations. The small-bowel obstruction was presumed to be due to adhesions and resolved with conservative management.

• Fig. 22.10 Small-bowel obstruction, 'string of beads' sign. Erect film. The dilated proximal small bowel is predominantly gas filled with a few long fluid levels. More distally, the small bowel is fluid filled and bubbles of gas are trapped between the valvulae conniventes, producing a chain of bubbles.

• Fig. 22.11 Small-bowel obstruction due to a metastatic deposit. Very dilated small bowel leads into the mass at the point of transition to collapsed small bowel.

• Fig. 22.12 Small-bowel obstruction due to left femoral hernia. (A) Dilated small-bowel loops in the midabdomen. (B) There is a left femoral hernia containing a bowel loop.

• Fig. 22.13 Strangulated small bowel loop. There is whorled mesenteric thickening with an adjacent loop of small bowel with a thickened wall.

• Fig. 22.14 Small-bowel obstruction due to an incisional hernia in an obese patient. (A) CT scout image showing dilated small bowel, and illustrating the degree of obesity. (B) CT demonstrating the midline incisional hernia containing a bowel loop.

• Fig. 22.15 Appendix abscess causing small-bowel obstruction. A small gas bubble which lies within the abscess (arrow) is seen in the right iliac fossa. Age 11 years, vomiting with some diarrhoea for 1 week.

• Fig. 22.16 Gallstone ileus. Supine film. Multiple dilated loops of small bowel are seen. A band of gas in the right hypochondrium (arrowheads) lies within the common bile duct. The obstructing gallstone cannot be identified.

• Fig. 22.17 Small-bowel obstruction due to an ileal faecolith. (A) Dilated small bowel loops. The gallbladder appeared normal. (B) Image through the pelvis. At the transition from dilated to collapsed bowel is a large densely calcified intraluminal faecolith.

• Fig. 22.18 Intussusception. Supine film. There are multiple gas-filled loops of slightly dilated small bowel. In addition, there is a soft-tissue mass in the right iliac fossa (arrow). A 5-month-old child with mesenteric adenitis.

• Fig. 22.19 Small-bowel obstruction due to a small-bowel melanoma metastasis which has caused jejunal intussusception. The grossly dilated loop of jejunum contains oral contrast medium, and leads into the intussusception, which contains the characteristic central mesenteric fat (arrow).

• Fig. 22.20 Large-bowel obstruction: the different types (after Love). Type IA: Competent ileocaecal valve. Distended large bowel, particularly ascending colon and caecum. No distension of small bowel. Type I B: Competent ileocaecal valve. Caecal distension and small-bowel distension. Type II: Incompetent ileocaecal valve. No distension of caecum and ascending colon but distension of small bowel. Caecal perforation is much more likely to occur in type I large-bowel obstruction.

• Fig. 22.21 Large-bowel obstruction type IA (competent ileocaecal valve). Supine film. There is gaseous distension of the large bowel from the sigmoid backward, including the ascending colon and caecum. The dilated caecum lies in the pelvis. There is no visible small-bowel distension. (Carcinoma of the sigmoid.)

• Fig. 22.22 Pseudo-obstruction: (A) supine abdomen; (B) barium enema. On the plain film, gas-filled loops of both small and large bowel can be identified, with gas extending down to the rectum. The barium examination demonstrates diverticular disease in the sigmoid but this is not obstructing, and barium flows freely into the dilated descending colon. Conservative management, using a flatus tube, failed and a laparotomy had to be undertaken. Dilated small and large bowel were found but there was no obstructing lesion. A caecostomy was performed.

• Fig. 22.23 Caecal volvulus. Supine. The considerably distended caecum with its haustral markings is readily identified lying low in the central abdomen. There is no significant small-bowel distension.

• Fig. 22.24 Sigmoid volvulus. Supine film. The hugely dilated ahaustral loop of sigmoid can be seen rising out of the pelvis in the shape of an inverted U. Haustrated ascending and descending colon can be identified separate from the volved sigmoid loop.

• Fig. 22.25 Paralytic ileus. Supine film. There is generalised dilatation of both small and large bowel. An 84-year-old woman with generalised peritonitis following perforation of a gastric ulcer.

• Fig. 22.26 Acute inflammatory bowel disease. Supine film. Loss of haustration and irregular mucosa, with mucosal island formation, are most readily identified in the transverse colon. A 35-year-old man with progressive severe bloody diarrhoea, subsequently proven to have ulcerative colitis.

• Fig. 22.27 Toxic megacolon. Supine film. A 37-year-old woman with progressively severe diarrhoea over a period of 3 weeks, which failed to respond to medical treatment, subsequently requiring a total colectomy. Final diagnosis: Crohn's disease.

• Fig. 22.28 Postoperative right subphrenic abscess. (A) Chest X-ray showing a raised right hemidiaphragm and small pleural effusion. (B) CT demonstrates the subphrenic collection (arrow).

• Fig. 22.29 (A,B) CT scans of prone patient showing a large right subhepatic abscess secondary to gallbladder surgery. Electronic cursors are used to measure (A) distance from midline to avoid kidney, and (B) distance to centre of abscess. (C) Prone X-ray, showing catheter in situ after insertion from posterior approach. A small amount of contrast medium has been injected. (Courtesy of Dr David Sutton.)

• Fig. 22.29 (A,B) CT scans of prone patient showing a large right subhepatic abscess secondary to gallbladder surgery. Electronic cursors are used to measure (A) distance from midline to avoid kidney, and (B) distance to centre of abscess. (C) Prone X-ray, showing catheter in situ after insertion from posterior approach. A small amount of contrast medium has been injected. (Courtesy of Dr David Sutton.)

• Fig. 22.30 Intra-abdominal abscess. "In-leucocyte scan, 24 h film. Postoperative repair of aortic aneurysm. No localising clinical signs. Accumulation of isotope in the right iliac fossa, with isotope in the right side of the colon indicating enteric communication. (Courtesy of Dr A. I. Coakley.)

• Fig. 22.31 Acute appendicitis. Ultrasound in the right iliac fossa demonstrating a hypoechoic non-compressible tubular structure measuring more than 6 cm in diameter, with surrounding hyperechoic fat.

• Fig. 22.32 Acute appendicitis. Ultrasound in the right iliac fossa demonstrating a non-compressible thickened appendix in transverse section, with surrounding hyperechoic fat.

• F19.22.33 Acute appendicitis. CT showing an appendix which contains a dense appendicolith, with surrounding inflammatory changes.

• Fig. 22.34 Appendix inflammatory mass. CT shows soft-tissue density in the right iliac fossa containing an appendicolith. Abscess formation was seen on adjacent images.

• Fig. 22.35 Acute cholecystitis. (A) Ultrasound examination. (B) Diagram. A distended gallbladder has been identified, with a considerably thickened gallbladder wall. Markers placed across the gallbladder wall indicate a thickness of 9 mm. No gallstones have been identified. (Courtesy of Dr M. 0. Downes.)

• Fig. 22.36 Acute pancreatitis-pancreatic pseudocyst. (A) Ultrasound. (B) Diagram. A large transonic area is demonstrated in the region of the head of the pancreas, and, within it, irregular echoes represent pancreatic debris. Ten days following an attack of acute pancreatitis. (Courtesy of Dr M. 0. Downes.)

• Fig. 22.37 Leaking aortic aneurysm. Supine film. The faintly calcified rim of an aortic aneurysm is identified (arrowheads). In addition, there is a large soft-tissue mass outside the aneurysm, indicating a retroperitoneal haematoma. The outlines of the psoas and renal margins on the left are lost.