estudo imagem abd

8/21/2019 Estudo Imagem Abd

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ESTUDO POR IMAGEM DO ABDOME NO PS

A investigação diagnostica destes pacientes requer estreitacorrelação entre o medico clinico e o radiologista para otimização dosexames.

O estudo por imagem do abdome irá depender do tipo depatologia que está sendo pesquisada; assim sendo, é interessanteclassificar clinicamente as principais doenças abdominais que levamo paciente a procurar a emerg!ncia", por sua localização no abdome equadro clinico.

#ntre as causas mais comuns de queixa abdominal que levam opaciente a procurar o serviço de emerg!ncia, temos$

%&'raumatismo abdominal contuso.(&)or no quadrante superior direito.*&)or no quadrante inferior direito.+&)or no quadrante inferior esquerdo.&)or abdominal aguda sem -ipotensão.&)or abdominal tipo c/lica.0&)or abdominal difusa com -ipotensão.1&)or abdominal em flanco ou lombar.2&)or pélvica aguda.

3ara cada estado patol/gico, clinicamente diagnosticado, deveráser utilizado um tipo de estudo por imagem, para sua confirmação eidentificar os casos passiveis de cirurgia.

TRAUMATISMO ABDOMINAL CONTUSO

#ste geralmente ocorre em pacientes politraumatizados. A rotina do A'45 inclui uma radiografia lateral da coluna cervical,

uma radiografia frontal do t/rax em dec6bito dorsal e uma radiografiada pelve. A radiografia do abdome no trauma traz pouca informação, pois

as condiç7es de realização deste exame são tecnicamenteinadequadas e os dados principais, como -emoperitonio epneumoperitonio são de dif8cil visualização.

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9o trauma grave do abdome, mais de : dos casossecundários a acidentes automobil8sticos", devido < dificuldade naavaliação clinica, os exames radiol/gicos passam a ter umaimport=ncia maior.

A '> fornece informação precisa quanto < presença depneumoperitonio, liquido na cavidade abdominal ou na pelve, além demostrar poss8veis sangramentos ou rupturas em v8sceras s/lidas;assim sendo nos casos de traumatismo abdominal contuso, compaciente estável" a '> deve ser o exame de escol-a.

Outra razão importante para o uso da '>, é a sua capacidade demensuração da densidade das coleç7es em unidades ?ounsfield,onde coleç7es com alto conte6do de prote8nas, como sangue e p6smedem acima de ( @?, enquanto que o conte6do seroso medeabaixo de % @?.

O sangue coagulado tem uma densidade pr/xima a @?. A maior parte dos l8quidos na cavidade são absorvidos entre * e0 dias nos casos de persist!ncia ou aumento da quantidade de liquido,complicaç7es como ressangramento, infecção e lesão das viasbiliares, com extravasamento de bile, deve ser considerada.

O baço seguido pelo f8gado são as v8sceras s/lidas do abdomemais freqentemente lesadas pelo trauma abdominal e estãofreqentemente associadas a fraturas dos arcos costais inferiores. Asles7es podem ser do tipo contusão, laceração, fratura ou formação de-ematomas intraparenquimatosos ou subcapsulares.

Os -ematomas agudos quando intraparenquimatosos aparecemna '> como áreas -ipodensas escuras", enquanto nas regi7essubcapsulares e extracapsular aparecem -iperdensos brancos".

>O4O>AB CDAE#D '> )# ?#DA'ODA #534#9C>O O@ ?#3A'C>O

#xiste na literatura varias graduaç7es deste tipo de lesão,levando em conta o taman-o e localização da lesão, contudo devido afalta de correlação com a evolução clinica destes pacientes emrelação ao grau da lesão, a tend!ncia atual é de evitar a intervençãocir6rgica nos pacientes clinicamente estáveis.

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O uso de contraste oral aFuda na observação de les7es naparede das alças intestinais e na individualização de l8quido nacavidade abdominal, contudo, a espera da progressão do contraste notubo digestivo, poderá postergar o tratamento do paciente, sembeneficio no diagn/stico da patologia. Assim sendo, o contrastedeverá ser administrado por sonda nasogástrica. >omo o obFetivoprincipal para o uso deste contraste, é a opacificação do estGmago eduodeno, por se tratar do local mais comum de lesão traumática dasalças intestinais, o exame de '> poderá ser realizado imediatamenteap/s administração do contraste pela sonda.

As les7es do duodeno podem ser -ematoma ou perfuração,ambas identificáveis pela '>.

'> com contraste ruptura traumática do duodeno>om extravasamento de contraste para o espaço para renalH

A demonstração de les7es nos ped8culos vasculares necessita ouso de contraste venoso, além de sangramento ativo no local da lesãopara serem visualizados. 9a pesquisa de coleç7es abscedidas intraparenquimatosas ouna cavidade, assim como em les7es do sistema coletor renal, ureter ebexiga também está indicado o uso de contraste endovenoso.

'> do abdome com sangue no espaço pararenal esquerdo.

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DOR NO QUANDRANTE SUPERIOR DIREITO

COLECISTITE AGUDA

A ultra&sonografia @5" e a cintigrafia tem resultadossemel-antes com sensibilidade de 2:, porém a cintigrafia, além demais demorada e mais cara, pode ter resultado falso positivo nacoleciste aguda, que não ocorre na ultra&sonografia.

A @5 por sua disponibilidade deve ser o exame inicial e acintigrafia utilizada nos casos em que o exame de @5 é negativo e aclinica sugere colecistite.

@5 mostrando calculo na ves8cula biliar.'> abscesso perivesicular.

'> colecistite enfizematosa.

A '> poderá ser utilizada nos casos de colecistite acalculosa,quando a @5 pode não ser conclusiva. 9estes casos a doença acabapor ser diagnosticada por suas complicaç7es, como inflamação peri&vesicular e


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'ambém as complicaç7es da colecistite gangrenosa, como gásna parede da ves8cula e abscesso peri&vesicular, são mais facilmentevistas na '> do que na @5.

4embre&se$ Os cálculos de bilirrubinato, freqente nas vias biliares, são maisfacilmente identificados por @5 que na '>, devido ao seu baixoconte6do de cálcio.

A espessura da parede da ves8cula biliar não deve superar *mm.O sinal de Durp-I guiado por @5 é um sinal indireto importante

na aus!ncia de cálculo e espessamento da parede.Juando todos os sinais estão presentes < especificidade e

sensibilidade c-ega a 22.Outras patologias que podem simular colecistite, tais como

pancreatite, 6lcera duodenal perfurada, abscesso no quadrante

superior direito, pielonefrite aguda e doença pleuro&pulmonar basaldireita, também podem ser identificadas ou suspeitadas pelo @5,contudo a distensão gasosa de alças intestinais que pode estar associada principalmente a pancreatite e ulcera duodenal podedificultar a analise pela @5, e seu colega radiologista poderá solicitar arealização de '>.

DOR NO QUADRANTE INFERIOR DIREITO

A apendicite aguda é a causa mais comum de dor aguda na KC). A -ip/tese diagnostica é reforçada quando a dor na KC) éacompan-ada de febre, alteração intestinal e irritação peritonial alémde exames laboratoriais sugestivos. Os exames de imagem sãoindicados para confirmação do diagnostico clinicoLlaboratorial eidentificar eventual complicação ou poss8veis diagn/sticos diferencias,que possam simular esta patologia.

A @5 tem sensibilidade entre 1: e 2: e está indicado em

pacientes grávidas, crianças e pacientes magros.O espessamento do ap!ndice maior que 0mm", que é aprincipal caracter8stica da apendicite, é facilmente identificada pela '>. Outros ac-ados incluem a presença de calcificaçãoapendicolito", edema ou abscesso peri&apendicular, alças com n8vell8quido e gás fora de alça, na região, também reforçam a -ip/tesediagnostica.

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Os diagn/sticos diferencias incluem diverticulite, doençainflamat/ria pélvica, ile8te regional ou infecciosa e adenite mesentéricaque também podem ser diagnosticados pela '>, contudo nos casos desuspeita de complicaç7es, o uso de contraste venoso é indicaçãoformal.

@5 apendicite aguda '> apendicite eapendicolito

.

DOR NO QUADRANTE INFERIOR ESQUERDO

9esta região a causa mais comum de dor é a doença diverticular do sigm/ide que é bem visualizada pela '>. As complicaç7es comoperfuração e formação de abscesso necessitam contraste endovenosopara mel-or identificação.

Os ac-ados na '> incluem espessamento parietal do sigm/ide

com encurtamento da alça e divert8culos. 9os casos complicados pode-aver edema do mesentério, gás na parede da alça ou formação deabscesso.

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'> com contraste diverticulite aguda.

A sensibilidade pela '> para confirmação de diverticulite é de1: á %::.

Os diagn/sticos diferenciais incluem colite infecciosa, doença de>-ron e carcinoma perfurado, todos bem identificados pela '>.

DOR ABDOMINAL AGUDA DIFUSA SEM TRAUMA

#ntre as causas mais comuns de dor abdominal aguda estão apancreatite aguda, ulcera perfurada e isquemia mesentérica. #stespacientes costumam apresentar distensão intestinal que dificulta autilização da @5 como ferramenta diagnostica.

Botina radiol/gica de abdome agudo radiografia do abdome emdec6bito dorsal, seguida de radiografia do abdome em ortostase eradiografia do t/rax", poderá ser realizada antes da '> nos casos emque existe distensão abdominal significativa.

A '> deverá ser feita antes e ap/s a administração de contrasteoral e antes e ap/s a inFeção de contraste venoso.

M importante a diferenciação entre a pancreatite edematosa enecrotizante. 9os casos de pancreatite aguda edematosa a '> irámostrar um aumento de volume da gl=ndula difuso e impregnação decontraste -omog!nea. 9a pancreatite aguda necrotizante ocorresangramento peripancreatico, que causa aumento de densidade dagordura peripancreática e áreas no par!nquima pancreático em que

não existe realce pelo contraste venoso áreas de necroseparenquimatosa".

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'> com contraste oral e venoso mostrando pancreatite agudaedematosa.

>oleç7es no retroperitGnio podem se formar na pancreatite,quando não são absorvidos em cerca de semanas, formam ospseudocistos.

O pseudocisto tem densidade baixa entre : e (: @?. 9o cisto

complicado ocorre infecção ou sangramento a densidade supera (@?.O diagnostico diferencial inclue outras doenças inflamat/rias e

raramente tumorais do retroperitGnio, que também são diagnosticadaspela '>.

DOR ABDOMINAL TIPO CÓLICA

9este tipo de queixa, as causas mais comuns estão relacionadasa oclusão ou suboclusao do tubo digestivo.

As patologias que podem causar obstrução intestinal, podem ter origem primaria na alça intestinal ou ser secundaria á algumaalteração na cavidade abdominal, como bridas causando ader!ncias,-érnias, coleç7es e neoplasias.

9estes pacientes o estudo inicial deve ser feito por radiografias. A rotina de abdome agudo inclue uma radiografia de t/rax em 3A

em ortostase e duas radiografias de abdome, uma em dec6bito dorsale uma em ortostase ou dec6bito lateral.

As radiografias em ortostase ou dec6bito lateral devem ser realizadas somente ap/s o paciente manter esta posição por pelomenos minutos, tempo suficiente para o gás se mover dentro ou foradas alças intestinais para as porç7es mais altas.

M caracter8stico de obstrução intestinal, a distensão das alçasintestinais no intestino delgado com n8veis -idroaéreos e di=metromaior que (, cm.

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Badiografia em ortostase Badiografia em dec6bitodorsal 98vel -idroaereo com mais de (,cm de di=metro.

Alguma dificuldade pode ocorrer quando as alças estãocompletamente preenc-idas por liquido e podem não mostrar o graude distensão intestinal e os n8veis -idroaéreos.

Ns vezes pode ser necessário realizar radiografias seriadas comintervalos de algumas -oras, para determinar o grau de obstrução esua localização. 9as obstruç7es completas irá ocorrer uma dilataçãoprogressiva proximal ao local da obstrução, ao mesmo tempo em quediminui a quantidade de gás distalmente. M importante determinar o

grau da oclusão, uma vez que a suboclusão pode ser maneFadaclinicamente enquanto que a oclusão completa independente dacausa, terá um encamin-amento cir6rgico. Assim sendo os quadros desuboclusao deverão continuar a investigação radiol/gica com '> paradeterminar a patologia básica da obstrução, pois a causa secundáriapoderá necessitar tratamento cir6rgico.

O principal diagn/stico diferencial é o 8leo paral8tico no qual oaspecto radiol/gico é de distensão difusa do delgado e colon semsegmentação" que muda pouco com estudos seriados.

9os casos em que o diagnostico é duvidoso, a '> está indicada

e o exame deverá ser realizado com contraste oral e venoso,conforme mencionado anteriormente.

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DOR ABDOMINAL COM HIPOTENSÃO ARTERIAL AGUDA

#ste tipo de apresentação clinica sugere ruptura de aneurismade aorta abdominal. A avaliação clinica é de suma import=ncia nestespacientes, uma vez que a mortalidade desta patologia é extremamenteelevada e diretamente relacionada ao tempo entre o in8cio dossintomas e a realização da cirurgia.

Assim sendo, poderá ser indicado cirurgia imediata sem examesde imagem, em pacientes muito instáveis ou ser realizada '> semcontraste nos pacientes mais estáveis, ou ainda nos casos maisurgentes a @5, que não deverá demorar mais que ( ou * minutos,tempo suficiente para identificar o aneurisma.

O uso do contraste endovenoso na '>, facilita o diagnosticocontudo não é primordial e deverá ficar restrito aquele paciente

estável, sem evidencias de ruptura em que um planeFamento cir6rgicoou colocação de endoprotese pode ser feito com tranqilidade. A sensibilidade para o diagnostico de aneurisma da aorta

abdominal, é de 20 pelo @5 e %:: pela '>.

'> aneurisma de aorta Angiotomografia aneurisma de aorta

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'> com contraste aneurisma rotoDOR LOMBAR OU EM FLANCO

A causa mais comum é a uropatia calculosa, que temapresentação clinica bastante caracter8stica. O obFetivo do exame por imagem é confirmar a presença do calculo, seu taman-o e localização.

Bx cálculo renal dir. '> calculo renal '> cL contraste#

calculo cLpionefrose.

A '> é o exame capaz de fornecer todas estas informaç7es semnecessidade de preparo intestinal sendo dispensável o uso decontraste endovenoso.

O contraste endovenoso devera ser utilizado nos casos deinfecção para identificar poss8veis abscessos.

9os pacientes pediátricos e grávidas com suspeita de calculourinário a @5 deverá ser o exame de escol-a. A sensibilidade e a especificidade da '> é de 20 nas uropatias

calculosas, além disto é capaz de identificar outras patologiasretroperitoniais e pélvicas que podem simular clinicamente a uropatiacalculosa.

DOR PELVICA AGUDA

9as mul-eres em idade fértil a possibilidade de gravidezect/pica deve ser sempre considerada e o exame mais adequado é a@5 e preferencialmente transvaginal.

#ntre os ac-ados sugestivos de gravidez ect/pica no @5 temos$%&3resença de reação decidual sem individualização do saco

gestacional (&3resença de liquido em fundo de saco.

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*&Dassa parauterina. A combinação destes ac-ados, a um relato clinico e exame f8sico

sugestivo de gravidez tem um valor preditivo positivo de 20, para odiagnostico de gravidez ect/pica.

O diagnostico diferencial deve incluir ruptura de cisto de corpol6teo e na aus!ncia de possibilidade de gravidez, torção ovariana oucisto -emorrágico são as -ip/teses mais prováveis e também serambem avaliados por @5.

@5 gravidez ect/pica.#ndométrio espesso e saco gestacional extra&uterino.

4embre&se$'oda paciente com dor pélvica aguda em idade fértil se faz

necessário < exclusão de gravidez laboratorial" e nos casos em quepor qualquer motivo seFa considerada a realização de '>, este fatoprecisa estar definido previamente..

DOR PELVICA AGUDA COM TESTE DE GRAVIDEZ

NEGATIVO

#m pacientes Fovens com dor pélvica aguda e teste paragravidez negativo, deve&se considerar a possibilidade de torçãoovariana que na maioria dos casos está relacionada a situaç7es emque ocorre aumento do peso do ovário -iperestimulação, cistos outumores".

9estes casos a @5 também é o exame de escol-a e a analiseespec8fica dos ovários é mel-or realizada pelo @5 transvaginal.

O ac-ado mais freqente no @5 é a presença de ovárioaumentado de volume com contornos indefinidos, fora de sua posição-abitual na cavidade pélvica, também pode -aver aumento da

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ecogenicidade do interst8cio devido ao edema e -emorragia, tambémos fol8culos ficam mais proeminentes. O uso do )oppler poderáidentificar aus!ncia total de fluxo arterial nos ovários completamenteinfartados.

@5 )oppler ovário infartado ondas arteriais com altaresist!ncia".

Outras causas de dor pélvica aguda incluem -emorragiaintrac8stica e endometrioma, doença inflamat/ria pélvica e cálculoureteral.

@5 endometriose ovariana '> cisto ovariano -emorrágico

'> com contraste. Abscesso tubo ovariano.

Outras patologias menos comuns como mioma uterino infartado,cisto derm/ide também podem ser origem da queixa pélvica; contudode uma maneira geral a investigação deverá começar sempre com a@5 transvaginal pois não depende de bexiga c-eia e pode ser realizado imediatamente fornecendo as informaç7es necessárias

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quanto a morfologia e topografia dos /rgãos pélvicos além deidentificar a presença de liquido na cavidade.

Evaluatio o! Bo"#l a$ M#%#t#&i' Blut T&au(a"it) Multi$#t#'to& CT*

PoQel and mesenteric inFuries are detected in of blunt abdominal t&au(apatients at laparotomI % R*" and are t-e t-ird most common tIpe of inFurI fromblunt t&au(a to abdominal organs + R0". '-ree basic mec-anisms maI causeboQel and mesenteric inFuries of blunt t&au(a$ )irect force maI crus- t-egastrointestinal tract; rapid deceleration maI produce s-earing force betQeen fixedand mobile portions of t-e tract; and a sudden increase in intraluminal pressuremaI result in bursting inFuries 1".

'-e common sites of blunt t&au(a inFurI in t-e small boQel are t-e proximal FeFunum, near t-e ligament of 'reitz, and t-e distal ileum, near t-e ileocecal valve.Cn t-ese regions, mobile and fixed portions of t-e gut are continuous and t-ereforeare susceptible to s-earing force 2".

)elaIed diagnosis of boQel and mesenteric inFuries results in increased morbiditIand mortalitI, usuallI because of -emorr-age or peritonitis t-at leads to sepsis%: R%". Alt-oug- abdominal pain from peritoneal irritation maI be a clinicalmanifestation of boQel and mesenteric blunt t&au(a inFuries, t-is sImptom isnonspecific; in addition, it mig-t not be present Q-en t-e patient is initiallIevaluated. Kurt-ermore, if t-e patient -as concomitant -ead and spinal cord

t&au(a, Q-ic- maSe abdominal assessment difficult, t-e results of a p-Isicalexamination maI not be reliable. '-e use of results of clinical assessment as t-esole indication for surgerI -as led to a negative laparotomI rate as -ig- as +:0,%,%0". 3atients in Q-om abdominal inFurI is suspected can be evaluated Qit-various diagnostic tests, including peritoneal lavage, ultrasonograp-I @5", andcomputed tomograp-I >'" 1".

)iagnostic peritoneal lavage -as a sensitivitI greater t-an 2: for t-e detection of -emoperitoneum %1 R(:", but it is not specific and not reliable for t-e assessmentof retroperitoneal inFuries %0 R(%". Cn addition, liSe anI invasive procedure,diagnostic peritoneal lavage carries some risSs. PoQel perforation maI be missed

at lavage in up to %: of cases in Q-ic- t-e diagnostic procedure is performedsoon after blunt abdominal t&au(a -as occurred ((".

Kocused assessment Qit- @5 in t-e t&au(a setting -as a sensitivitI of 1 andspecificitI of 21 for t-e detection of free intraabdominal fluid (*", Dultidetector >' is more sensitive and specific t-an diagnostic peritoneal lavage, abdominal @5,and clinical examination for t-e diagnosis of boQel and mesenteric inFuries 2", andit -as become t-e diagnostic test of c-oice for t-e evaluation of blunt abdominal

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t&au(a in -emodInamicallI stable patients (+". '-e results of various studiess-oQ sensitivities of 2R2 and specificities of 2+R%:: for t-e diagnosis of boQel and mesenteric inFuries Qit- >' ( R(1". '-e main goal in evaluationg t-esesigns is to distinguis- significant boQel and mesenteric inFuries t-at require surgicalintervention from t-ose t-at can be managed nonsurgicallI. 5ignificant boQel inFurI

is defined as eit-er a complete tear of t-e boQel Qall

or an incomplete tear t-atinvolves t-e serosa and t-at extends to but does not involve t-e mucosa.9onsignificant boQel inFuries include a -ematoma and a tear limited to t-e serosa.5ignificant mesentric inFuries include active mesentric bleeding, disruption of t-emesentrI, and mesentric inFurI associated Qit- boQel isc-emia. An isolatedmesenteric -ematoma is considered non&significant.

CT Fi$i+%

Fi$i+% S,#'i!i' to Bo"#l I-u&.

Bowel Wall Discontinuity.— '-is is an uncommon finding on >' images 1".PoQel Qall discontinuitI Qas present in onlI four 0" of + patients Qit- boQeland mesenteric inFuries Kig %". '-e relative infrequencI of observations of t-isfeature is liSelI due to t-e small size of t-e discontinuities, Q-ic- are evident atsurgerI onlI Qit- careful inspection.

Vi#" la&+#& v#&%io %*2T"$

Fi+u */ UeFunal perforation in a &Iear&oldQoman after a motor ve-icle accident. Axial >'image s-oQs -Ipervascular t-icSened FeFunumQit- a suspicious defect curved arroQ" and Qit-focal fluid, fat stranding, and extraluminal air

straig-t arroQ" adFacent to FeFunal loops. '-epatient later underQent resection of a (:&cmsegment of t-e small boQel. 9o mesentericinFurI Qas found at surgerI.

Extraluminal Contrast Material.— '-is sign Qas present in onlI t-ree " of +patients Qit- boQel and mesenteric inFuries Kig (". '-e infrequencI of suc-findings maI be due to a lacS of boQel distention during >' or to t-e transience of extraluminal contrast en-ancement. '-ere is also t-e potential for a false&positive

finding Q-en t-ere

is an intraperitoneal extension of contrast material because

of abladder inFurI Kig *".

15

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Vi#" la&+#& v#&%io%:*T"$

Fi+u 0a/ PoQel inFuries in a *0&Iear&old malepedestrian strucS bI a motor ve-icle. 1a2 Axial>' image s-oQs free air curved arroQ" and freeoral contrast material in t-e left upper quadrant,adFacent to t-e FeFunum arroQ". T&au(atic

devascularization of t-e left SidneI V" also isvisible on bot- images. '-e patient underQent apartial small&boQel resection and primarIsurgical repair for FeFunal rupture and necrosis, asegmental resection for transverse colonnecrosis, and repair of a colonic serosal tear distal to t-e necrotic transverse colon. 9omesenteric inFurI Qas seen at surgerI.

Vi#" la&+#& v#&%io %:+T"$

Fi+u 03/ 132 Axial >' image at a level loQer t-an a s-oQs a t-icSened Qall of t-e transversecolon Qit- decreased en-ancement arroQs".

Vi#" la&+#& v#&%io%:T"$

Fi+u 4a/ Buptured bladder in a +*&Iear&oldfemale pedestrian Q-o Qas strucS bI a car. 1a2

Axial abdominal >' image s-oQs intraperitonealareas of free contrast material straig-t arroQs"and free air curved arroQ". '-ese featuresmimic t-ose found in boQel inFurI but, instead,are secondarI to a bladder rupture, Q-ic- Qasfound at surgerI.

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17/30

Vi#" la&+#& v#&%io%%T"$

Fi+u 43/ 132 Axial >' image s-oQs aretroperitoneal area of extraluminal contrasten-ancement arroQ".

Extraluminal Air.— #xtraluminal intraperitoneal air is -ig-lI specific for adiagnosis of boQel perforation, but it also maI be observed in t-e absence of boQelperforation Kig +". )espite t-e -ig- specificitI of t-is sign, its sensitivitI is usuallIloQ. Ct Qas seen in onlI %% (:" of + patients Qit- boQel and mesenteric inFuries.Cn most patients Qit- full&t-icSness boQel inFurI, pneumoperitoneum is not observed

on >' scans at admission (2,*:". Eas originating from a boQel rupture usuallIaccumulates in locations deep to t-e anterior abdominal Qall and maI be seen alsoin t-e porta -epatis, mesenterI or mesenteric veins, and portal vein Kig " *%".Ot-er causes of foci of intraperitoneal and extraluminal air include mec-anicalventilation and pulmonarI barot&au(a *%", peritoneal lavage prior to >',pneumot-orax, ')#%t inFurI, entrI of air via t-e female genital tract fallopiantubes", and intraperitoneal laceration of t-e bladder secondarI to cIstograp-I*%,*(". 3seudopneumoperitoneum, defined as t-e presence of air confined to t-einner laIer of t-e abdominal Qall and external to t-e parietal peritoneum, maImimic true pneumoperitoneum *(", and for t-is reason it represents a diagnosticpitfall Kig ".

Vi#" la&+#& v#&%io %%1T"$

Fi+u 5/ Kalse&positive findings of boQel inFurIin a ((&Iear&old Qoman Q-o Qas a front&seatpassenger and Qas Qearing a seat belt during amotor ve-icle accident. Axial >' image s-oQst-icSening of t-e Qall of t-e ascending colon,Qit- adFacent fat stranding straig-t arroQ", freeair curved arroQs", and -ematoma of t-e rig-toblique internus muscle V". Alt-oug- t-e free air Qas initiallI attributed to boQel inFurI, no boQelor gastric inFuries Qere found at diagnosticlaparoscopI. '-e free intraperitoneal air maI

instead be attributable to t&au(aticpneumot-orax.

17

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18/30

Vi#" la&+#& v#&%io %(T"$

Fi+u 6a/ PoQel and mesenteric inFuries in a0:&Iear&old male pedestrian strucS bI a car. 1a2

Axial >' image s-oQs a trace of fluid t-atextends from t-e cecum, Qit- pericecal fatstranding and t-icSening of t-e lateroconal fascia

curved arroQ" and focal retroperitoneal air straig-t arroQ". At surgerI, full&t-icSness cecaland mesenteric tears Qere identified andrepaired.

Vi#" la&+#& v#&%io%:+T"$

Fi+u 63/ 132 Axial >' image s-oQs air in t-esuperior mesenteric vein arroQ" as Qell ascontrast en-ancement of t-e duodenaldiverticulum arroQ-ead", a finding t-atsimulates duodenal inFurI. At surgerI, full&t-icSness cecal and mesenteric tears Qereidentified and repaired.

Vi#" la&+#& v#&%io %(0T"$

Fi+u 7a/ PoQel and mesenteric inFuries in a&Iear&old Qoman after a motor ve-icleaccident. 1a2 Axial >' image at t-e level of t-eloQer abdomen s-oQs a segment of t-e smallboQel Qit- decreased en-ancement straig-tarroQ" and free fluid curved arroQ". 1 At surgerI,a *:&cm segment of t-e distal ileum t-at -adbeen separated from its mesenterI bI s-earingforce, Qit- resultant devascularization, Qasresected.

18

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19/30

Vi#" la&+#& v#&%io%(2T"$

Fi+u 73/ 132 Axial >' image at t-e level of t-emiddle abdomen s-oQs mesenteric fat strandingcurved arroQ", subcutaneous emp-Isemaextending to t-e extraperitoneal space andproducing pseudopneumoperitoneum

arroQ-eads", and -Iperattenuating mesentericnodes straig-t arroQs" t-at mig-t be mistaSenfor foci of extravasated contrast material.

Cn addition to t-ese boQel inFurIRrelated findings, t-ere Qere tQo additional findingsof free intraperitoneal air in patients in Q-om onlI serosal tears of t-e boQel Qerefound. Pot- patients also -ad a KoleI cat-eter in place because of intraperitonealbladder rupture, and t-is fact -elps explain t-e presence of t-e free air. '-efindings of extraluminal intraperitoneal air in t-ese patients maI be consideredfalse&positive.

Fi$i+% L#%% S,#'i!i' to Bo"#l I-u&.Bowel Wall Thickening.— 'Qelve " of (( patients Qit- small&boQel inFurIand four %2" of (% patients Qit- large&boQel inFurI -ad boQel Qall t-icSening.Csolated, localized, unequivocal boQel Qall t-icSening in t-e context of t&au(ausuallI indicates boQel Qall contusion and maI not be associated Qit- significantinFurI (+". Our false&positive findings of small&boQel Qall t-icSening couldrepresent a lacS of boQel distention Kig 0". )iffuse small&boQel Qall t-icSening isatIpical for contusion and maI represent boQel edema secondarI to sIstemicvolume overload or to -Ipoperfusion complex s-ocS boQel" **" Kig 1".?Ipoperfusion complex is usuallI associated Qit- ot-er findings of s-ocS, suc- asa flat inferior vena cava, increased en-ancement of adrenal glands and boQel, andpancreatic and retroperitoneal edema Kig 1". ?oQever, sIstemic volume overload,in most cases after intravenous over-Idration, maI manifest as boQel Qallt-icSening alone Kig 2".

Fi+u 8/ 5plenic laceration Qit- active bleedingin a patient after a fall from a -eig-t of feetonto a pole. Axial >' image s-oQs apparentt-icSening of t-e intestinal Qall in several small&boQel loops arroQs", an appearance caused bIinsufficient boQel distention. At surgerI, nosmall&boQel inFurI Qas identified, but spleniclaceration Qit- active bleeding Qas seen.

19

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20/30

Vi#" la&+#& v#&%io%++T"$

Vi#" la&+#& v#&%io %(:T"$

Fi+u 9a/ Kalse&positive findings of boQelinFurI in a (&Iear&old Qoman after a Fump froma -eig-t of four stories. 1a2 Axial >' images-oQs a t-icSened cecal Qall straig-t arroQ"and a posterior abdominal Qall tear on t-e rig-tside curved arroQ", findings suggestive of boQelinFurI. 9o boQel inFuries Qere found at emergentlaparotomI, and t-e cecal Qall t-icSening QasprobablI related to -Ipoperfusion complex.

Vi#" la&+#& v#&%io %+(T"$

Fi+u 93/ 132 Axial >' image s-oQs t-et-icSened cecal Qall arroQs" Qit- attenuationsimilar to t-at of Qater, a finding suggestive of s-ocS boQel.

Vi#" la&+#& v#&%io %*0T"$

Fi+u :/ Axial >' image in a (&Iear&old manafter a motor ve-icle accident s-oQs evidence of s-ocS boQel arroQ-eads" liSelI related to fluid

resuscitation, Qit-out flattening of t-e inferior vena cava arroQ". At surgerI, -epatic lacerationQit- active bleeding, renal laceration, and aorticdissection Qere noted. 9o small&boQel inFurIQas identified.

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Abnormal Bowel Wall Enhancement.— Cncreased boQel Qall en-ancement maIrepresent boQel inFurI Qit- vascular involvement Kig %:" or maI be part of t-e-Ipoperfusion complex Kig %%". A possible cause is increased vascular permeabilitI due to -Ipoperfusion, Q-ic- maI result in interstitial leaSage of

contrast material *%". 3atc-I or irregular increases in

boQel Qall en-ancementafter t-e administration of intravenous contrast material are suggestive but notdiagnostic of full&t-icSness inFurI (+". On t-e ot-er -and, areas of decreased or absent contrast en-ancement are indicative of isc-emic boQel Kig %(". 4acS of en-ancement Qas uncommon in t-is series; it Qas present in onlI seven %*" of + patients. ?oQever, t-e finding Qas specific, Qit- onlI one false&positive case.

Vi#" la&+#& v#&%io %+:T"$

Fi+u *;a/ PoQel and mesenteric inFuries in a*(&Iear&old Qoman after a motor ve-icleaccident. Axial 1a2 and coronal. 9o free or focalair Qas visible on >' images. At surgerI,mesenteric tears in a middle segment of t-e

FeFunum and a distal segment of t-e ileum Qerefound, Qit- bleeding mesenteric vessels andmultiple areas of perforation in t-e middlesegment of t-e FeFunum and t-e proximal andmiddle segments of t-e ileum. '-e affectedsegments of small boQel Qere resected.

Vi#" la&+#& v#&%io %:T"$

Fi+u *;3/ 132 >' images s-oQ abnormal-Ipervascular t-icSened FeFunal loops arroQs in

3" and -ig-&attenuation foci of intraperitonealfluid arroQ-eads in a" consistent Qit- blood. 9ofree or focal air Qas visible on >' images..

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22/30

Vi#" la&+#& v#&%io %*:T"$

Fi+u **/ PoQel inFurI in an %1&Iear&old manQit- severe -ead t&au(a from a motor ve-icleaccident. Axial >' image s-oQs -Ipervascular t-icSened FeFunal loops Qit- mucosal feat-eringarroQs", features c-aracteristic of s-ocS boQel.

'-e patient died % daI after -ospital admission.

Vi#" la&+#& v#&%io %%2T"$Win t-is QindoQXWin a neQ QindoQXW)oQnload 33' slideX

Fi+u *0a/ PoQel and mesenteric inFuries in a*0&Iear&old Qoman after a motor ve-icle

accident in Q-ic- s-e Qas a rear&seatpassenger. >' images s-oQ -Ipervascular t-icSened segments of small boQel, especiallIevident in t-e left upper quadrant V". Axialsource images also s-oQ a tear in t-e abdominalQall on t-e rig-t side arroQ in a". Obliquecoronal image also s-oQs unen-anced small&boQel loops in t-e loQer abdomen arroQ in '".

At surgerI, s-earing inFurI to t-e small&boQelmesenterI Qas found, Qit- active bleeding andQit- complete devascularization and necrosis of

a 2:&inc- ((2&cm" segment of t-e distal FeFunumand ileum and a perforation of t-e middle FeFunum.

Vi#" la&+#& v#&%io%%2T"$

Fi+u *03/ and mesenteric fat strandingarroQ in 3". Oblique coronal image also s-oQsunen-anced small&boQel loops in t-e loQer abdomen arroQ in '". At surgerI, s-earing inFurIto t-e small&boQel mesenterI Qas found, Qit-

active bleeding and Qit- completedevascularization and necrosis of a 2:&inc-((2&cm" segment of t-e distal FeFunum andileum and a perforation of t-e middle FeFunum.

22

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Vi#" la&+#& v#&%io %++T"$

Fi+u *0'/ Oblique coronal image also s-oQsunen-anced small&boQel loops in t-e loQer abdomen arroQ in '". At surgerI, s-earing inFurIto t-e small&boQel mesenterI Qas found, Qit-active bleeding and Qit- complete

devascularization and necrosis of a 2:&inc-((2&cm" segment of t-e distal FeFunum andileum and a perforation of t-e middle FeFunum.

Mesenteric Features.— Desenteric foci of fluid, air, or fat stranding maI besecondarI to boQel inFurI alone Kig %*". Betroperitoneal air is seen Qit- duodenalinFurI or inFurI to t-e retroperitoneal aspect of t-e ascending or descending colon

Kig ".

Vi#" la&+#& v#&%io %++T"$

Fi+u *4a/ PoQel inFurI in a 00&Iear&old manafter a motor ve-icle accident. Axial >' imagess-oQ a defect in t-e proximal FeFunum arroQ ina" and a mesenteric -ematoma in t-e left upper quadrant arroQ in 3". Alt-oug- no free air Qasseen on >' images, a bloQout perforation in t-eantimesenteric aspect of t-e proximal FeFunumQas found at surgerI. 9o mesenteric inFurI Qasdescribed in t-e surgical report.

Vi#" la&+#& v#&%io %*T"$

Fi+u *43/ Axial >' images s-oQ a defect int-e proximal FeFunum arroQ in a" and amesenteric -ematoma in t-e left upper quadrantarroQ in 3". Alt-oug- no free air Qas seen on>' images, a bloQout perforation in t-e

antimesenteric aspect of t-e proximal FeFunumQas found at surgerI.

23

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Fi$i+% S,#'i!i' to M#%#t#&i' I-u&.Mesenteric Extraasation.— '-is sign -as a specificitI of %:: for t-e diagnosisof significant mesenteric inFurI, but it Qas seen in onlI nine %0" of + patientsQit- boQel and mesenteric inFuries Kig %+". A finding of mesenteric extravasation is

usuallI an indication for urgent

laparotomI.

Vi#" la&+#& v#&%io %*1T"$

Fi+u *5a/ PoQel and mesenteric inFuries in a(&Iear&old Qoman Q-o Qas a front&seatpassenger during a motor ve-icle accident. 1a2>oronal >' image s-oQs an unen-ancedsegment of small boQel, a feature consistentQit- a boQel infarct arroQ". 13


25/30

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Fi+u *5'/ PoQel and mesenteric inFuries in a(&Iear&old Qoman Q-o Qas a front&seatpassenger during a motor ve-icle accident. 1a2>oronal >' image s-oQs an unen-ancedsegment of small boQel, a feature consistent

Qit- a boQel infarct arroQ". 1 FeFunum V". AtsurgerI, an extensive small&boQel mesenterictear Qas found, Qit- active bleeding from a

FeFunal branc- of t-e superior mesenteric arterIand Qit- isc-emia in a (:&cm&long segment of

FeFunum; t-e segment Qas resected. A smallserosal tear also Qas found in t-e FeFunumproximal to t-e margin of resection and in t-ececum and Qas repaired.

Mesenteric !ascular Bea"ing.— '-is feature appears on >' images as an

irregularitI in mesenteric

vessels Kig %". 4iSe mesenteric extravasation of contrast material, it is indicative of vascular inFurI. Cn our patient series, t-e findingof mesenteric vascular beading Qas sensitive for t-e diagnosis, and it Qas presentin (% *2" of + patients Qit- boQel and mesenteric inFuries; in ot-er Qords, it Qasobserved more frequentlI t-an Qas active extravasation of contrast material.

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Fi+u *6a/ Desenteric inFuries due to a motor ve-icleaccident. 1a2 Axial >' image s-oQs a c-ange in caliber, or beading, of some mesenteric vessels in t-e area of inFurIarroQs". At surgerI, a tear Qas found in t-e ileocecalmesenterI t-at Qarranted resection of t-e terminal ileum,cecum, and ascending colon. 5ee Dovie % at

radiographics.rsnajnls.org/cgi/content/full/26/4/1119/DC1."radiographics.rsnajnls.org/cgi/content/full/26/4/1119/DC1."

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Fi+u *63/ 132 Axial >' image from anot-er patient s-oQs beading of a mesenteric vessel int-e area of inFurI arroQs". At surgerI, a-ematoma Qas found in t-e FeFunal mesenterI.."

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Termination o# Mesenteric !essels.— Abrupt termination of a mesenteric arterIor vein is also an indication of vascular inFurI. Ct Qas seen in %2 *" of + patientsand t-us Qas more common t-an extravasation of contrast material. '-e findingQas false&positive in onlI one patient; t-erefore, it Qas -ig-lI specific for significant

mesenteric

inFurI in our patient series Kigs %, %0".

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Fi+u *7/ Dultiple inFuries in a 1&Iear&old man after a(&foot fall from a roof. 5agittal reformatted image fromabdominal >' s-oQs lesser sac stranding arroQ" andabrupt termination of t-e left gastric arterI arroQ-ead" att-e level of stranding. 5ee Dovie * atradiographics.rsnajnls.org/cgi/content/full/26/4/1119/DC1."

Vi#" la&+#& v#&%io %*2T"$

Fi+u *8a/ PoQel and mesenteric inFuries in a(*&Iear&old man Q-o Qas eFected from a car during a motor ve-icle accident. At surgerI, t-reesmall&boQel mesenteric tears Qere found. '-emost proximal tear Qas repaired, but t-e tQomore distal ones Qere larger and Qarrantedresection of t-e affected small&boQel segment.9o primarI inFurI to t-e small boQel Qas found.'-ree subserosal tears in t-e colon also Qerefound, one in t-e rectosigmoid segment and tQoin t-e ascending colon, and Qere repaired. 1a2

>oronal >' image at t-e level of t-e middleabdomen s-oQs a mesenteric -ematoma t-atextends to t-e rig-t upper quadrant arroQs".

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Fi+u *83/ rig-t upper quadrant arroQs". 132Oblique coronal >' image s-oQs abrupttermination of t-e left&sided tributariesarroQ-ead" of t-e superior mesenteric vein(SMV).

L#%% S,#'i!i' Fi$i+%Mesenteric $n#iltration.— ?aziness and fat stranding in t-e mesenterI maI

indicate mesenteric inFurI Qit- or Qit-out boQel Qall inFurI. '-is finding -ad t-e-ig-est sensitivitI for mesenteric inFurI and Qas seen in *0 2" of + patients butis nonspecific. Betractile mesenteritis maI simulate mesenteric inFurI, but it can bedifferentiated from mesenteric infiltration bI t-e Qell&defined contour of t-eabnormallI t-icSened mesenterI and t-e presence of flat mesenteric lImp- nodessurrounded bI -alos Kig %1".

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Fi+u *9/ Betractile mesenteritis mimicSingmesenteric inFurI in a *&Iear&old man after amotor ve-icle accident. Axial >' image s-oQs asignificant and Qell&defined increase inattenuation and fat stranding in t-e root of t-e

mesenterI arroQs" associated Qit- flat lImp-nodes surrounded bI -alos of -IpoattenuationarroQ-eads". At surgerI, no mesenteric or boQel inFurI Qas found.

Mesenteric %ematoma.— Yell&defined mesenteric -ematoma indicative of laceration of a mesenteric vessel Qas present in (% *2" of + patients. '-isfinding Qas false&positive in onlI tQo cases. Alt-oug- specific to mesenteric inFurI,mesenteric -ematoma does not alQaIs indicate a need for surgerI. Cn four of our patients Qit- mesenteric -ematoma, t-e mesenterI Qas not repaired surgicallIbecause t-ere Qas no active bleeding Kig %2".

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Fi+u *:/ Desenteric inFurI in a 0&Iear&oldman after a fall from a scaffold. Axial >' images-oQs a -ematoma surrounded bI fat strandingarroQ" in t-e splenic flexure mesocolon, Qit- noevidence of active bleeding. At surgerI, a

nonexpanding mesenteric -ematoma Qas foundt-at did not require repair.

Bowel Features.— PoQel Qall t-icSening and abnormal en-ancement maI besecondarI to mesenteric inFurI, indicating vascular compromise Kig %+".5eventeen +2" of * patients Qit- mesenteric inFurI -ad boQel Qall t-icSeningKigs %(, %+" and %( *" of *+ -ad abnormal boQel Qall en-ancement Kigs %(,%+". PoQel isc-emia secondarI to mesenteric inFurI maI not be evident on initial

>' images.

Co((o F#atu% i Bo"#l a$ M#%#t#&i' I-u&i#%$ntra&eritoneal an" 'etro&eritoneal Flui".— KiftI 2*" of + patients Qit-eit-er boQel or mesenteric inFurI -ad intraperitoneal fluid. ?oQever, t-e specificitIis loQ for bot- intraperitoneal and retroperitoneal fluid because of ot-er concomitantinFuries. '-e location of t-e fluid maI indicate t-e location of inFurI. Betroperitonealfluid maI indicate inFurI of a retroperitoneal segment of boQel. Betroperitonealblood tends to localize at t-e site of inFurI Kig (:". ?emoperitoneum in t-e absenceof solid organ inFurI s-ould raise t-e possibilitI of boQel or mesenteric inFurI(+,*%".

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Fi+u 0;a/ Desenteric lacerations in a +&Iear&old man after a -ead&on automobile collision.

Axial >' images s-oQ a retroperitoneal-ematoma near t-e cecum arroQ in a" andomental fat stranding on t-e left side of t-eabdomen arroQ-ead in 3". At surgerI, amesenteric tear Qit- active bleeding Qas foundin t-e midFeFunal area. )espite t-e absence of obvious FeFunal inFurI, t-is finding resulted inresection of a s-ort %&cm" segment of t-e small

boQel. A second mesenteric tear Qas found near t-e cecum, Qit- a retroperitoneal -ematomarepaired" and omental bleeding. 9o boQelinFuries Qere found.

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Fi+u 0;3and omental fat stranding on t-e leftside of t-e abdomen arroQ-ead in 3". AtsurgerI, a mesenteric tear Qit- active bleedingQas found in t-e midFeFunal area. )espite t-eabsence of obvious FeFunal inFurI, t-is finding

resulted in resection of a s-ort %&cm" segmentof t-e small boQel. A second mesenteric tear Qas found near t-e cecum, Qit- a retroperitoneal-ematoma repaired" and omental bleeding. 9oboQel inFuries Qere found.

Ab"ominal Wall $n(ury.— '-ere is a significant association betQeen abdominalQall inFurI tear, -ematoma, or Zseat beltZ sign Wsubcutaneous fat stranding alongt-e course of t-e fastened seat beltX" and boQel and mesenteric inFuries *+" Kig(%". 9ine %0" of + patients Qit- boQel and mesenteric inFuries -ad abdominalQall inFurI, compared Qit- t-ree 0" of +( patients Qit-out boQel and mesentericinFuries.

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Fi+u 0*/ Desenteric inFuries in a %2&Iear&oldman after a motor ve-icle accident. Axial >'image s-oQs a sigmoid mesenteric -ematomaarroQ" and a normal appearance of t-e sigmoidcolon arroQ-ead". A complete tear of t-eabdominal Qall V" is visible in t-e rig-t loQer quadrant. Avulsion of t-e sigmoid colonmesenterI associated Qit- an isc-emic sigmoidcolon segment subsequentlI resected" Qasfound at surgerI.

Co'lu%io%

PoQel and mesenteric inFuries maI be significant and require

immediate surgerI or maI be nonsignificant and permit nonsurgical treatment. A number of >' signs arespecific to, or indicative of, significant inFurI. '-ese signs include boQel Qalldefects; intraperitoneal, mesenteric, or retroperitoneal free air after ot-er causesof extraluminal air -ave been excluded"; intraperitoneal presence of boQelcontrast material; extravasation of contrast material from mesenteric vessels; andevidence of boQel infarct. ?oQever, t-e sensitivitI of t-ese signs is loQ. 'Qoadditional signs of mesenteric inFurIRmesenteric vascular beading and t-e abrupt

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termination of mesenteric vesselsR-ad -ig- specificities in our patient series andQere more frequentlI seen t-an Qere signs previouslI reported to be specific.Kocal boQel Qall t-icSening and mesenteric -ematoma are less specific signs andmaI be indicative of nonsignificant boQel or mesenteric inFurI. Kocal mesentericfluid and fat stranding are nonspecific findings and could be due to ot-er inFuries. Cf

t-ere is no

ot-er explanation for intraperitoneal fluid, boQel or mesenteric

inFurIs-ould be considered.

Y-en nonspecific features of significant boQel or mesenteric inFurI are t-e onlI >'findings, t-e need for surgical intervention is -ig-lI dependent on clinical Fudgment.Beevaluation Qit- >' Qit-in R1 -ours after t-e initial evaluation maI -elp toelucidate t-e significance of suc- findings.

estudo imagem abd

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