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An appendiceal diameter of higher than 6 mm is suggestive of appendicitis; nonetheless, up to 40% of regular appendixes can have diameters higher than 6 mm. An vague wall or focal areas of nonenhancement might indicate ischemia and infarction, while signs of perforation embrace extraluminal air and periappendiceal collections. This was identified as a focal deposit of endometriosis at histopathologic evaluation following surgical resection. T2-weighted fast spin-echo sequences and fat-suppressed T2-weighted images are the mainstay diagnostic sequences carried out. Periappendiceal fat stranding will seem hyperintense relative to regular fat on T2-weighted imaging and is accentuated on fat-suppressed T2-weighted pictures. Diffusion-weighted imaging has been proven to be useful in the prognosis of acute appendicits. Epiploic appendagitis: the classic appearance is of a rounded fat density/fat signal area adjoining to the colon with surrounding inflammatory stranding. Chronic appendicitis: this might be secondary to partial or intermittent obstruction of the appendiceal lumen. Management/Clinical Issues Acute appendicitis is a vital radiologic diagnosis and imaging aids prompt surgical choice making and treatment. Attempts should be made to visualize the appendix and exclude appendicitis on all cross-sectional imaging studies carried out for stomach ache. If acute appendicitis is identified, the referring physician should be contacted immediately to facilitate surgical administration without unnecessary delay. Periappendieal fluid collections and/or abscesses might require image-guided percutaneous catheter drainage. A fluid-filled, distended appendix with surrounding irritation is the hallmark of prognosis. Ultrasound is most useful in thin sufferers and pediatric and pregnant affected person populations. Clinical coverage: crucial issues in the evaluation and administration of emergency department patients with suspected appendicitis. Appendiceal Carcinoid Tumors Definition Gastrointestinal carcinoid tumors arise from cells of the neuroendocrine system, occurring most regularly throughout the midgut. The appendix is the most typical web site for gastrointestinal carcinoid, adopted by the small bowel and rectum. Clinical Features Carcinoid tumors of the appendix could be discovered in patients of any age. However, patients are typically youthful than those presenting with different tumors of the appendix or different sufferers with gastrointestinal carcinoid tumors. Appendiceal carcinoids are slow-growing tumors which may be often incidentally recognized on the time of appendectomy or surgical procedure for other abdominal pathology. For example, the tumors can impede the appendiceal lumen, resulting in appendicitis, with identification of the tumor at the time of resection. Pathophysiology Carcinoids are well-differentiated neuroendocrine tumors, often showing as small yellow or white nodules throughout the wall of the appendix. Approximately two thirds of tumors occur on the tip or in the distal third of the appendix. Lesions can invade regionally along the mesoappendix and then to native mesenteric nodes, with further spread to the small bowel mesentery. Goblet cell carcinomas are a uncommon subtype of carcinoid tumors that present mixed endocrine and glandular differentiation. These lesions are more aggressive than common carcinoid tumors but less aggressive than appendiceal adenocarcinoma. Imaging Features Because carcinoid tumors are often small on the time of analysis, abdominal radiographs and barium research are hardly ever useful. Ultrasound is unlikely to be diagnostic; however, if the lesion has obstructed the appendiceal lumen, features of appendicitis may be current. Tumor invasion into the mesoappendix could seem just like the inflammatory stranding seen in appendicitis. The surrounding mesenteric fats should be assessed for domestically enlarged lymph nodes. Metastatic disease may lengthen to the base of the small bowel mesentery and appear as an irregular delicate tissue mass that usually shows foci of calcification. After the mesentery, metastases normally go to the liver, typically appearing as multiple arterially enhancing lesions. These examinations may be helpful within the characterization of incidental lesions identified within the appendix, but they also have a task in assessing for the presence of metastatic disease, which can typically additionally accumulate the radioisotope. Differential Diagnosis Appendicitis: the appendix will normally seem diffusely thick-walled somewhat than focally thickened. Management/Clinical Issues Appendiceal carcinoid tumors have a extra benign course than carcinoid tumors throughout the remainder of the gastrointestinal tract, and metastatic illness is rare. Surgical resection is the principle remedy and is based totally on the scale of the tumor at the time of prognosis, with appendectomy usually considered curative for tumors smaller than 2 cm. Right hemicolectomy is often reserved for patients with tumors larger than 2 cm, tumor invasion into the mesoappendix, lymphatic system, or lymph nodes, and tumors with optimistic margins or aggressive features at histopathologic examination. Usually incidentally discovered at imaging, at surgical procedure, or on histopathologic evaluation of the resected appendix. Appendiceal Mucinous Cystadenoma Definition Mucinous cystadenomas are benign mucin-producing epithelial neoplasms arising within the appendix and, after carcinoid tumors, are the second most typical tumor of the appendix. Clinical Features Mucinous cystadenomas are the most typical explanation for mucoceles, which arise when the appendiceal lumen becomes chronically obstructed and the appendix slowly fills with mucin. Other causes of mucoceles embrace appendicoliths, scarring (usually related to previous inflammation), or different appendiceal or cecal epithelial neoplasms. A mucocele might present with low-grade right-lower-quadrant ache or discomfort or as an incidental discovering of a mass on medical examination or imaging. Acute presentations are often secondary to superinfection, the end result mass impact on adjacent structures, or as a result of intussusception of the mucocele into the cecum, causing bowel obstruction. Perforation of the mucocele can even happen, leading to leakage of gelatinous material into the peritoneal cavity, known as pseudomyxoma peritonei. When that is related to the benign mucinous cystadenoma or one other benign etiology, it carries an excellent prognosis after removal of the mucin. Pseudomyxoma peritonei, nonetheless, is extra commonly related to appendiceal mucinous cystadenocarcinoma and carries a worse prognosis, since it has an insidious development, often requiring a quantity of debulking surgical procedures. Appendectomy or proper hemicolectomy within the remedy of appendiceal carcinoid tumors Primary neoplasms of the appendix: radiologic spectrum of disease with pathologic correlation. Longitudinal ultrasound picture of the pelvis (A) reveals an elongated cystic lesion with inner echoes instantly superior to the bladder. Pathophysiology Mucinous cystadenomas of the appendix are benign epithelial lesions; the corresponding malignant lesion is an appendiceal mucinous cystadenocarcinoma. It will not be potential to pathologically classify a small variety of tumors, which can be categorized as mucinous tumors of unsure malignant potential. Imaging Features Imaging of mucinous cystadenomas depends on the prognosis of the resultant mucocele. Abdominal radiographs may show a well-circumscribed delicate tissue density in the best decrease quadrant. Curvilinear calcifications inside the wall, while rarely identified on plain radiographs, help the prognosis. A phase of normal nondistended appendix may be visible between the mucocele and the cecum. The mucocele may indent the cecum or can invaginate by way of the appendiceal orifice into the cecum. If the mucocele obstructs the cecum or ileocecal valve, there may be resultant small bowel obstruction. Air throughout the mucocele, thickening of the appendiceal wall, or stranding inside the adjacent fats all indicate attainable underlying superinfection and may be indistinguishable from easy appendicitis. The mucocele also can endure torsion, resulting in infarction and perforation; hardly ever, it might be the lead point for intussusception.

Histopathologic examination usually exhibits volcano-like eruptions of fibrin and leukocytes from mucosal crypts. While most patients have a superficial mucosal illness, on occasion the disease can progress to poisonous megacolon with transmural damage. Imaging Features the findings on belly radiographs could also be regular or nonspecific, with ileus, moderate to marked distention of the colon, and moderate distention of the small bowel. Owing to the chance of perforation, barium enema is contraindicated in energetic or severe cases. Infectious Colitis 237 Sonographically, pseudomembranous colitis often manifests as a pancolitis with marked mural thickening of the colon, exaggerated haustral markings, and heterogeneous thickened submucosa with virtual apposition of the mucosal surfaces. Ischemic colitis: Colonic involvement is most commonly seen in the splenic f lexure in aged sufferers with atherosclerosis and cardiac disease. Infectious colitis: Other infectious colitides can even cause a segmental or pancolitis with mucosal ulcerations, mural thickening, submucosal edema, pericolonic irritation and mesenteric, omental, and/ or peritoneal fluid. Ulcerative colitis: Inflammatory mural thickening of the colon begins within the rectum and extends proximally in a contiguous fashion, the degree of mural thickening and intraperitoneal fluid is less, and sufferers sometimes have long-standing bowel signs. Coronal reformatted picture reveals marked mural thickening of the sigmoid colon with mucosal hyperenhancement and intensive submucosal edema (arrow). The appearance of the colon has been likened to that of an accordion, as positive contrast materials is trapped between thickened haustral folds. After administration of intravenous distinction material, the "target signal" may be seen, corresponding to hyperenhancement of the mucosa and muscularis propria. Coronal reformatted pictures of the transverse colon (arrows in A) and coronal reformatted image (B) of the ascending (black arrow) and descending colon (white arrow) show marked mural thickening with mucosal hyperenhancement, submusosal edema, and engorgement of the vasa recta. The cross-sectional imaging findings of pseudomembranous colitis are nonspecific and might mimic other infectious and inflammatory colitides. Accordingly, correlation with a historical past of antibiotic use, laboratory studies, and endoscopy is important. Laboratory research obtainable for detection include bacterial cultures, enzyme immunoassay, and cytotoxin assay. Management/Clinical Issues Therapy for pseudomembranous colitis consists of discontinuation of causative antibiotics, nonspecific supportive measures, and antimicrobial brokers directed against C. Vancomycin and metronidazole are the antibiotics mostly employed in pseudomembranous colitis. Relapses occur in 5% to 50% of patient owing to the reality that, because of sporulation, C. Pseudomembranous colitis must be suspected in any affected person with colitis who has obtained antibiotics. The definitive analysis is made with the help of colonoscopy and stool cultures constructive for C. Neutropenic Colitis Definition Neutropenic colitis is a doubtlessly life-threatening dysfunction affecting the ileum and cecum. The time period typhlitis is usually used when the inflammatory process is confined to the cecum. Demographic and Clinical Features the probability of growing neutropenic colitis in high- danger individuals varies from 1% to 46%. The most typical presentation is fever, diarrhea, nausea, vomiting, and right- lower-quadrant stomach pain in a patient receiving antineoplastic medicine. Localized tenderness could rapidly progress to diffuse indicators of peritonitis ensuing from intestinal perforation. There is a profound neutropenia and blood cultures are optimistic in as much as 50% of sufferers. Pathology the initial injury is an ulceration of the bowel mucosa, which can end result from leukemic infiltration, stasis of bowel contents, splanchnic vasoconstrictors, and direct drug-induced damage of the mucosa. In the setting of mucosal damage and impaired host defenses, infectious colitis subsequently happens. The cecum might become gangrenous and perforate as a result of luminal distention, ischemia, and an infection. Imaging Features Abdominal radiographs are usually nonspecific but may show ileocecal dilation with air-fluid levels and a small bowel obstruction secondary to inflammation. The diploma of cecal thickening could also be much less spectacular and the small bowel and other segments of colon are often concerned. Ischemic colitis: Most generally the splenic flexure is affected in immune competent, elderly patients with atherosclerosis and cardiac illness. Infectious colitis: Immunocompetent and immunocompromised sufferers might current with a segmental or pan colitis with mucosal ulcerations, mural thickening, submucosal edema, percolonic irritation and mesenteric, omental, and/or peritoneal fluid. Common Variants There is commonly medical and imaging overlap of patients with pseudomembranous colitis and neutropenic colitis. The absence of neutrophils within the face of great an infection and cell harm permits assured prognosis of neutropenic colitis. Patients with pseudomembranous colitis typically show giant numbers of neutrophils in the colonic exudates. Abscess formation, intramural perforation, intestinal necrosis, or hemorrhage may happen in severe instances. Acute watery diarrhea in adults is often bacterial in origin, most commonly due to enterotoxigenic E. Bacterial enteropathogens similar to Shigella, Salmonella, Campylobacter, and enterohemorrhagic Eschericia coli and the protozoan E. Pathology Invasive colonic enteropathogens corresponding to Salmonela, Shigella, and Campylobacter commonly produce a macroscopic colitis that may indistinguishable from the colitis of inflammatory bowel illness. Biopsies taken inside the first 24 to seventy two hours of infection present mucosal edema, straightening of the glands, and an acute inflammatory infiltrate. Some organisms could be identified in mucosal biopsies, together with trophozoites of E. Some-such as those attributable to Salmonella, Yersinia, tuberculosis, and amebiasis-are more usually limited to the proper colon, together with or excluding the ileum. Other Infectious Colitides Definition Infectious colitis is responsible for vital morbidity and mortality worldwide. Demographic and Clinical Features Following the regular increase in reports of Salmonella and Campylobacter infections, the importance of infectious colitis is now widely recognized. There have been a sequence of major outbreaks of enterohemorrhagic Eschericia coli infection, with a mortality price of 1% to 2% and a comparatively high incidence of significant complications, such as the hemolytic-uremic syndrome. Scan of the midabdomen shows marked mural thickening of the colon with submucosal edema (arrow), hyperenhancement of the mucosa, and ascites. Marked mural thickening of the ascending and descending colon are current associated with submucosal edema and pericolonic inflammatory change. Coronal reformatted picture exhibits marked mural thickening (arrows) of a redundant sigmoid colon with submucosal edema, pericolic inflammatory change, fluid, and ascites. Amebiasis typically manifests as acute fulminating colitis with ulcerations and skip lesions. Although a diffuse colitis can happen, the best colon and rectum are inclined to be most severely concerned. In advanced illness, a cone-shaped cecum and colonic "applecore-like" strictures might develop. Endoscopic and sometimes laparoscopic specimens are needed for a definitive diagnosis, which is predicated on the presence of caseating granulomas or constructive cultures for acid-fast bacillus. Ischemic colitis: this is most commonly seen in the splenic flexure in elderly patients with atherosclerosis and cardiac disease. The diploma of mural thickening is much less, splanchnic vascular emboli or thrombi may be visualized, and the amount of associated intraperitoneal fluid is less. There is typically a history of antibiotic use in sufferers with pseudomembranous colitis. Ulcerative colitis: the inflammatory mural thickening of the colon begins within the rectum and extends proximally in a contiguous style, the diploma of mural thickening and intraperitoneal fluid is less, and patients usually have long-standing bowel signs. There is a pancolitis with marked mural thickening of the transverse (arrows) and descending colon, hyperenhancement of the mucosa and muscularis propria, and ascites. Key Points There is considerable overlap within the imaging look of infectious colitis-mural thickening, pericolonic stranding, and various degrees of ascites; most cases of infectious colitis produce a pancolitis, especially with E. Salmonella, Yersinia, tuberculosis, and amebiasis trigger a predominantly right-sided colitis. Schistosomiasis, shigellosis, herpes, gonorrhea, syphilis, and lymphogranuloma venereum trigger predominantly left-sided colitis. The analysis of infectious colitis is usually confirmed clinically on the premise of stool evaluation and/or colonoscopic imaging and biopsy results.

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These tumors can even invade the palatine tonsils, valleculae, or pharyngoepiglottic folds. The supraglottic laryngeal constructions (epiglottis, aryepiglottic folds, mucosa overlying the muscular means of the arytenoid cartilages, false vocal cords, and laryngeal ventricle) come up from the pharyngobuccal anlage, forming a portion of the anterior wall of the hypopharynx. Supraglottic cancers are often categorized as a subtype of laryngeal rather than pharyngeal tumors. The supraglottic region has an extensive lymphatic bed; supraglottic cancers subsequently tend to unfold all through the supraglottic area into the preepiglottic house. Squamous cell carcinomas of the piriform sinuses are usually bulky plenty that, in 70% to 80% of patients, have already unfold to lymph nodes on the time of presentation. Tumors of the medial piriform sinus could invade the ipsilateral aryepiglottic fold, arytenoid and cricoid cartilage, and paraglottic area, often resulting in hoarseness. Tumors of the lateral piriform sinus could invade the thyroid cartilage, thyrohyoid membrane, and neck, including the carotid sheath. Squamous cell carcinomas of the posterior pharyngeal wall are giant, bulky tumors that cause few signs, typically presenting as painless neck plenty ensuing from metastases to cervical lymph nodes. More than half of these sufferers have lymph node metastases at the time of prognosis. These exophytic tumors may unfold superiorly or inferiorly into the nasopharynx or cervical esophagus, respectively, and posteriorly into the retropharyngeal house. Patients with pharyngeal lymphoma incessantly current with a neck mass, and cervical lymph nodes are initially involved in 60% of circumstances. Frontal spot picture of the pharynx reveals an advanced ulcerated carcinoma (black arrows) obliterating the left piriform sinus. Also observe marked swallowing dysfunction, with aspirated barium within the larynx and trachea (white arrows) as a outcome of continual radiation change within the pharynx. The palatine tonsil is the first web site of involvement by pharyngeal lymphoma in 40% to 60% of patients, the nasopharynx in 18% to 28%, and the lingual tonsil in 10%. Pharyngeal lymphomas sometimes seem on barium studies as large, cumbersome, lobulated plenty. Nevertheless the mucosal surface may be relatively easy because of the submucosal location of these tumors. Radiation Change Patients with carcinoma of the larynx or pharynx are generally treated with radiation therapy. Chronic radiation injury to the pharynx is characterized by vascular damage with mucosal atrophy and fibrosis of muscle and submucosal tissue. Paresis of the constrictor muscles may end in poor clearance from the hypopharynx with overflow aspiration. Carcinomas of the bottom of the tongue: prognosis using double-contrast radiography of the pharynx. Pharyngography after head and neck irradiation: differentiation of postirradiation edema from recurrent tumor. Demographic and Clinical Features Primary achalasia sometimes happens in young or middle-aged adults who present with long-standing dysphagia that slowly progresses over a period of years. Affected particular person are usually able to preserve their weight by modifying their diets, even in superior illness. In distinction, secondary achalasia is most incessantly attributable to malignant tumors involving the gastroesophageal junction; due to this fact affected patients are probably to be aged individuals (over 60 years of age) who current with a current onset of dysphagia (less than 6 months) and weight loss. Pathology Primary achalasia is an idiopathic condition ensuing from the degeneration of ganglion cells in the distal esophagus and on the gastroesophageal junction. In distinction, secondary achalasia is an acquired condition attributable to malignant tumor in North America and by Chagas disease in South America. Many sufferers with secondary achalasia have tumor that immediately infiltrates the gastroesophageal junction, destroying the ganglion cells in this area. In North America, as many as 75% of sufferers with secondary achalasia are found to have a carcinoma of the cardia or fundus as the cause of this condition. Carcinoma of the lung, breast, and pancreas and different malignant tumors also can metastasize to the gastroesophageal junction, inflicting secondary achalasia. Other sufferers might develop secondary achalasia because of tumor involving the vagus nerve, dorsal motor nucleus of the vagus nerve, or brain stem. Still other sufferers have tumors that secrete a vasoactive substance, producing a paraneoplastic syndrome that mimics achalasia. Barium research typically reveal a standing column of barium within the thoracic esophagus with markedly delayed emptying into the stomach. Some patients with achalasia have related nonperistaltic contractions of varying severity in the esophagus, a situation known as vigorous achalasia. In secondary achalasia, nonetheless, the esophagus is far less dilated because of fast development of illness. The narrowed distal esophagus can also be asymmetric, nodular, or ulcerated because of underlying tumor in this area. In patients with secondary achalasia brought on by main carcinoma of the cardia, barium studies may reveal different indicators of malignant tumor, with an ulcerated, polypoid, or infiltrating lesion in the cardia and fundus. In sufferers with markedly delayed emptying of barium from the esophagus, the abdomen paradoxically could empty more quickly than it fills, limiting evaluation of the cardia and fundus. In such cases, the affected person can be requested to sip additional barium in a recumbent, left-side-down position to facilitate radiologic evaluation of the proximal abdomen. This patient has an extended section of narrowing and higher angulation than is often seen in main achalasia. There can also be marked narrowing and irregularity of the proximal stomach as a end result of encasement by an advanced scirrhous carcinoma invading the distal esophagus (arrow), producing an achalasia-like appearance. Differential Diagnosis Peptic stricture: A tapered peptic stricture within the distal esophagus could resemble achalasia but main peristalsis is preserved, and peptic strictures are virtually at all times related to hiatal hernias. Extrinsic compression by an ectatic or aneurysmal descending thoracic aorta: this indentation can also cause tapered narrowing of the distal esophagus, but the dilated aorta will displace the distal esophagus and is commonly calcified and esophageal peristalsis is preserved. This patient has a massively dilated esophagus with a tortuous distal configuration (also often identified as a sigmoid esophagus) and considerable retained debris. Also note tapered narrowing of the distal esophagus just above the gastroesophageal junction (arrow). In such circumstances, however, the distal esophagus opens normally and first peristalsis is regular on prone right-anterior indirect Esophageal Motilit y Disorders 13 radiographs. Rarely, patients with end-stage achalasia could require an esophagogastrectomy and gastric pull-through for amelioration of symptoms. In distinction, patients with secondary achalasia require a tumor workup for analysis and staging of the underlying malignant tumor answerable for their situation. Diffuse Esophageal Spasm Definition Diffuse esophageal spasm is an unusual esophageal motility dysfunction characterised by intermittent weakening or absence of primary peristalsis with simultaneous, repetitive nonperistaltic contractions in the esophagus. Demographic and Clinical Features Diffuse esophageal spasm is a illness of the elderly; most sufferers with this situation are over 60 years of age. Affected individuals sometimes present with substernal chest pain, dysphagia, or both. The chest pain is believed to be brought on by a quantity of repetitive nonperistaltic contractions of moderate to marked depth. This situation usually involves the graceful muscle portion of the esophagus at or under the level of the aortic arch. In some sufferers, the esophageal wall might turn out to be markedly thickened owing to hypertrophy and thickening of the muscularis propria. It has therefore been postulated that the latter patients have a transitional type of diffuse esophageal spasm that will progress over time to basic achalasia. Imaging Features Diffuse esophageal spasm seems on esophagography by intermittently weakened or absent main esophageal peristalsis related to a number of repetitive nonperistaltic contractions of various intensity. Therefore the absence of a corkscrew esophagus on barium studies in no way excludes this prognosis. In patients with achalasia, however, primary peristalsis is absent on all swallows, whereas in sufferers with diffuse esophaeal spasm, primary peristalsis is current on Further Reading 1. Diagnosis of main versus secondary achalasia: reassessment of clinical and radiographic criteria. Differential Diagnosis Presbyesophagus: A form of esophageal dysmotility associated with getting older.

Upright chest radiographs are the most delicate radiographs for the detection of pneumoperitoneum as a outcome of the x-ray beam strikes the diaphragm tangentially at its highest point. The upright chest radiograph exhibits free intraperitoneal air beneath the hemidiaphragms (arrows in B). Left lateral decubitus abdominal radiographs are additionally very delicate for pneumoperitoneum because, when the patient is positioned in a left-side-down place, small amounts of free air might be positioned between the liver and lateral side of the peritoneal cavity. The observation of pneumoperitoneum on an upright chest radiograph or left lateral decubitus stomach radiograph is based on air rising to the nondependent portion of the peritoneal cavity. Supine radiographs are much less sensitive for the detection of small amounts of free intraperitoneal air. Identification of pneumoperitoneum on the supine radiograph is dependent on the visualization of air outlining the outer (serosal) floor of an intraperitoneal organ or ligament. One of the easiest locations to observe free air is adjoining to the serosa of the bowel. Triangular lucencies of air can also be seen when air is trapped between adjacent bowel segments. On supine stomach radiographs, pneumoperitoneum may outline the falciform ligament ("football" sign), the ligamentum teres, the undersurface of the central portion of the diaphragm ("cupola" sign), or diaphragmatic insertion sites ("leaping dolphin" sign). In the pelvis, free air may define the lateral umbilical ligaments ("inverted V" sign). Therefore any unexplained lucency on belly radiographs ought to increase concern for pneumoperitoneum. Pneumoperitoneum is normally a normal finding for as much as week following abdominal surgery. Very small foci of pneumoperitoneum may be troublesome to separate visually from mesenteric or omental fat when the image is being considered with routine belly soft tissue windows. The supine radiograph (A) exhibits generalized lucency over the right higher quadrant and air on each side of the bowel wall. Note the Rigler signal, which is visualization of gasoline on both sides of the bowel wall (arrow) and triangular lucency between bowel loops (arrowhead in A). The upright belly radiograph (B) exhibits free air beneath the hemidiaphragms (arrowheads) and dilated small bowel with air-fluid ranges. The left lateral decubitus abdominal radiograph (B) reveals air between the liver and proper lateral stomach wall (arrowhead in B). Ultrasound has been proven to have a sensitivity of 93% and specificity of 64% for the detection of pneumoperitoneum. Care must be taken to not mistake fuel in the colon or small bowel lumen for free air. Visualization of the gas contained by the bowel wall and the lack of movement of intraluminal gas to the nondependent portion of the peritoneum can help to verify the situation of gasoline within the bowel lumen. In some cases, fuel contained inside a right-upper-quadrant fluid collection or abscess can also be difficult to differentiate from pneumoperitoneum. Occasionally pneumoperitoneum may be by the way found or may be current in a postoperative affected person. On basic spin-echo and quick spin-echo sequences, air is a signal void and due to this fact tough to visualize. Air produces a susceptibility artifact on gradient-echo T1-weighted sequences, enhancing its visualization. Transverse ultrasound image of the right lobe of the liver exhibits pneumoperitoneum as poorly outlined echogencity anterior to the liver (arrow), producing soiled posterior shadowing. Pneumoperitoneum 639 nondependent portion of the peritoneal cavity on upright or left lateral decubitus films. It may be troublesome to exclude pneumoperitoneum on routine stomach radiographs in these sufferers. Upright chest radiographs or left lateral decubitus radiographs of the stomach may be essential to evaluate for pneumoperitoneum. Portal venous gas or pneumobilia: Branching lucencies in the right higher quadrant. Portal venous fuel sometimes extends to the hepatic margin on abdominal radiographs, and pneumobilia is located centrally. Colonic interposition: Colon interposed between the liver and proper hemidiaphragm could mimic pneumoperitoneum on a chest radiograph. Pneumomediastinum: Air from pneumomediastinum might dissect into the peritoneal cavity, especially within the setting of barotrauma from positive-pressure ventilation. Key Points Upright chest radiographs are the most sensitive radiographs for detection of pneumoperitoneum. Management/Clinical Issues In the vast majority of sufferers the finding of pneumoperitoneum indicates bowel perforation. A small volume of ascites might trigger no signs and sufferers could additionally be unaware of the presence of intraperitoneal fluid. It may be tough for patients to eat as a end result of giant quantities of ascites could exert mass impact on the abdomen. Other causes embrace coronary heart failure, renal failure, peritonitis, portomesenteric thrombosis, and malignant ascites from peritoneal carcinomatosis. As the amount of peritoneal fluid increases, it fills the paracolic gutters to attain the subdiaphragmatic areas. Peritoneal fluid typically collects and moves towards the subdiaphragmatic areas on the right and in proper paracolic gutter as a end result of the phrenicocolic ligament causes the left paracolic gutter to be shallow and never steady with the left subdiaphragmatic space. As fluid passes by way of the inframesocolic Pathophysiology the peritoneal cavity usually accommodates a really small quantity of sterile fluid, which has similarities to plasma. The movement of peritoneal fluid to attain the undersurface of the hemidiaphragm is because of the fluctuations in intra-abdominal stress throughout respiration and the peristaltic movement of the intestines, which create a reproducible circulatory pathway of fluid throughout the peritoneal cavity. When subphrenic and submesothelial lymphatics are blocked by tumor cells or the quantity of fluid is pathologic, ascites develops. The mixture of portal hypertension, hypoalbuminemia, and altered hemodynamics within the mesenteric circulation cause lymphatic leakage from intraperitoneal organs. Intraperitoneal fluid collects in the gravity-dependent deep recesses of the pelvis and paracolic gutters. Intestinal peristalsis and fluctuations of intra-abdominal pressure throughout respiration create a circulatory pathway to transfer fluid from the gravity-dependent recesses cephalad to the subdiaphragmatic areas. The fluid may be redirected to the pelvis centrally through the mesocolic compartments. If the fluid contains inside echoes, septations, or floating particles, exudative causes of ascites such as carcinomatosis and peritonitis should be thought-about, in addition to hemoperitoneum. The determination of loculation of ascites can be made with ultrasound because the patient could be examined in decubitus positions to ascertain whether the fluid is cell and septations can be seen. As beforehand mentioned, ascites initially collects within the dependent peritoneal areas and eventually fills the complete peritoneal cavity, displacing bowel loops centrally when the patient is within the supine or recumbent position. The radiographic (A) findings of ascites are current with moderate to large volumes of fluid. Uncomplicated ascites is seen ashigh sign depth on T2-weighted photographs and low signal depth on T1-weighted photographs. Classification Clinically, to aid in diagnosis within the underlying trigger, ascites is classed as a transudate or exudate. The findings of an elevated lactate dehydrogenase and a excessive peritoneal fluid complete protein relative to that of serum suggests the presence of an exudate. Paracentesis may be performed to give patients symptomatic reduction from giant volumes of ascitic fluid. In patients with cirrhosis and refractory ascites, transjugular portacaval shunt could also be considered to offer long-term control of ascites accumulation. Key Points Accumulation of ascites follows the pathway of fluid circulation throughout the peritoneal cavity. Demographic and Clinical Features Intraperitoneal abscesses can happen at any age from a wide selection of inflammatory, infectious, iatrogenic, postoperative, and posttraumatic situations. Clinical symptomatology varies relying on the etiology, location, and size of the abscess. Patients will usually have more severe and profound symptoms, similar to hypotension from septic shock, if the an infection is complicated by bacteremia and sepsis. Common signs from localized abscesses embrace fever, anorexia, and localized or diffuse abdominal ache.