Uncommon and Unusual Gastrointestinal Causes of the Acute Abdomen: Computed Tomographic Diagnosis

https://doi.org/10.1053/j.sult.2008.06.007Get rights and content

There is a wide variety of uncommon and unusual gastrointestinal causes of acute abdominal and pelvic pain that may be prospectively diagnosed on computed tomography. We demonstrate 10 such diagnoses and briefly review the current computed tomography and clinical literature on intussusception occurring beyond early childhood, small bowel obstruction from internal hernia, cecal volvulus, intramural small bowel hemorrhage, Boerhaave's syndrome, gastrointestinal luminal foreign bodies, small bowel diverticulitis, hemoperitoneum secondary to abdominal tumor; gallstone ileus, and gallbladder torsion. Radiologists and clinicians need to be aware of these disorders, particularly with the widespread utilization of computed tomography (CT) in the management of patients with acute abdominal pain.

Section snippets

Intussusception Occurring Beyond Early Childhood

Intussusception of the bowel is a different entity in older children and adults than in young children. When the colon is the primary or sole portion of bowel involved, in up to 95% of cases there is an identifiable pathologic leading point. This point is a malignant tumor in between one-half and three-quarters of colonic cases.1, 2 Symptoms of colonic intussusception in such patients may be acute, intermittent, or chronic.2 The diagnosis should be established prospectively on CT. Findings

Small Bowel Obstruction from Internal Hernia

Internal hernia is a relatively rare cause of small bowel obstruction (SBO). It is related to congenital mesenteric defects or prior surgery.10, 11 The presentation ranges from asymptomatic (with no associated obstruction) to intermittent symptoms to acute small bowel obstruction with strangulation. Prospective CT diagnosis may be difficult. Distinguishing SBO secondary to internal hernia from closed loop SBO due to adhesions can be challenging. The radiologist needs to be aware of the entity

Cecal Volvulus

Colonic volvulus causes up to 10% of large bowel obstructions. Untreated, this closed-loop obstruction can lead to colonic ischemia and infarction, which may be fatal. Up to 25% of the population have failure of peritoneal fixation, allowing the proximal colon to be more mobile.18 Sigmoid volvulus is the most common type of colonic volvulus. Cecal volvulus is less common. Transverse colonic volvulus is the rarest form.

Plain films may show the classic “coffee bean” appearance of cecal volvulus,

Intramural Small Bowel Hemorrhage

Intramural small bowel hemorrhage is relatively rare but is likely underdiagnosed. It can be trauma-related or can occur spontaneously. In adults, spontaneous hematoma is usually related to anticoagulation or an underlying bleeding disorder. It may also be secondary to ischemia or closed loop obstruction.20, 21, 22 Gastrointestinal bleeding occurs in half or fewer patients. Symptoms are usually vague and subacute, and some patients are asymptomatic. The correct diagnosis is often unsuspected

Boerhaave's Syndrome

Esophageal intramural hematoma and frank esophageal perforation (Boerhaave's syndrome) have a variety of etiologies, including iatrogenic (approximately 75%, eg, following endoscopic procedures) and self-induced (particularly postemetic, following excessive food and/or alcohol intake). Mucosal injury often occurs at the esophagogastric junction, with associated hemorrhage (Mallory–Weiss tear). A transmural perforation (Boerhaave's syndrome) may occur into the mediastinum, typically on the left

GI Luminal Foreign Bodies

Few reports of CT identification of nonmetallic luminal GI tract foreign bodies have been published. The diagnosis of GI tract perforation related to an ingested foreign body is usually not established prospectively without cross-sectional imaging.28 There may be a substantial lag time between ingestion and the development of symptoms, and for nonmetallic foreign bodies (eg, fishbones) the object(s) may be obscured by contrast media.28, 29 The radiologist, therefore, needs to be aware of these

Small Bowel Diverticulitis

With the exception of Meckel's diverticula, small bowel diverticula are acquired and involve only the mucosal and submucosal layers, usually along the mesenteric border. The pathogenesis of small bowel diverticulosis is unclear, although intestinal dyskinesis and high intraluminal pressures have been implicated. They are typically found in older patients, often incidentally on imaging studies. Duodenal diverticula are the most common and are solitary, whereas small bowel diverticula in other

Hemoperitoneum Secondary to Abdominal Tumor

Although hemoperitoneum secondary to abdominal tumor is an uncommon scenario in Western countries, it is a relatively common presentation in parts of Africa and Asia. It is usually related to capsular rupture of a hepatocellular carcinoma (HCC) (Fig. 15). Occasionally, hepatic adenomas, metastases (eg, hypervascular metastases such as melanoma, but also from colon and lung, among others), or angiosarcomas can also present with hemoperitoneum, as may other GI tract tumors (such as GI stromal

Gallstone Ileus

Gallstone “ileus” is bowel obstruction secondary to a gallstone, which has eroded into the gastrointestinal tract as a result of chronic cholecystitis. The gallstone (or occasionally gallstones) usually erodes into the bowel at the level of the duodenum. The obstruction occurs at a site of bowel narrowing, especially the ileocecal valve, and less likely at the duodenal–jejunal junction, at the sigmoid colon, or at a pathologic site of stricture.44, 45, 46 Rarely, obstruction occurs in the

Gallbladder Torsion

Gallbladder torsion (a.k.a. volvulus) is rare and rarely correctly diagnosed preoperatively. In a review of 400 cases, only four such patients were identified prospectively prior to surgery. Gangrenous changes were found at surgery and pathology in half.51 Torsion may be incomplete (<180 degree twist) or complete. First reported in 1898 by Wendell as the “floating gallbladder,” gallbladder torsion is usually seen in older women (3:1 ratio).51 Predisposing factors include a long mesentery, a

Summary

This potpourri of uncommon and unusual causes of the acute abdomen as demonstrated by CT is not intended to be all-inclusive, but reflects what we believe to be representative of entities which, while not encountered on a routine basis, can occasionally be identified in radiology practices where CT imaging of patients with acute abdominal and pelvic complaints occurs on a daily basis. Radiologists need to be aware of these disorders so that appropriate patient management may occur prospectively.

References (55)

  • T. Azar et al.

    Adult intussusception

    Ann Surg

    (1997)
  • Y.H. Kim et al.

    Adult intestinal intussusception: CT appearances and identification of a causative leading point

    Radiographics

    (2006)
  • D.M. Warshauer et al.

    Adult intussusception detected at CT or MR imaging: clinical-imaging correlation

    Radiology

    (1999)
  • N. Lvoff et al.

    Distinguishing features of self-limiting adult small-bowel intussusception identified at CT

    Radiology

    (2003)
  • J.D. Rea et al.

    Approach to management of intussusception in adults: a new paradigm in the computed tomography era

    Am Surg

    (2007)
  • K. Sandrasegaran et al.

    Proximal small bowel intussusceptions in adults: CT appearance and clinical significance

    Abdom Imaging

    (2004)
  • S. Tresoldi et al.

    Adult intestinal intussusception: can abdominal MDCT distinguish an intussusception caused by a leading point?

    Abdom Imaging

    (2008)
  • R. Zissin et al.

    Congenital internal hernia as a cause of small bowel obstruction: CT findings in 11 patients

    Br J Radiol

    (2005)
  • A. Blachar et al.

    Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteria

    Radiology

    (2001)
  • M.E. Lockhart et al.

    Internal hernia after gastric bypass: sensitivity and specificity of seven signs with surgical correlation and controls

    AJR Am J Roentgenol

    (2007)
  • N. Takeyama et al.

    CT of internal hernias

    Radiographics

    (2005)
  • S.S. Hong et al.

    Current diagnostic role of CT in evaluating internal hernia

    J Comput Assist Tomogr

    (2005)
  • L.C. Martin et al.

    Review of internal hernias: radiographic and clinical findings

    AJR Am J Roentgenol

    (2006)
  • S.A. Reddy et al.

    Diagnosis of transmesocolic internal hernia as a complication of retrocolic gastric bypass: CT imaging criteria

    AJR Am J Roentgenol

    (2007)
  • C.J. Moore et al.

    CT of cecal volvulus: unraveling the image

    AJR Am J Roentgenol

    (2001)
  • E. Delabrousse et al.

    Cecal volvulus: CT findings and correlation with pathophysiology

    Emerg Radiol

    (2007)
  • M. Macari et al.

    Intestinal ischemia versus intramural hemorrhage: CT evaluation

    AJR Am J Roentgenol

    (2003)

    • Cited by (11)

    • Comparative analysis of MDCT and MRI in diagnosing chronic gallstone perforation and ileus

      2015, European Journal of Radiology
      Citation Excerpt :

      In additional, MDCT could present the exact location of ectopic gallstone and the extent of SBO, also visualize other signs of the cholecystitis and pericholecystitis, gallbladder atrophy or augmentation with or without gallstone, edema and thickening of the gallbladder wall and the abnormality of intestine nearby. Evidently, MDCT was a rapid noninvasive technology in preoperatively diagnosing GSI with a sensitivity of 93%, 100% specificity and 99% accuracy [6], which could speed the early diagnosis and prompt treatment making, and reduce the morbidity and mortality of GSI [10–14]. In our study, it was also showed that MDCT could precisely visualize the extent of intestinal obstruction (100%), pneumobilia (100%) and location of the ectopic stone (88.5% (23/26)) respectively.

    • Bowel Obstruction

      2015, Radiologic Clinics of North America
      Citation Excerpt :

      CT identifies bowel obstruction as distended bowel loops (>2.5–3 cm) seen proximal to collapsed loops and can reveal the cause of obstruction, such as tumor, volvulus, appendicitis (Fig. 6A), or diverticulitis (see Fig. 6B). The transition zone should be carefully evaluated for masses.12–21 CT can accurately predict the etiology of obstruction in 70% to 95% of patients and can often suggest superimposed ischemia and intestinal perforation.22,23

    • Intramural Hematoma of Gastrointestinal Tract in People with Hemophilia A and B

      2023, Journal of Clinical Medicine

    • Acute Surgical Abdomen Due to Sporadic Polyarteritis Nodosa

      2021, Journal of Clinical Rheumatology

    • Biliodigestive fistula and gall stone ileus: A case report

      2020, Chirurgia (Turin)

    • The gallbladder: uncommon gallbladder conditions and unusual presentations of the common gallbladder pathological processes

      2015, Abdominal Imaging
    View all citing articles on Scopus
    View full text
    Copyright © 2008 Elsevier Inc. All rights reserved.