CLASE 6

IMAGENOLOGÍA • Radiografía de abdomen

(RxA):
Abdomen • Principios
• Anatomía
• Abdomen agudo en RxA:
• Patrones a identificar
• Oclusión intestinal
(intestino delgado y colon)

Dra. Liliana Hernández Marín • Apendicitis

Imagenología Diagnóstica y Terapéutica

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 Indicaciones: Radiografía de abdomen (RxA)

• Sospecha de oclusión
intestinal.

• Sospecha de
perforación de víscera
hueca (de preferencia
en bipedestación)

• Sospecha de cuerpo
extraño.
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ABDOMEN AGUDO: Apoyo imagenológico

RIESGO DE CONDICIÓN
MUERTE AUTOLIMITADA
Aneurisma aórtico roto (TAC)
Apendicitis (Adulto TAC)
Gastroenteritis (Clínica)

Pancreatitis (TAC+C)
Colecistitis (USG)
Adenitis (Ped. USG)

Isquemia mesentérica (TAC+C)

Diverticulitis sigmoidea (TAC)
Apendagitis epiplóica (USG)

Úlcera péptica perforada (TAC, RxA)

Salpingitis (USG TV) Infarto epiplóico (TAC)

Diverticulitis perforada (TAC) Diverticulitis cecal (TAC)

Abdomen agudo: Término impreciso que abarca todas las entidades que se
presentan con hallazgos clínicos de corta duración (<10 días) que pueden
encontrarse en relación con alguna patología abdominal progresiva que pone
en riego la vida o es capaz de causar morbilidad severa. Los pacientes están
considerados en riesgo hasta que se complete una evaluación quirúrgica. El
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síntoma principal es el dolor abdominal.

Clinical surgery. Michael Henry - Saunders/Elsevier - 2012

 questions to ask yourself are ‘has everything been included on the radiograph?’ a
adequate?’
Valoración de calidad: Radiografía de abdomen (RxA)
• INCLUSIÓN: Inclusion
Desde hemidiafragmas
hasta sínfisis del pubis. The entire anatomy shou
hemi‐diaphragms to the
1. Cúpula hepática
t
The superior aspect
2. Hemidiafragma izq.
3. Pared abdominal
should be included
lateral t
The lateral abdomin
Exposure is less of a problem nowadays as inadequate images are usually term
4. Sínfisis del pubis on either side of th
repeated. Also, when viewing the radiograph, the contrast and brightness can
poor exposure. However, under‐exposure in t
The
obese pubic
patients symphysi
can remain a prob
value of the radiograph. To check the exposure is adequate, ensure the spine
A veces en pacientes exposure is rarely an issue. visualised at the bo
obsesos esto no es
posible.
Note: The average de
• EXPOSICIÓN: La abdomen is slightly sm
columna debe ser normal adult abdome
visible.
are needed to image
obese patients, somet
Sobreexposición:
Radiolucidez to be used in the ‘lan
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Exposición include everything.

inadecuada:
Radiopacidad. Pacientes
obesos.
Exposure
Figure 6: An underexposed abdominal radiograph demonstrating poor visualisation o
make out the bowel gas and the diagnostic value of this radiograph may be somewha
 Proyecciones de rutina: Radiografía de abdomen (RxA)

AP EN DECÚBITO
AP EN
SUPINO
BIPEDESTACIÓN

• Visualización de • Visualización de
patrón gaseoso (SIN
niveles
NIVELES
hidroaéreos
HIDROÁREOS)
• Estómago - Fondo
• Estómago - Antro
Niveles hidroaéreos
• Visualización del
psoas

AIRE

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AIRE +
LÍQUIDO
LÍQUIDO SOBREPUESTO
RxA: Cuadrantes y regiones abdominales
Figure 7

CUADRANTES;
Q
• CSD
• CSI T
• CID
• CII CSD CSI
• REGIONES r
1. Hipocondrio der
2. Epigastrio
3. Hipocondrio izq
4. Lumbar (flanco) der
5. Umbilical (mesogastrio)
6. Lumbar (flanco) izq
7. Fosa Iliáca der
CID CII
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Suprapúbico (hipogastrio)
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Figure 8

RxA: Vísceras abdominales

Abdominal viscera 1 (Figure 9)

Normal anatomy on an abdominal X‐ray 9

1. Hígado
2. Bazo
1. Liver (purple) 3. Topografía
2. Spleen (pink)
3. Location of the pancreas (white outline) – not normally visualised pancreática*

Abdominal viscera 2 (Figure 10)

Figure 9
1. Riñón der (2½ cpos.
Abdominal X-rays for Medical Students, First Edition. Christopher G.D. Clarke and Anthony E.W. Dux.
© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. vertebrales)
2. Riñón izq
3 y 4. Topografía
ureteral der e izq*
5. Vejiga
6. Gas en ámpula rectal
7 y 8: Topografía
adrenal der e izq*
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9. Topografía de
vesícula biliar*

*Usualmente no visibles
 RxA: Esqueleto y psoas
Skeletal structures (Figure 11)

1. 12o arco costal

2. Psoas der
3. Psoas izq
4. Pedículos de vértebra L1
5. Apófisis transversas
Figure 11
lumbares
1. Left 12th rib (light green) 6.8. Coccyx
Apófisis espinosa de L4
(rose)
2. Psoas outline – left and right (red) 7.9. Right
Sacrohemi‐pelvis (yellow)
3. Vertebral body of L3 (light blue) 8.10. Right
Cóccixsacroiliac joint (green)
4. Pedicles of L1 vertebra (orange) 11. Right femur (pink)
5. Right transverse processes of L1–L5 (black) 9.12. Left
Hemi-pélvis der
femur (purple)
6. Spinous process of L4 (brown) 10. Articulación sacroiliaca
7. Sacrum (blue) 11. Cabeza femoral der
12. Cabeza femoral izq
Pelvis (Figure 12)

1. Ilium (green)
Figure 11 1.
2.
Ílion
Pubis (red)
2.
3. Pubis (yellow)
Ischium
1. Left 12th rib (light green) 8. Coccyx (rose)
3.
4. Ísquion foramen (purple)
Obturator
2. Psoas outline – left and right (red) 9. Right hemi‐pelvis (yellow) 5. Location of right inguinal ligament
3. Vertebral body of L3 (light blue) 10. Right sacroiliac joint (green) 4. Forámen obturador
normally visualised. The inguinal ligam
4. iDESIGN
Pedicles of L1 vertebra (orange) 11. Right femur (pink) 5. Topografía
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5. Right transverse processes of L1–L5 (black) 12. Left femur (purple) inguinal der
tubercle
6. Spinous process of L4 (brown) 6. Shenton’s line (black outline) – imagi
6. along
Línea de Shenton
7. Sacrum (blue) the inferior border of the superio
ramus and inferomedial border of the
femur
Pelvis (Figure 12)
 Note: If you look carefully at the lung bases, you can often see the pulmonary vasculature as branching linear
opacities (as seen in the earlier example).
RxA: Vísceras huecas
Bowel 1 (Figure 14)

1. Estómago
2. Ciego
3. Colon
ascendente
4. Flexura
hepatocólica
5. Colon
transverso
6. Flexura
esplenocólica
7. Colon
descendente
8. Sigmoides

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1. Stomach – note the stomach wall rugae 5. Transverse colon
(highlighted between the white arrows) 6. Splenic flexure
2. Caecum 7. Descending colon
3. Ascending colon 8. Sigmoid colon
4. Hepatic flexure
 the entire diameter of the lumen. Dilated small bowel rarely
exceeds 5 cm in diameter, although large bowel is not consid-

RxA: Patrón “normal” del aire intestinal

ered dilated until it exceeds 5 cm in diameter. Large bowel is
bdomen
eritoneal
pread of

assess-
“acute
anterior
ographs
al detec-
hat may Antro gástrico
nal film
and the
he diag- Psoas
efinitive

conven-
ment of
mal gas

ID
Sigmoides

FIGURE 25.18. Normal Bowel Gas Pattern. Supine radiograph

on • Flecha (F) grande: Estómago
iDESIGN
shows the normal distribution of gas in the stomach (large arrow) and
Usualmente existe una pequeña cantidad
•
thebyduodenum (small arrow). The normal mottled pattern of stool is
F pequeña: Duodeno
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eases seen in the distribution of the right colon (arrowhead). A few gas col-
de aire en 2 o 3 asas de intestino delgado
• Punta de F: Patrón moteado en
lections within small bowel (curved arrow) are seen in the pelvis.
(ID) sin dilatación <2.5cm
colon derecho
• F curvada: Pequeñas burbujas de
aire en colon distal.
RxA: Patrón “normal” del aire intestinal

ID
Colon:
Intestino delgado: Haustras. No se extienden
Válvulas conniventes de pared a pared.
(VC) que se extienden Mayor separación que VC.
de pared a pared. Diámetro promedio: 6cm
Pliegues más cercanos Ciego: <10cm
que las haustras. Ascendente: <8cm
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Colon: Periférico
Intestino delgado: Central
12 RxA: Distribución normal del aire intestinal
Normal anatomy on an abdominal X‐ray

Bowel 2 (Figure 15)

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Figure 15
RxA: Líneas grasas properitoneales (LGP)

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• Líneas de grasa adyacentes a la musculatura de la pared abdominal lateral

• Inmediatamente observamos asas del colon ascendente adyacentes
• Engrosamiento del espacio LGP - colon: Sospechar líquido libre, procesos inflamatorios, etc.
RxA: Líneas grasas properitoneales (LGP)

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• Líneas de grasa adyacentes a la musculatura de la pared abdominal lateral

• Inmediatamente observamos asas del colon ascendente adyacentes
• Engrosamiento del espacio LGP - colon: Sospechar líquido libre, procesos inflamatorios, etc.
Estudios contrastados: Normal
Orofaringe (mecanica de la deglución) Esofagograma

Esófago a
repleción

Esófago
colapsado:
Pliegues
esofágicos

SEGD - Serie esofagogastroduodenal

Bulbo
Fondo gástrico duodenal
Bulbo
duodenal

Antro
gástrico Cuerpo
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Esofagograma y Serie esofagogastroduodenal (SEGD)

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Esófago normal Reflujo gastroesofágico

Tránsito intestinal: Normal
Estómago
Estómago fondo
fondo

Estómago
antro
Bulbo
duodenal Bulbo
duodenal Estómago
antro

Duodeno
Colon
ascendente Yeyuno
Yeyuno

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Íleon
TAC reconstrucción coronal con contraste oral iodado hidrosoluble: Normal

Estómago
Estómago fondo
fondo Hígado
Bulbo
duodenal

Yeyuno
VB
Yeyuno

Colon
ascendente

Ciego
Íleon Íleon

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 Colon por enema: Normal
Flexura Estómago
Flexura esplenocólica fondo
hepatocólica
Flexura
esplenocólica
Flexura
hepatocólica
Colon
transverso
Colon
ascendente Colon
transverso

Colon
ascendente
Colon
descendente Apéndice
Ciego Colon
descendente
Ciego
Colon
Colon sigmoides
sigmoides
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Ámpula
rectal
Ámpula
rectal
ColoTAC: Contraste (Aire) - Pólipo

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 t
Large soft tissue density (light grey) mass
t
Loops of bowel often displaced by the mass

RxA: Organomegalia
t
Location often gives a clue as to the origin:
t
right upper quadrant: liver, right kidney
t
left upper quadrant: spleen, left kidney, fluid filled stomach
t
lower abdomen: ovaries, uterus, distended urinary bladder

Aumento de tamaño de un órgano o una tumoración DE GRAN TAMAÑO.

Example 1
La Rx no caracteriza adecuadamente
la composición de la masa.

Megalias visibles:
• Hepatomegalia
• Esplenomegalia.
• Masa renal
• Masa pélvica
72 D – Disability (bones and solid organs)

Hallazgos radiológicos: Hepatomegalia

• Densidad de tejidos blandos.
Example 2
Figure 105: Two identical abdominal radiographs showing a Riedel’s lobe (normal variant). The right lobe of the liver is

• Desplazamiento de las asas

enlarged and extends inferiorly. The right radiograph shows the enlarged liver marked in purple. (You can also see an ECG
lead in the left upper quadrant).

intestinales.

La localización puede ser sugestiva del

origen:
• CSD: Hígado, riñón der
• CSI:iDESIGN
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líquido
• Pelvis: Ovarios, útero, vejiga distendida
Esplenomegalia
Figure 106: Two identical abdominal radiographs showing a large soft tissue mass in the left lumbar region. There is a
rounded soft tissue density in the region of the left kidney. In this case the underlying cause was a large renal cyst. The
RxA: Organomegalia Figure 106: Two identical abdominal radiographs showing a large soft tissue mass in the left lumbar region. There is a
rounded soft tissue density in the region of the left kidney. In this case the underlying cause was a large renal cyst. The

Aumento de tamaño de un órgano o una tumoración DE GRAN TAMAÑO.

right radiograph shows the soft tissue mass marked in red.

La Rx no caracteriza adecuadamente Example 3

la composición de la masa. D
Megalias visibles:
• Hepatomegalia
• Esplenomegalia.
• Masa renal
• Masa pélvica
Hallazgos radiológicos:
• Densidad de tejidos blandos. Tumor ovàrico (cistoadenoma)
Figure 107: Two identical abdominal radiographs showing a large soft tissue mass in the pelvis/central abdomen. There is a

• Desplazamiento de las asas large soft tissue density arising from the pelvis and extending into the left upper quadrant. It is displacing the surrounding
loops of bowel to the edge of the radiograph. In this case the underlying cause was a large ovarian cyst. The right

intestinales. radiograph shows the large pelvic/central abdominal mass marked in pink.

La localización puede ser sugestiva del

origen:
• CSD: Hígado, riñón der
• CSI:iDESIGN
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líquido
• Pelvis: Ovarios, útero, vejiga distendida

Vejiga neurogénica
Variantes anatómicas: Signo de Chilaiditi
Signo de Chilaiditi:
Interposición
anterior del colon
sobre el hígado y
bajo el
hemidiafragma der.
Incidencia 0.1 a 1%.

Sx. de Chilaiditi:
Signo + Dolor
abdominal CSD.

Limita el estudio por

USG del hígado y
vías biliares

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Variantes anatómicas: Lóbulo de Riedel
• PSEUDO-
crecimiento del
Lóbulo hepático
derecho el cual
se proyecta hacia
el cuadrante
inferior derecho.
• 17% de la
población.

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 IMAGENOLOGÍA
ABDOMEN AGUDO -
Radiología convencional

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Imagenología básica:
Abdomen agudo en RxA

Buscar 3 cosas principalmente.

1. Aire en lugares que no debería de

haber

2. Calcificaciones anómalas

3. Patrón de aire intestinal anómalo

(dilatación del tracto
gastrointestinal)

• Otros: Edema de asas intestinales,

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líquido libre
RxA: Abdomen agudo -
Aire en lugares que no debería de haber

Búsqueda de aire en:

• Cavidad peritoneal (Neumoperitoneo).

• Signo de Rigler (gas en el interior y exterior del intestino)
• Gas que delimita el ligamento falciforme
• Retroperitoneo (Neumoretroperitoneo)
• Gas que delimita los riñones
• Aire hepática: biliar (pneumobilia) o portal
• Gas central en forma de ramas - biliar
• Gas periférico en ramas - portal
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• Aire en las paredes del intestino

• Neumatosis intestinal
 RxA: Neumoperitoneo
Aire libre en la cavidad
peritoneal indicativa de
perforación de víscera hueca.

Causas principales:
• Úlcera péptica perforada
• Perforación de víscera
hueca (apendicular o
diverticular)
• Postquirúrgico (normal
hasta 3 días) y trauma
penetrante

HALLAZGOS RADIOLÓGICOS:
• Aire libre
subdiafragmático: (Rx
tórax en posición erecta
detecta desde 5ml de aire
libre
• AireiDESIGN
libre
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tangencial o proyección
en decúbito lateral
 RxA: Neumoperitoneo Tangencial

Aire libre en la cavidad

peritoneal indicativa de
perforación de víscera hueca.

Causas principales:
• Úlcera péptica perforada
• Perforación de víscera
hueca (apendicular o
diverticular)
• Postquirúrgico (normal
hasta 3 días) y trauma
penetrante Decúbito lateral
HALLAZGOS RADIOLÓGICOS:
• Aire libre
subdiafragmático: (Rx
tórax en posición erecta
detecta desde 5ml de aire
libre
• AireiDESIGN
libre
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tangencial o proyección
en decúbito lateral
 wall marked in turquoise. The best example of Rigler’s sign is marked with a white circle. An area of normal appearing
bowel wall is marked with a white dashed circle for comparison. (You can also see dilated loops of large bowel.)

RxA: Neumoperitoneo Example 2

• Signo de Rigler
(Doble pared): Aire
presente en la luz del
intestino y en el
exterior.
Normalmente solo el
aire del lumen es
visible.
• No confundir con dos
asas adyacentes. A – Air in the wrong place 23

Example 1

Figure 24: Two identical abdominal radiographs showing a large pneumoperitoneum. There are loops of bowel with gas
outlining both sides of the bowel wall in keeping with Rigler’s sign. The right radiograph shows in turquoise the areas
where the pneumoperitoneum is most clearly seen. Where Rigler’s sign is most clearly seen, the lumen of the bowel is
marked in brown. The best example of Rigler’s sign is marked with a white circle. You can also see gas outlining the liver
as shown by the white line.

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 Figure 25: Two identical abdominal radiographs showing a pneumoperitoneum. There is a dilated loop of bowel with gas
outlining both sides of the bowel wall in keeping with Rigler’s sign. The right radiograph shows in turquoise and brown the

RxA: Neumoperitoneo areas where Rigler’s sign is most clearly seen. The lumen of the bowel is marked in brown and the free gas outlining the
bowel wall marked in turquoise. The best example of Rigler’s sign is marked with a white circle.

Example 4
HALLAZGOS
RADIOLÓGICOS:
• Aire que rodea el
hígado: Halo
radiolúcido
perihepático.

• Signo del ligamento

falciforme: A – Air in the wrong place 25
Normalmente no es
visible.
Example 5
Figure 26: Two identical abdominal radiographs of a young child showing a pneumoperitoneum. There are loops of bowel
with gas outlining both sides of the bowel wall in keeping with Rigler’s sign, and there is gas outlining the falciform
ligament in keeping with the falciform ligament sign. The right radiograph shows in turquoise and brown the areas where
Rigler’s sign is most clearly seen. The lumen of the bowel is marked in brown and the free gas outlining the bowel wall
marked in turquoise. The position of the falciform ligament is shown with white arrows. The best example of Rigler’s sign
is marked with a white circle. (You can also see dilated loops of bowel.)

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 27

RxA: Neumoretroperitoneo
A – Air in the wrong place

Example 1

Causas:
• Perforación de víscera
hueca (especialmente
duodeno
retroperitoneal por
úlcera, post CPRE, post
esfinterotomía)
• Postquirúrgico. Figure 30: Two identical abdominal radiographs showing gas in the retroperitoneal space. There are patchy areas of
blackness (gas) seen outlining both kidneys either side of the spine. The right radiograph shows the retroperitoneal gas
marked in turquoise, clearly outlining both kidneys.
HALLAZGOS
RADIOLÓGICOS: Example 2

• Aire que rodea el Figure 30: Two identical abdominal radiographs showing gas in the retroperitoneal space. There are patchy areas of
blackness (gas) seen outlining both kidneys either side of the spine. The right radiograph shows the retroperitoneal gas
riñones, intestino marked in turquoise, clearly outlining both kidneys.
retroperitoneal
(duodeno, colon Example 2
ascendente y
descendente,
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recto).

• Puede co-existir con

neumopertioneo Figure 31: Two identical abdominal radiographs of the upper abdomen showing gas in the retroperitoneal space. There
are patchy areas of blackness (gas) seen outlining both kidneys either side of the spine. The right radiograph shows the
retroperitoneal gas marked in turquoise, clearly outlining both kidneys.
 t
Emphysematous cholecystitis (acute cholecystitis with gas‐forming organism)

RxA:
Example Neumobilia

n the wrong place

stent aórtico

bilia (gas in the biliary tree)

CAUSAS:
s gasFigure
in the 33: biliary tree.
Two identical It appears
abdominal as branching
radiographs of the upper abdomen showing gas within the biliary tree. There are
• CPRE dark
branching
the centre
reciente, post
lines (gas) esfinterotomía
projected (esfínter
over the centre
of the liver, usually larger and more
de larger
of the liver, Oddiand more prominent towards the hilum. There is
incompetente).
also a biliary stent projected over the midline (arrows). This is situated within the common bile duct and explains why gas
wards • the
is easily hilum.
Drenaje Sometimes
able tobiliar
travel you caninto also
intenvencionista/colocación
from the duodenum see gas
the biliary de prótesis
system. The presence of pneumobilia indicates that the stent is
on bile biliarpatent.
duct.
probably (stent) The right radiograph shows the gas within the biliary tree marked in dark blue.
• Conexión bilio-entérica (quirúrgica - procedimiento
Whipple, espontánea)
• Infecciónrepresentation
: Diagrammatic (ej. colecistitisofenfisematosa)
the appearance of gas in
tree on a iDESIGN
plain
HiSlide.io abdominal radiograph. The gas appears as a
HALLAZGOS RADIOLÓGICOS:
by

nching pattern (like a Aire

tree) en
andlaisvía
seen in the centre
• Neumobilia: biliar.
• Líneas
r, becoming more prominent towards
radiolúcidas the hilum.
en el centro del hígado (más
prominente hacia el hilio vascular).
• Aspecto muy similar a aire en la vía portal.
 Note: Remember pneumobilia can appear very similar to portal venous gas as both CMC:give a branching
Causa gas
más común

RxA: Gas en la vía portal

pattern within the liver. The way to tell them apart is to look at the location of the gas. Gas in the biliary tree
(pneumobilia) is seen in the centre (hilum) of the liver, not the periphery. Portal venous gas is seen in the
periphery of the liver because blood in the portal vein flows from the centre (hilum) towards the periphery.

Example
CAUSAS:
• Isquemia intestinal A – Air in the wrong p
(CMC)
• Enterocolitis Portal venous gas (gas in the portal vein)
necrotizante
(neonatos)
Gas in the portal vein appears as branching dark lines within the periphery of the liver on a plain
• Sepsis abdominal radiograph. In adults, it indicates serious intra‐abdominal pathology and is associated with
intraabdominal high mortality rate. In infants it is a finding of far less consequence.
severa (diverticulitis,
Main causes of gas in the portal vein:
absceso pélvico,1. Ischaemic bowel (most common)
apendicitis) 2. Necrotising enterocolitis (NEC) (most common in an infant)
3. Severe intra‐abdominal sepsis (diverticulitis/pelvic abscess/appendicitis)
HALLAZGOS Figure 35: Two identical abdominal radiographs of a child showing gas in the portal venous system. There are branching
RADIOLÓGICOS: dark lines (gas) projected over the periphery of the liver. In this case the gas is so extensive that it is also seen in splenic vein
1 2
• 1. Ramificación
The right radiograph shows the gas within the portal venous system marked in dark blue. Gas in the splenic vein is marked
in light blue. (You can also see dilated loops of large bowel.)
linear radiolúcida
periférica.
• 2. SiiDESIGN
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portal e inclusive la
vena esplénica.

Figure 34: Diagrammatic representation of the appearance of portal venous gas on a plain abdominal radiograp
RxA: Neumatosis intestinal

Sacro

Signo de Rigler
Aire en la pared del intestinal.

CAUSAS:
• Niños: Enterocolitis nercrotizante
• Adultos: Isquemia mesentérica,
enfermedades autoinmunes.
iDESIGN
by HiSlide.io

HALLAZGOS RADIOLÓGICOS (RxA):

• Densidad aire entre las paredes del
intestino

TAC es más sensible (ventana pulmonar).

 RxA: Calcificaciones en la RxA
Baja sensibilidad (identificación ocasional)
r quadrant for calcified gallstones
• CSD: Litos biliares calcificados (<10%),
f the kidneys
vesícula en and (1) for renal
ureters
porcelana
ok specifically in the region of both
• Topografía renal y ureteral: Litos renales
n calculus or nephrocalcinosis
(30-50%), nefrocalcinosis, litos ureterales. (2)

• Región
c region forsuprapúbica: Litos vesicales,
bladder stones (yellow).
miomas calcificados, tumores (teratomas)
ral abdomen for pancreatic
flebolitos. (3)
e).
• Región
the upper poles of both
epigástrica: kidneys for
Calcificaciones
pancreáticas. (4)
(pink).
egion for abdominal aortic
• Topografía adrenal (polos superiores de
ification (red).
riñones): Calcificación adrenal. (5)
iDESIGN
ok•for
Región central: Aneurismas
withdethe
la aorta
by HiSlide.io

a foetus (‘skeleton
abdominal (AAA) con placa de
). arterioesclerosis. (6)

• Feto Figure 16: Diagrammatic representation

 UtD: UpToDate
RxA: Calcificaciones en la RxA

Calcificaciones
biliares

Calcificación en
topografía renal

Riesgo de
Vesícula en cáncer
porcelana (2-3%) UtD. Calcificaciones en
Históricamente topografía renal
se reportaba
hasta 60%

iDESIGN
by HiSlide.io

Calcificación
ureteral
RxA: Calcificaciones en la RxA

DIU Calcificación Calcificación en

en topografía topografía adrenal
pancreática

DIU
Lito vesical

iDESIGN
by HiSlide.io
RxA: Calcificaciones en la RxA

Aneurisma de la aorta abdominal (AAA)

AAA AAA

iDESIGN
by HiSlide.io
RxA: AAA en TAC

AAA - Roto

Líquido libre
Sangre

AAA
Aorta >3cm

Aorta normal
iDESIGN
by HiSlide.io
RxA: Calcificaciones NORMALES en la RxA

Flebolitos: Calcificaciones Cartílagos costales

venosas con centro radiolúcido calcificados
Miomas uterinos calcificados

Flebolitos

iDESIGN
by HiSlide.io
 44 B – Bowel
B – Bowel 43 CUCI: Colitis ulcerativa
RxA: Edema de
Bowel wallasas intestinales
inflammation
Example 1
crónica inespecífica

owelInflamación
wall inflammation
intestinal: Puede ocurrir
Bowel wall inflammation can occur anywhere along the bowel, but is most commonly seen in the large
bowel. Inflammation of the large bowel is termed colitis.
en todas las asas, Main lugar más común
es el colon (colitis)
causes
wel wall inflammation can occurt
anywhere
of colitis:
Inflammatory
alongbowel
B
the disease
bowel, but is most commonly seen in the large
(e.g. ulcerative colitis or Crohn’s disease)
wel. Inflammation of the large bowel is termed colitis.
t
Ischaemic bowel
Main causes of colitis: t
Infection (e.g. pseudomembranous colitis from Clostridium difficile)
CAUSAS:bowel disease (e.g. ulcerative colitis or Crohn’s disease)
t
Inflammatory
• Enfermedad
t
Ischaemic bowel inflamatoria intestinal
Note: It is impossible to differentiate between the different causes of colitis using a plain abdominal radiograph;

(CUCI/Enf.
t
Infection Crohn)
(e.g. pseudomembranous B
however, remember that ulcerative colitis only affects the large bowel, Crohn’s and infection may affect
colitis from Clostridium difficile)
anywhere along the gastrointestinal tract and ischaemic bowel usually affects a specific vascular territory B
• Isquemia (e.g. superior mesenteric artery territory [midgut]
Figure 60: Two or inferior
identical mesenteric
abdominal arteryshowing
radiographs territory [hindgut]).
colonic bowel wall inflammation. There is thickening of the

•
ote: It is impossible to differentiate between the different causesbowel of colitis using
wall with a plain
thickening abdominal
of the haustral foldsradiograph;
in the transverse colon. The descending colon is featureless with loss of the
Infección, trauma
owever, remember that ulcerative colitis only affects the largenormal haustra. The right radiograph shows the inflamed bowel marked in green and the bowel wall thickening marked

B
bowel, Crohn’s and infection may affect
in light green. (You can also see an umbilical piercing.)
nywhere along the gastrointestinal Radiological signs
tract and of bowel wall
ischaemic bowelinflammation:
usually affects a specific vascular territory
HALLAZGOS
.g. superior RADIOLÓGICOS
mesenteric artery 1. Bowel[midgut]
territory (RxA):
wall thickening: Inflammation
or inferior mesenteric causes mucosal
artery oedema
territory and therefore thickening of the bowel
[hindgut]).
• Engrosamiento defatpared
wall. Often you can see the thickened bowel wall outlined by gas within the bowel lumen and peritoneal
Example 2
intestinal
outside of the bowel. Figure 60: Two identical abdominal radiographs showing colonic bowel wall inflammation. There is thickening of the
- Edema visualizado como pared
t
‘Thumbprinting’: Mucosal oedema maywith
bowel wall cause severeofthickening
thickening the haustral of thein haustral
folds foldscolon.
the transverse of the
Thecolon, suchcolon is featureless with loss of the
descending
adiological signs of bowel wall inflammation:
engrosada con gas that hacia la luz
the folds y as ‘thumb‐shaped’
appear normal haustra. The right radiograph
projections
in light green.
shows the
into the bowel
(You can also thickening
see an umbilicalof
inflamed bowel marked in green and the bowel wall thickening marked
lumen.
piercing.)
. Bowel wall thickening: Inflammation causes mucosal oedema and therefore the bowel
grasa
wall. Often youhacia
can seeel
theexterior.
1
thickened bowel wall outlined by gas within the bowel lumen and peritoneal
fat • Edema
outside of thede mucosa - Impresiones
bowel. Example 2
digitiformes
t
‘Thumbprinting’: en colon
Mucosal oedema proyectados
may cause severe thickening of the haustral folds of the colon, such
that hacia
the foldslaappear
luz. as ‘thumb‐shaped’ projections into the bowel lumen.
NL 1 Edema 2
Figure 59: 1. Diagrammatic representation of normal appearances of the
colonic bowel wall with thin haustral folds projecting into the bowel lumen.
2. Diagrammatic representation of the appearances of ‘thumbprinting’.
iDESIGN The colonic wall is inflamed causing severe thickening of the haustral folds,
by HiSlide.io which now appear as ‘thumb‐shaped’ projections into the bowel lumen.

• Pérdida de las haustras

2 - “Colon en
tubo”. t
Featureless bowel: Chronic bowel wall thickening causes complete loss of the normal
Figure
haustral 59: 1. Diagrammatic
markings. representation
The colon appears of normal
smooth walled. appearances
In chronic ulcerativeof the
colitis
• Pérdida de materia fecalcan
colonic
the colon en
bowel
havecolon
wall with thin
a classical haustral
‘lead folds projecting
pipe’ appearance – theinto
bowelthelooks
bowellikelumen.
a curvy
izquierdo. 2. Diagrammatic
lead pipe. representation of the appearances of ‘thumbprinting’.
Figure 61: Two identical abdominal radiographs showing bowel wall inflammation throughout the colon. There is thickening
The colonic wall is inflamed causing severe thickening of the haustral folds,
of the bowel wall and the colon appears featureless with loss of the normal haustra due to chronic inflammation. This is an
 B – Bowel 45
B – Bowel 43 CUCI: Colitis ulcerativa
RxA: Edema de
Bowel wallasas intestinales
inflammation
Example 3 crónica inespecífica

owelInflamación
wall inflammation
intestinal: Puede ocurrir
Bowel wall inflammation can occur anywhere along the bowel, but is most commonly seen in the large
bowel. Inflammation of the large bowel is termed colitis.
en todas las asas, Main lugar más
causes común
of colitis:
wel wall inflammation can occurt
anywhere along the bowel, but is most commonly seen in the large
es el colon (colitis) Inflammatory bowel disease (e.g. ulcerative colitis or Crohn’s disease)
wel. Inflammation of the large bowel is termed colitis.
t
Ischaemic bowel
Main causes of colitis: t
Infection (e.g. pseudomembranous colitis from Clostridium difficile)
CAUSAS:bowel disease (e.g. ulcerative colitis or Crohn’s disease)
t
Inflammatory
• Enfermedad
t
Ischaemic bowel inflamatoria intestinal
Note: It is impossible to differentiate between the different causes of colitis using a plain abdominal radiograph;

B
however, remember that ulcerative colitis only affects the large bowel, Crohn’s and infection may affect
(CUCI/Enf.
t
Infection Crohn)
(e.g. pseudomembranous colitis from Clostridium difficile)
anywhere along the gastrointestinal tract and ischaemic bowel usually affects a specific vascular territory
• Isquemia mesentérica
(e.g. superior mesenteric artery territory [midgut] or inferior mesenteric artery territory [hindgut]).

•
ote: It is impossible to differentiate between the different causes of colitis using a plain abdominal radiograph;
Infección, trauma
B
owever, remember that ulcerative colitis only affects the large bowel, Crohn’s and infection may affect
nywhere along the gastrointestinal Radiological signs
tract and of bowel wall
ischaemic bowelinflammation:
usually affects a specific vascular territory
Figure 62: Two identical abdominal radiographs showing colonic bowel wall inflammation. The bowel wall thickening is most
HALLAZGOS
.g. superior RADIOLÓGICOS
mesenteric artery 1. Bowel[midgut]
territory (RxA):
wall thickening: Inflammation
or inferior mesenteric causes
easily seen mucosal
inartery oedema
territory
the transverse colon and therefore
[hindgut]).
with severe thickening ofthickening
the haustral of the
folds bowel
giving the appearance of ‘thumbprinting’.

• Engrosamiento defatpared
wall. Often you can see the thickened bowel wall outlined by gas within the bowel lumen and peritoneal
intestinal
outside of the bowel.
The right radiograph shows the inflamed bowel marked in green and the bowel wall thickening marked in light green.

- Edema visualizado como pared

t
‘Thumbprinting’: Mucosal oedema
Example may 4cause severe thickening of the haustral folds of the colon, such
adiological signs of bowel wall inflammation:
engrosada con gas that hacia la luz
the folds y as ‘thumb‐shaped’
appear Figure 62: Twoprojections into theradiographs
identical abdominal bowel lumen.showing colonic bowel wall inflammation. The bowel wall thickening is most
. Bowel wall thickening: Inflammation causes mucosal oedema and
easily seen therefore
in the thickening
transverse colon with severeof the bowel
thickening of the haustral folds giving the appearance of ‘thumbprinting’.
grasa
wall. Often youhacia
can seeel
theexterior.
thickened bowel wall outlined by
1 The right radiograph shows the inflamed bowel marked in green and the bowel wall thickening marked in light green.
gas within the bowel lumen and peritoneal
fat • Edema
outside of thede mucosa - Impresiones
bowel.
Example 4
digitiformes
t
‘Thumbprinting’: en colon
Mucosal oedema proyectados
may cause severe thickening of the haustral folds of the colon, such
that hacia
the foldslaappear
luz. as ‘thumb‐shaped’ projections into the bowel lumen.
NL 1 Edema 2
Figure 59: 1. Diagrammatic representation of normal appearances of the
colonic bowel wall with thin haustral folds projecting into the bowel lumen.
2. Diagrammatic representation of the appearances of ‘thumbprinting’.
iDESIGN The colonic wall is inflamed causing severe thickening of the haustral folds,
by HiSlide.io which now appear as ‘thumb‐shaped’ projections into the bowel lumen.

• Pérdida de las haustras

2 - “Colon en
tubo”. t
Featureless bowel: Chronic bowel wall thickening causes complete loss of the normal
Figure
haustral 59: 1. Diagrammatic
markings. representation
The colon appears of normal
smooth walled. appearances
In chronic ulcerativeof the
colitis
• Pérdida de materia fecalcan
colonic
the colon en
bowel
havecolon
wall with thin
a classical haustral
‘lead folds projecting
pipe’ appearance – theinto
bowelthelooks
bowel
likelumen.
a curvy
izquierdo. 2. Diagrammatic
lead pipe. representation of the appearances of ‘thumbprinting’.
The colonic wall is inflamed causing severe thickening of the haustral folds,
 LGP: Línea grasa

RxA: Líquido libre intraperitoneal properitoneal

Difícil identificación sin

experiencia, la ecografía o
TAC es mas sensible.

CAUSAS:
• Trauma y hemorragia
(fractura de pelvis,
ruptura de víscera sólida
o estructura vascular, ej.
AAA)
• Infecciones (abscesos)
• Ascitis
HALLAZGOS
RADIOLÓGICOS (RxA):
• Desplazamiento de asas
intestinales hacia el
centro
• Densidad líquida
(radiopaca) - aspecto en
iDESIGN
“vidrio deslustrado”.
by HiSlide.io

• Pelvis con densidad

homogénea.
• Engrosamiento del
espacio de la LGP-asas
 USG: Detección rápida de líquido libre - FAST
Focused assessment LL: Líquido libre
with sonography for
trauma (FAST)
Detección rápida de
Hígado Hígado
líquido libre (sangre
fresca) intraperitoneal
LL Riñon der
HALLAZGOS
ECOGRÁFICAS:
• Colecciones de LL
líquido anecoico en:
• Pericardio (rodeando
al corazón)
• Pleura
• Espacio hepato-renal
• Espacio
esplenorrenal Vejiga
• Correderas
pertietocólicas LL
• Espacio
iDESIGN paravesical
• Fondo de saco
by HiSlide.io

Útero
rectouterino (de
Douglas) o
rectovesical
USG: Detección rápida de líquido libre - FAST

iDESIGN
by HiSlide.io
 Imagenología básica: Signos de abdomen agudo en TAC
Deshilachamiento de la
Engrosamiento difuso del
grasa mesentérica
intestino

Aire libre

Líquido libre Líquido libre

iDESIGN
by HiSlide.io
Imagenología básica: Signos de abdomen agudo en TAC
Engrosamiento difuso del intestino

Deshilachamiento de la
grasa mesentérica

Líquido libre

Líquido libre
Absceso (nivel
hidroaéreo)

iDESIGN
by HiSlide.io

Laceración
(bazo)

Deshilachamiento de
la grasa mesentérica
 Indicaciones de imagen para patologías
abdominales comunes

En la mayoría de las situaciones clínicas no se recomienda la placa simple de

abdomen si hay un estudio alternativo mas apropiado:

Indicaciones comunes:
• Trauma abdominal severo: TAC+C IV - Valora alteraciones óseas, de
órganos sólidos, asas intestinales, sitios de hemorragia activa significativa.
• Dolor en CSD: USG hígado y vías biliares
• Litiasis renal y urinaria: TAC abdomen simple o UROTAC
• Colección intraabdominal: TAC, secundariamente USG
• Sangrado del tubo digestivo alto: Endos/colonoscopía (si se localiza el sitio
es terapéutica). Si la endoscopía inicial es negativa (o en sitios no
alcanzables) : TAC+constraste (no sensible) angiografía, gammagrafía
• Sospecha de malignidad intra-abdominal: TAC+contraste, en caso de ser
positiva la misma estadifica.
iDESIGN

• Constipación: Diagnóstico clínico. Rx sólo es útil en pacientes geriátricos

by HiSlide.io

para mostrar la extensión de la impactación fecal.

Sugerencias de métodos de imagen urgentes en Abdomen agudo

CSD Epigastrio CSI

Úlcera duodenal
Endoscopía Neumonía
Rx tórax -Neumonía
USG hepático /TAC -Tumor Úlcera duodenal Gastritis Infarto
hepático Endoscopía Endoscopía
esplénico TAC
USG hepático /TAC -Absceso
Cólico biliar
hepático
Colangitis USG vías
biliares Úlcera gástrica Pancreatitis TAC (multifase pancreática)
Clínica/USG hepático SÓLO -Hepatitis Endoscopía
si se sospecha complicación Colecistitis
Pancreatitis - Pielonefritis Clínico / Complicada: TAC
Pielonefritis TAC (multifase
pancreática) - Cólico renal TAC simple / UROTAC
Cólico renal
- Infarto renal TAC contrastada
Infarto renal
Apendicitis
retrocecal
TAC Central
Aneurisma USG no complicado
aórtico TAC (roto)
Diverticulitis
Cólico renal
de Meckel Intusucepción
Cólico renal TAC Gammagrafía USG (niños), IVU
IVU Clínica/ adultos (TAC)
Complicado TAC
Vólvulo
Diverticulitis sigmoideo Colitis Colonoscopía,
de Meckel Oclusión Rx/TAC
Gammagrafía Rx/TAC ulcerosa TAC,RM
(CUCI)
Isquemia mesentérica AngioTAC
Apendicitis aguda TAC Enf. de Crohn Colonoscopía,
TAC,RM Diverticulitis TAC
Enf. de Crohn Colonoscopía, Colonoscopía en situación
TAC,RM no inflamatoria
Rx (perforación) Ca cecal
TAC (estadificación) perforado

Quíste ovárico USG pélvico

Salpingitis USG Endovaginal Suprapúbico Quíste ovárico
iDESIGN Emb. ectópico USG Endovaginal
Salpingitis
by HiSlide.io Emb. ectópico
Diverticulitis
TAC
CID Apendicitis
Torsión de mioma
CII
pélvica TAC
USG pélvico
Quiste ovárico
USG pélvico
USG pélvico Salpingitis
Clínica Cistitis
IMAGENOLOGÍA
ABDOMEN AGUDO -
Patrón de aire intestinal anómalo
(dilatación del tracto gastrointestinal)
 Figure
Figure54:54:Diagrammatic
Diagrammaticrepresentation
representationofofthe
theappearance
appearanceofofaadilated
dilatedstomach
stomach

Dilatación gástrica: Gastromegalia

full
fullof
ofgas.
gas.There
Thereisisaalarge
largeU‐shaped
U‐shapedor orstomach‐shaped
stomach‐shapedloop
loopofofbowel
bowelininthe
the
left
leftupper
upperquadrant.
quadrant.IfIfvery
verylarge,
large,the
thestomach
stomachcan
canextend
extendinferiorly
inferiorlyover
overthe
the
centre
centreofofthe
theabdomen.
abdomen.

SOBREDISTENSIÓN Example
Example

ESTOMACAL.

Dilatación con AIRE

• Oclusión gástrica: Proceso
maligno o estenosis del duodeno
POR enfermedad ácido péptica
(EAP) Vólvulo organo-axial

• Aerofagia

Dilatación con NIVEL

HIDROAÉREO Figure
Figure55:
55:Two
Twoidentical
identicalabdominal
abdominalradiographs
radiographsshowing
showingaagas‐filled
gas‐filleddilated
dilatedstomach.
stomach.There
Thereisisaaloop
loopof
ofstomach‐shaped
stomach‐shaped

• Oclusión GI: Tumor gástrico o distended

distendedbowel
distended
distendedas
bowelininthe
asvalvulae
theupper
upperabdomen.
abdomen.On
valvulaeconniventes
conniventesare
Onthe
areseen.
theright
seen.The
rightside
Thefindings
sideof
findingsare
ofthe
theabdomen,
abdomen,you
aresuggestive
suggestiveof
youcan
cansee
ofaaproximal
seethat
thatthe
proximalsmall
theduodenum
smallbowel
duodenumisispartially
bowelobstruction,
partially
obstruction,possibly
possiblyinin

estenosis del duodeno por EAP, the

theregion
the
regionof
theloop
loopof
ofthe
thedistal
ofduodenum
distalduodenum
duodenumor
duodenumininblue.
blue.
orproximal
proximaljejunum.
jejunum.TheTheright
rightradiograph
radiographshows
showsthe
thedilated
dilatedstomach
stomachininlight
lightblue
blueand
and

vólvulo gástrico
• Gastroparesia crónica
(neuropatía autonómica por
DMT2)

Hallazgos por imagen:

• Dilatación en forma de U en
CSI, puede distenderse hasta
iDESIGN Vólvulo mesentero-axial
meso o hipogastrio +/- nivel
by HiSlide.io

hidroaéreo
• Vólvulo gástrico: Gastroparesia Gastroparesia
Sobredistensión de Rx Decúbito Rx Bipedestación
morfología y posición ‘bizarra’
Oclusión intestinal - Intestino delgado y colon
Tipos de obstrucción:

• Asa cerrada • Oclusión completa: Luz completamente ocluida

• Asa abierta • Oclusión parcial (sub-oclusión): Parte del
contenido intestinal puede transitar

Vólvulo

• Obstrucción simple:
• No hay cambios en la irrigación intestinal
• Obstrucción estrangulada: Vascularización
comprometida. La mayoría de las obstrucciones
soniDESIGN
de asa cerrada (ocurre en hernias
by HiSlide.io

incarceradas y vólvulos)
 Dilated small bowel
Dilatación del intestino delgado (ID)
Distension of the small bowel is a sign of mechanical obstruction or ileus. In a normal individual the small
bowel is not visualised because it is collapsed or contains fluid.
La distensión del ID es signo de obstrucción mecánica o íleo.
There are two main processes causing dilated small bowel:
OBSTRUCCION MECÁNICA:
1. Mechanical Distensión
obstruction: Physicalde las asasofproximales
obstruction a la obstrucción,
the intestine preventing entre
normal transit mas
of digestive
distal más asasproducts.
serán Thevisualizadas. Causas:
bowel proximal to the obstruction is dilated. Therefore, the more distal the obstruction, the
more loops of bowel are visible. Causes of mechanical obstruction are divided into acquired and congenital:

Acquired causes: Intrinsic

Adquiridas intrínsecas:

Malignancy

B Adquiridas extrínsecas:
•
Extrinsic
Adhesiones 75% •

Intussusception
Malignidad

Stricture
•
(irradiation/surgery)
Intususcepción
• Hernias

Adhesions
20%

Hernias • Estenosis (radiación, cirugía)
• Vólvulos

Volvulus Conditions in
• Masa extrínseca Intra-luminal
red are the four
most important
causes of

Inflammation (e.g. Crohn’s)
small bowel

Gallstone ileus
Adquiridas Intraluminales:

Foreign body
obstruction to
Congenital causes:
Congénitas: • Inflamación (ej. Crohn) remember.

• Estenosis

Bowel stenosis or atresia
o atresia intestinal

Midgut volvulus • Íleo biliar
• Vólvulo intestinal • Cuerpo extraño
Figure 36: Causes of mechanical small bowel obstruction. • Parasitario

2. Ileus: Disruption of the normal propulsive ability of the gastrointestinal tract (i.e. failure of peristalsis).
Causes include the following:
iDESIGN
by HiSlide.io t
post‐operative
t
intra‐abdominal infection or inflammation
t
anti‐cholinergic drugs
Mechanical obstruction and ileus appear identical, and in most cases the underlying cause cannot be
Hernia
determined Adhesiones
on an abdominal X‐ray. look for include the following: Vólvulo
Radiological signs toIntususcepción
(Bridas)
t
Dilation >3 cm: The small bowel is dilated if it measures over 3 cm in diameter. Note: The height of an
Oclusión del INTESTINO DELGADO - RxA

Decúbito Bipedestación

SIGNOS RADIOLÓGICOS (RxA) - Diagnóstica en 50-60%:

• Dilatación
iDESIGN
de asas: >3cm (altura de cpo. vertebral 4cm)
• Localización
by HiSlide.io
central: Centralización de asas
• Visualización de válvulas conniventes
• Niveles hidroáereos (>2.5cm altura) en diferentes niveles - AP en bipedestación, si el
intestino contiene líquido los niveles pueden ser reemplazados por la apariencia de ‘collar de
perlas’ (burbujas entre válvulas)
Oclusión del INTESTINO DELGADO - RxA

Decúbito

SIGNOS RADIOLÓGICOS (RxA) - Diagnóstica en 50-60%:

• Dilatación
iDESIGN
de asas: >3cm (altura de cpo. vertebral 4cm)
• Localización
by HiSlide.io
central: Centralización de asas
• Visualización de válvulas conniventes
• Niveles hidroáereos (>2.5cm altura) en diferentes niveles - AP en bipedestación, si el
intestino contiene líquido los niveles pueden ser reemplazados por la apariencia de ‘collar de
perlas’ (burbujas entre válvulas)
 B – Bowel 31

Oclusión
Example 1 del ID - RxA - Ejemplos

B
Figure 38: Two identical abdominal radiographs showing dilated small bowel. The bowel is visible as there is gas (black) • Localización central.
within. You can tell that it is small bowel as it is centrally located and valvulae conniventes can be seen throughout. The loops
measure >3 cm in diameter therefore they are dilated. The right radiograph shows the dilated small bowel marked in blue. • Visualización de
válvulas conniventes.
Example 2 • Dilatación >3cm
Figure 38: Two identical abdominal radiographs showing dilated small bowel. The bowel is visible as there is gas (black)
within. You can tell that it is small bowel as it is centrally located and valvulae conniventes can be seen throughout. The loops
measure >3 cm in diameter therefore they are dilated. The right radiograph shows the dilated small bowel marked in blue.

Example 2

iDESIGN
by HiSlide.io

Visualización de asa
solitaria (asa sentinela)
dilatada >3cm
 Oclusión del ID - RxA - Ejemplos
Example 3

Figure 40: Two identical abdominal radiographs showing dilated small bowel. The small bowel is visible as there is gas

•
(black) within. You can tell that it is small bowel as it is centrally located and valvulae conniventes can be seen throughout.
The loops measure >3 cm in diameter and are therefore dilated. The right radiograph shows the dilated small bowel Localización central
marked in blue. (You can also see a wire from an intra‐cardiac device.)
• Visualización de válvulas
Example 4 • Dilatación >3cm
Figure 40: Two identical abdominal radiographs showing dilated small bowel. The small bowel is visible as there is gas
(black) within. You can tell that it is small bowel as it is centrally located and valvulae conniventes can be seen throughout.
The loops measure >3 cm in diameter and are therefore dilated. The right radiograph shows the dilated small bowel
marked in blue. (You can also see a wire from an intra‐cardiac device.)

Example 4

iDESIGN
by HiSlide.io • Localización central
• Visualización de válvulas
• Dilatación >3cm
• Visualización del colon
derecho periférico
Oclusión del ID - TAC

SIGNOS RADIOLÓGICOS (TAC).

Más sensible. Muestra la causa en
80%

• Dilatación de asas >2.5-3cm

• Punto de transición: Asas
dilatadas proximales. Asas
normales o disminuidas de grosor
distales
• Asa cerrada: Estiramiento de vasos
mesentéricos convergentes hacia el
punto de torsión. Morfología del
asa en U o C.
• Signo del pico (punta de lápiz)
en la zona de oclusión.
• Signo del remolino: Rotación de
asas al rededor de un punto
fijo.

Estrangulamiento:
• Engrosamiento
iDESIGN de la pared de las
asas (>3mm)
by HiSlide.io
con aumento de la
atenuación y ↓ realce con contraste.
• Neumatosis intestinal, gas en
sistema porta
• No es necesario el contraste oral para el diagnóstico de
oclusión (de preferencia sólo IV)
 UtD: UpToDate
Dilatación del intestino delgado (ID): Íleo
ÍLEO ADINÁMICO:
Interrupción de la
peristalsis habitual.

Causas:
• Post-operatoria (fisiológico: 2-3 días en
promedio, patológico: > 4 días) *UtD
• Infección intra-abdominal (peritonitis),
proceso inflamatorio difuso (gastroenteritis) o
focal (pancreatitis, apendicitis, colecistitis)
• Fármacos anticolinérgicos y opiodes
• Metabólico (DM, hipertiroidismo, ↓K, ↑Ca)
• Trauma
• Isquemia
• Enf. de la colágena
• Lesión medular

SIGNOS RADIOLÓGICOS (RxA)

• Dilatación proporcional de
estómago, ID y colon
• Distensión difusa, simétrica,
predomina el aire (en decúbito).
• Niveles
iDESIGN hidroaéreos al mismo nivel
• Más asas dilatadas que el
by HiSlide.io

obstrucción mecánica
• Puede no haber gas en el ámpula
rectal
 Oclusión mecánica del ID vs. Íleo

El contexto clínico es
más útil que la imagen.

OCLUSIÓN INTESTINAL (ID)

• Niveles hidroáereos en
diferentes niveles focales.
• Ausencia de visualización
Bipedestación Decúbito del colon

iDESIGN ÍLEO
• Niveles hidroáereos al
by HiSlide.io

mismo nivel
Bipedestación Decúbito • Visualización de todo el
tracto intestinal
 CMC: Causa más común
Dilatación del intestino grueso (IG):
Oclusión del colon
20% de obstrucciones intestinales.
Presentación radiológica: Dilatación del colon
(porción proximal dilatada y distal colapsada).

CAUSAS:
• Carcinoma colorectal: CMC de oclusión intestinal en
adultos (50-60%)
• Diverticulitis
• Estenosis secundaria a diverticulitis, enfermedades
inflamatorias (CUCI, Crohn), adherencias
• Impactación fecal: CMC en adultos mayores inmóviles
• Vólvulo: Cecal, sigmoideo.

HALLAZGOS RADIOLÓGICOS (RxA):

• Dilatación >5.5- 6cm (excepto en ciego en donde
debe ser >9-10cm). Punto de transición. Depende
de la capacidad de descompresión hacia el
intestino delgado.
• Localización
iDESIGN
by HiSlide.io
periférica (excepto en el colon
transverso que puede centralizarse hacia la
pelvis).
• Visualización de haustras y pliegues haustrales
(alisamiento si la distensión es excesiva)
Dilatación del IG (colon) - Ejemplos:
Figure 44: Two identical abdominal radiographs showing dilated large bowel. The
B –itBowel
(black) within. You can tell that 35 as it is distended >5.5 cm, circumfe
is large bowel

Oclusión
Example 1
del colon within. The right radiograph shows the dilated large bowel marked in green.

Example 2 B – Bowel 35

Example 1

Figure 44: Two identical abdominal radiographs showing dilated large bowel. The large bowel is visible as there is gas
(black) within. You can tell that it is large bowel as it is distended >5.5 cm, circumferentially located and haustra are seen
B – Bowel 35 within. The right radiograph shows the dilated large bowel marked in green.

Example 2
Example 1

iDESIGN
Figure 44: Two identical abdominal radiographs showing dilated large bowel.Figure 45:bowel
The large
B Two identical
is visibleabdominal radiographs showing dilated large bowel. The
as there is gas
by HiSlide.io
(black) within.located
(black) within. You can tell that it is large bowel as it is distended >5.5 cm, circumferentially You can tellhaustra
and that it is
arelarge
seenbowel as it is distended >5.5 cm (much la
within. The right radiograph shows the dilated large bowel marked in green. usually get) and haustra are seen within. The right radiograph shows the dilated lar

Example 2
 Figure 46: Two identical abdominal radiographs showing dilated large bowel.
Dilatación
36B – Bowel del IG (colon) - Ejemplos: (black) within. You can tell that it is large bowel as it is distended >5.5 cm, circ
within. The right radiograph shows the dilated large bowel marked in green.
Oclusión
Example 3
del colon Example 4

36 B – Bowel

Example 3

Figure 46: Two identical abdominal radiographs showing dilated large bowel. The large bowel is visible as there is gas
36 B – Bowel (black) within. You can tell that it is large bowel as it is distended >5.5 cm, circumferentially located and haustra are seen
within. The right radiograph shows the dilated large bowel marked in green.

Example 3 Example 4

Figure 46: Two identical abdominal radiographs showing dilated large bowel. The Figure
large47: Twoisidentical
bowel visible asabdominal radiographs showing dilated large bowel
there is gas
iDESIGN bowel is visible as there is gas (black) within. The large bowel loops are distend
(black) within. You can tell that it is large bowel as it is distended >5.5 cm, circumferentially
by HiSlide.io located and haustra are seen
within. The Bright radiograph shows the dilated large bowel marked in green. few haustra are seen within. The two loops of distended small bowel are iden
and indicate incompetence of the ileocecal valve since gas has passed retrogra
Example 4 bowel. The right radiograph shows the dilated large bowel marked in green an
 Dilatación del IG (colon) - Oclusión del colon (carcinoma)
Cáncer más común del tracto GI.
98% son adenocarcinomas

• Rectosigmoides: 55%
• Ciego* y ascendente: 20%
• Válvula IC*: 2%
• Transverso: 10%
• Descendente: 5%
*Patrón radiológico de oclusión de ID

- Colon DER - masa exofítica

- Colon IZQ - masa infiltrante /
anular. Clinical radiation oncology. Elsevier. 2016
p53, DCC
KRAS
APC

colon colon en adenoma carcinoma

NL riesgo
pólipo pólipo > malignidad
tamaño

iDESIGN
by HiSlide.io

CA Ciego CA Sigmoides
CA Áng. Esplenocól.
Oclusión del colon:
Vólvulos

Torsión del intestino girando

en su mesenterio.
Causas una obstrucción
completa o parcial.

Tipos mas comunes en el

colon:
• Sigmoideo
• Cecal
Síntomas:
• Oclusión intestinal.
• Isquemia
iDESIGN intestinal: La
torsión puede comprometer
by HiSlide.io

la irrigación vascular.
• Isquemia → Necrosis
 2. Bowel ischaemia: In some cases the twisting of the bowel mesentery compromises the vascular supply
to the bowel leading to ischaemia and eventually necrosis, which can be fatal.
Oclusión del colon: Vólvulo sigmoideo
Sigmoid volvulus
A sigmoid volvulus is caused when the sigmoid colon twists on its
mesentery. It is usually seen in the elderly or institutionalised patients.
- Frecuente en
ancianos y personas Radiological signs of a sigmoid volvulus:
con dietas ricas en 1. Coffee bean sign: The shape of the distended
gas filled ‘closed loop’ of colon looks like a large
residuos (fibra). coffee bean.
- 75% de casos de 2. General lack of haustra: Often the bowel is so
vólvulo distended that haustra flatten out and are no longer seen.
- 3-8% de 3. Distension of the ascending, transverse and descending
colon: The colon proximal to the obstruction (volvulus) is often
obstrucciones del
distended, but not always.
colon
- Obstrucción de asa
cerrada.
- Colon proximal
dilatado, distal vacío. Figure 48: Diagrammatic representation of a sigmoid volvulus. The sigmoid colon has its own mesentery, which is liable
to twisting causing obstruction and distension of the sigmoid colon with gas.

Caecal volvulus
HALLAZGOS RADIOLÓGICOS A caecal(RxA):
volvulus is caused when the caecal colon twists on its mesentery. In most patients the caecum is a

•
retroperitoneal structure, but in some patients the caecum is intraperitoneal with a mesentery. These patients
Oclusión originada en pelvis extendida
have an increased risk of developing a caecal volvulus.
hacia abdomen (a menudo hasta diafragma) Radiological signs of a caecal volvulus:
- Imagen en U invertida o grano de café 1. Comma shaped: The shape of the distended gas filled ‘closed

• iDESIGN
En fosa
by HiSlide.io iliacas (particularmente
“signo de 3 líneas”: Paredes laterales de
asas y suma de paredes centrales.
• Segmento oclusivo sin haustras
loop’ of colon often looks like a large comma (more rounded in
izquierda) shape than a sigmoid volvulus).
2. Haustra often visible: The haustral folds are often still clearly
visualised, even when the bowel is very distended.
3. Collapse of the ascending, transverse and descending
colon: The colon distal to the obstruction (volvulus) is often
collapsed.
38 B – Bowel distended bowel crossing the midline and extending to the right upper quadrant. Th
proximal large bowel is somewhat distended secondary to the obstruction from the v
Oclusión del colon: Vólvulo sigmoideo the sigmoid volvulus marked in brown. (You can also see a left hip prosthesis.)

Sigmoid volvulus example 1 Sigmoid volvulus example 2

38 B – Bowel

Sigmoid volvulus example 1

Figure 50: Two identical abdominal radiographs showing a sigmoid volvulus. There is a ‘coffee bean’–shaped loop of
distended bowel crossing the midline and extending to the right upper quadrant. There is a general lack of haustra. The
proximal large bowel is somewhat distended secondary to the obstruction from the volvulus. The right radiograph shows
38 B – Bowel the sigmoid volvulus marked in brown. (You can also see a left hip prosthesis.)

Sigmoid volvulus example 2

Sigmoid volvulus example 1

Figure 51: Two identical abdominal radiographs showing a sigmoid volvulus. There i
Figure 50: Two identical abdominal radiographs showing a sigmoid volvulus. There bowel
distended is a ‘coffee bean’–shaped
crossing loop
the midline and of
extending to the right upper quadrant. Th
iDESIGN
distended bowel crossing the midline and extending to the right upper quadrant. There is shows
right radiograph a general lack of volvulus
the sigmoid haustra.marked
The in brown.
by HiSlide.io
proximal large bowel is somewhat distended secondary to the obstruction from the volvulus. The right radiograph shows
the sigmoidBvolvulus marked in brown. (You can also see a left hip prosthesis.)

Sigmoid volvulus example 2

Figure 51: Two identical abdominal radiographs showing a sigmoid volvulus. There is a ‘coffee bean’–shaped loop of
 Caecal volvulus
Oclusión delAretroperitoneal
colon: Vólvulo cecal
caecal volvulus is caused when the caecal colon twists on its mesentery. In most patients the caecum is a
structure, but in some patients the caecum is intraperitoneal with a mesentery. These patients
have an increased risk of developing a caecal volvulus.

- 30-60 años de Radiological signs of a caecal volvulus:

1. Comma shaped: The shape of the distended gas filled ‘closed
edad. loop’ of colon often looks like a large comma (more rounded in

- 1-3% de shape than a sigmoid volvulus).

2. Haustra often visible: The haustral folds are often still clearly
obstrucciones visualised, even when the bowel is very distended.
de intestino 3. Collapse of the ascending, transverse and descending
colon: The colon distal to the obstruction (volvulus) is often
grueso. collapsed.
- Obstrucción de
asa cerrada,
torsión por
arriba de la
Figure 49: Diagrammatic representation of a caecal volvulus. The caecum has
válvula IC. twisted causing obstruction and distension of the caecum with gas.

HALLAZGOS RADIOLÓGICOS (RxA):

• Ciego dilatado en posición ectópica

(CSD).
• Ciego en forma de riñón, coma o “feto”.
iDESIGN
by HiSlide.io

• Poco aire en colon distal

• Segmento oclusivo con haustras
visualizables
 distended large bowel in the centre of B the abdomen 39
– Bowel with haustra seen within. T
caecal volvulus (obstruction) is collapsed. The right radiograph shows the caecal

Oclusión del colon:

Caecal volvulus example 1
Vólvulo cecal
Caecal volvulus example 2

B – Bowel 39

Caecal volvulus example 1

Figure 52: Two identical abdominal radiographs showing a caecal volvulus. There is a rounded comma‐shaped loop of
distended large bowel in the centre of the abdomen with haustra seen within. The remainder of the colon distal to the
caecal volvulus (obstruction) is collapsed. The right radiograph shows the caecal volvulus marked in red.
B – Bowel 39

Caecal volvulus example 2

Caecal volvulus example 1

Figure 52: Two identical abdominal radiographs showing a caecal volvulus. Figure
There53:
is Two identicalcomma‐shaped
a rounded abdominal radiographs
loop ofshowing a caecal volvulus. Ther
distended large bowel in the centre of the abdomen with haustra seen within. distended
The large bowel of
remainder in the
thecentre
colonof the abdomen
distal to the with a few haustra seen wi
iDESIGN
caecal volvulus
to the caecal volvulus (obstruction) is collapsed. The right radiograph shows the
(obstruction) is collapsed. The right radiograph shows the caecal volvulus marked in red.
by HiSlide.io

B
Caecal volvulus example 2
 B
Dilatación intestinal del colon: Coprostasis
Note: Constipation is usually a clinical diagnosis without the need for any imaging tests. There is little
evidence correlating abdominal X‐ray findings with constipation. The only exception is in elderly patients
where an abdominal X‐ray may be useful to show faecal impaction (see page 49).
Alto volumen de
materia fecal,
Example of faecal loading
clínicamente de
consistencia sólida.

La constipación es un
diagnóstico clínico que
no requiere estudios
de imagen.

CAUSAS:
• Constipación
crónica

HALLAZGOS
RADIOLÓGICOS (RxA):
• Material fecal sólida:
Aspecto moteado,
masas redondas
dentro del colon.
iDESIGN
• La heces
by HiSlide.io
tienen una Figure 66: Two identical abdominal radiographs showing faecal loading. There is faecal material throughout the large
textura bowel in keeping with faecal loading. Please note this is not the same as constipation which is a clinical diagnosis. The
right radiograph shows the faecal material marked in brown. (You can also see sterilisation clips in the pelvis.)
“granular” (burbujas
de aire en la materia
fecal). 

Dilatación intestinal del colon: Coprostasis
Alto volumen de
materia fecal,
clínicamente de
consistencia sólida.

La constipación es un
diagnóstico clínico que
no requiere estudios
de imagen.

CAUSAS:
• Constipación
crónica

HALLAZGOS
RADIOLÓGICOS (RxA):
• Material fecal sólida:
Aspecto moteado,
masas redondas
dentro del colon.
iDESIGN
• La heces
by HiSlide.io
tienen una
textura
“granular” (burbujas
de aire en la materia
fecal). 

Dilatación intestinal del colon: Impactación fecal
Example of faecal impaction

Heces sólidas,
inmóviles que se
depositan en el recto
resultado de la
constipación crónica.

Factores de riesgo:
Pacientes inmóviles o
institucionalizados.

HALLAZGOS
RADIOLÓGICOS (RxA):
• Material fecal sólida
con extensión Figure 67: Two identical abdominal radiographs showing faecal impaction. There is a huge volume of faecal material
extending from the pelvis to the left upper quadrant in keeping with a huge faecal impaction causing massive distension
proximal - Fecaloma of the rectum. The right radiograph shows the faecal material marked in brown.

• Complicación:
Colitis estercoral -
iDESIGN
Fecaloma impactado
by HiSlide.io

que puede causar

isquemia de la
pared.
Dilatación intestinal del colon: MEGACOLON

MEGACOLON

Megacolon agudo Megacolon crónico Megacolon tóxico

(Sx. de Ogilvie) (Sx. de Hirschprung)

Pseudo-obstrucción Ausencia congénita de ganglios Colitis tóxica no obstructiva

aguda del colon. mioentérticos (neuronales) en como complicación de
Aperistasis colónica. porciones distales del colon enfermedades inflamatorias
o infecciosas intestinales

iDESIGN
by HiSlide.io
Dilatación intestinal del IG: Pseudo-obstrucción aguda
del colon (Sx. Ogilvie)

- Usualmente en ancianos o
pacientes encamados de manera
crónica.
- Pérdida de la peristalsis con
dilatación masiva del colon.
- Distensión abdominal
pronunciada y RsIs hiperactivos o
normales.
- Causa: ¿Desequilibrio del SNA?

Asociaciones
• Medicamentos anticolinérgicos
(antidepresivos, fenotiazinas,
antiparkinsonianos, opiáceos)
• Enfermos críticos
• Desequilibrio electrolítico
• Cirugía reciente
HALLAZGOS (RxA):
• Dilatación
iDESIGNdel colon >6cm
by HiSlide.io

• Ciego >9-10cm
• NO HAY PRESENCIA DE
LESIÓN OBSTRUCTIVA
 CMC: Causa más común
Dilatación intestinal del IG: Megacolon tóxico

- Toxemia sistémica.
- Dilatación extensa de la totalidad o
porción focal del colon.
- Intestino grueso atónico.
- Riesgo extremo de perforación
intestinal: 20% de mortalidad

CAUSAS:
• CUCI (CMC)
• Colitis pseudomembranosa
• Isquemia, otras infecciones, etc.
HALLAZGOS RADIOLÓGICOS (RxA):

• Dilatación del colon con

borramiento de haustras
• Dilatación del colon transverso
>6cm, ciego >9-10cm*
• Probable:
iDESIGNDilatación del colon
>5cm con mucosa anormal.
by HiSlide.io

• TAC: Pared del colon delgada e

irregular.


*Large-Bowel Obstruction in the Adult: Classic Radiographic and CT Findings, Etiology, and Mimics. Tracy Jaffe-William Thompson - Radiology - 2015
Oclusión intestinal: Evaluación mediante medio de contraste
0 hrs

5 hrs

11 hrs 16 hrs
iDESIGN Colon por enema - Vólvulo sigmoideo
Tránsito intestinal - Adhesiones en íleon proximal
by HiSlide.io

(signo del punta de lápiz o pico de ave)

por antecedente de colecistectomía.
Tiempo normal de tránsito intestinal (duodeno-vávula
íleo cecal): 30 a 120 mins (Rx cada 15 a 30 mins)
Practical fluoroscopy of the GI and GU tracts. Levine M, et al. - Cambridge University Press - 2012
Crash Course: Imaging. Barry Kelly-Ian Bickle - Mosby - 2007

0-4 pt. Riesgo bajo: 7.7% prob.

IMAGENOLOGÍA 5-7 pt. Riesgo intermedio: 57.6%. prob.

Hospitalización y solicitar laboratorios y

ABDOMEN AGUDO -
estudios de imagen.

8-10 pt. Riesgo alto: 90.6% prob.

Apendicitis
Cirugía de inmediato.
 Abdomen agudo: Apendicitis aguda
MÉTODOS DE ELECCIÓN de
IMAGEN:

• Pediátrico: ULTRASONIDO
• Apéndice no compresible
>6mm diámetro
anteroposterior
• Colección periapendicular
• Adenitis mesentérica
• Vascularidad ↑ (doppler)
• Se requiere de experiencia
del operador para
aumentar su poder Colección
periapendicular
diagnóstico.

Apendicolito

iDESIGN
Apéndice NL
by HiSlide.io
Abdomen agudo: Apendicitis aguda
MÉTODOS DE ELECCIÓN
de IMAGEN:

• Adultos: TAC -
Sensibilidad (94-98%),
especificidad (>97%)
• Apéndice >6-7mm
• Pared apendicular y/o
ciego engrosada
• Inflamación
(deshilachamiento) de
grasa peri-apendicular
• Líquido libre
• Apendicolito
• Adenitis mesentérica Absceso: *

*
Apéndice NL

iDESIGN
by HiSlide.io
 LGP: Línea grasa
Abdomen agudo: Apendicitis aguda properitoneal

Radiografía de abdomen:
• Especificidad 40% aprox.
• Sensibilidad reportada hasta de 0%
• Útil para descartar perforación u
obstrucción/íleo intestinal

HALLAZGOS (uno, múltiples o

ninguno)
• Apendicolito (5-14%)
• Íleo reflejo o localizado (asa
centinela) en FID (51-81%)
• Patrón de oclusión intestinal ID (40%
de apendicitis perforadas)
• Aumento de la radiopacidad de CID
(borramiento de la articulación
sacroíliaca derecha) (12-33%) psoas izq
• Aire libre (perforación), pueden solo
ser microburbujas
• Desplazamiento del gas cecal y
engrosamiento de la pared (4-5%)
• Engrosamiento del espacio de la
LGP/asas
iDESIGN o borramiento de la LGP
• Borramiento
by HiSlide.io
de la línea del psoas
derecho.
• Columna toracolumbar con “curva
antiálgica”
• Signo de “carga fecal en el ciego”
 LGP: Línea grasa
Abdomen agudo: Apendicitis aguda properitoneal

Radiografía de abdomen:
• No específica en 68%
• Sensibilidad reportada hasta de 0%
• Útil para descartar perforación u
obstrucción intestinal
??
HALLAZGOS (uno, múltiples o
ninguno)
• Apendicolito (5-14%)
• Íleo reflejo o localizado (asa
centinela) en FID (51-81%)
• Patrón de oclusión intestinal ID (40%
de apendicitis perforadas)
• Aumento de la radiopacidad de CID
(borramiento de la articulación
sacroíliaca derecha) (12-33%)
• Aire libre (perforación), pueden solo
ser microburbujas
• Desplazamiento del gas cecal y
engrosamiento de la pared (4-5%)
• Engrosamiento del espacio de la
LGP/asas
iDESIGN o borramiento de la LGP
• Borramiento
by HiSlide.io
de la línea del psoas
derecho.
• Columna toracolumbar con “curva
antiálgica”
• Signo de “carga fecal en el ciego”
 Gracias

Dudas o comentarios: radestudiantes@gmail.com

Referencias principales:
• Learning radiology: recognizing the basics, William Herring, 4a Ed. - Elsevier - 2020
• Abdominal X-rays For Medical Students, Christopher Clarke-Anthony Dux - John Wiley & Sons Inc. - 2015