Abdo: non-obstetric/traumatic abdo pain in pregnancy

Playlist contributed by Daniel Teh
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Key Points:

  • US first line test
  • MRI is safe in pregnancy
  • Contrast is not usually required
  • DWI is important
  • Retroperitoneal pitfalls: Ureter and ovarian vein
  • No appendix seen + no oedema / restricted diffusion = likely no appendicitis

Acute Appendicitis on MRI: (DWI and F/S images are key)

  • Diameter > 7 mm
  • Wall thickness > 2 mm
  • Luminal fluid
  • Adjacent oedema / fluid
  • Phlegmon
  • (Appendicoliths)

Bowel obstruction: US can be used to look for fluid filled bowel loops. but limited in finding transition point etc.

Cases 1-4: Identify normal appendix. If unable to, find inflammatory changes

  • 1: Retrocaecal appendix
  • 2: Subcaecal appendix
  • 3: Unable to find appendix, no inflammatory change
  • 4: Unable to find appendix, no inflammatory change

Cases 5-10: Acute appendicitis

  • 5: unable to find appendix, inflammatory changes seen. Confirmed on surgery.
  • 6: Dilated appendix with inflammatory changes seen.
  • 7: Acute appendicitis with local perforation
  • 8: Acute appendicitis with phlegmon
  • 9: Acute appendicitis with collection; subsequent abscess
  • 10: Acute appendicitis with perforation into right perinephric space

Cases 11-12: Bowel Obstruction

  • 11: Closed loop small bowel obstruction from adhesions?
  • 12: Sigmoid volvulus

Cases 13-20: Gynaecological Causes

  • 13-14: Carneous Degeneration of Fibroid
  • 15-17: Ruptured ectopic / heterotopic pregnancy (heterotopic also has normal preg)
  • 18: Ovarian torsion
  • 19: Ovarian dermoid cyst
  • 20: Ovarian hyperstimulation

Cases 21-22: Urologic causes

  • 20: Physiologic hydronephrosis compressing against psoas. If transition well above or below, think of stones more.
  • 21: Pyelonephritis: Use DWI to look for areas of signal changes more easily.