Abdome e Pelve

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26/02/2016 
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Abdome e Pelve 
Líquido na cavidade peritoneal 
• Ascite: líquido seroso; geralmente por cirrose, 
hipoproteinemia ou insuficiência cardíaca 
congestiva. 
• Ascite exsudativa: processos inflamatórios, 
como abcessos, pancreatite, peritonite ou 
perfuração intestinal. 
• Hemoperitônio: traumatismo, cirurgia ou 
hemorragia espontânea 
• Ascite neoplásica: tumores intraperitoneais 
• Urina, bile e quilo 
Ascite 
• Necessário ao menos 500 ml de líquido; 
1) Aumento difuso na densidade do abdome (abdome 
cinza); 
2) Bordas indistintas do fígado, baço e músculos psoas; 
3) Deslocamento medial do cólon cheio de gás, do fígado e 
do baço a partir da opacidade linear da faixa no flanco 
pró-peritoneal; 
4) Abaulamento dos flancos; 
5) Separação aumentada das alças do intestino delgado 
cheio de gás; 
6) Aspecto de “orelhas de cachorro” de densidades 
simétricas na pelve, produzido pelo líquido derramado da 
escavação retouterina em ambos os lados da bexiga. 
A simple case of ascites. The 
loops of small bowel seen here 
are congregated within the 
middle of the abdomen as the 
fluid within the peritoneal cavity 
pushes them into the most 
dependant position: the centre. 
Large-volume ascites (asterisk) and a small left basal pleural 
effusion in CT image (arrow). 
Ascites. Generalised 
‘greying’ of the abdominal 
film in AXR with several 
centralised bowel loops. 
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Ascites: Abdominal US showing large-volume ascites (asterisk). 
Pseudomixoma peritoneal 
“jelly belly” 
• Ascite gelatinosa por disseminação 
intraperitoneal de células produtoras de 
mucina, devido ruptura da mucocele 
apendicular ou adenocarcinoma mucinoso do 
ovário, cólon ou reto. 
• Calcificações pontilhadas ou semelhantes a 
anéis espalhadas por toda a cavidade 
peritoneal. 
• Tipicamente, o líquido mucinoso é loculado e 
provoca um efeito de massa sobreo fígado e o 
intestino. 
Pseudomyxoma Peritonei. A CT scan of a 60-year-old man with intraperitoneal 
spread of mucinous adenocarcinoma of the colon shows loculations (arrowheads) of fluid 
indenting the surface of the liver (L), giving evidence of mass effect. The attenuation of the 
fluid measured 32 H, indicating exudative ascites. 
Pneumoperitônio 
• Sinal de perfuração intestinal (causas: úlcera duodenal 
ou gástrica), traumatismo, cirurgia, laparoscopia 
recentes e infecções peritoneais. 
• Pequenas quantidades de ar são mostradas abaixo das 
cúpulas diafragmáticas. (Ortostatismo). Para decúbito 
dorsal: 
1) Presença de gás em ambos os lados da parede 
intestinal (sinal de Rigler); 
2) Ligamento falciforme delineado por gás; 
3) Cavidade peritoneal delineada por gás (sinal de 
‘football’); 
4) Gás extralumial localizado, triangular ou linear no 
quadrante superior direito. 
The football sign is seen in cases of 
massive pneumoperitoneum, where 
the abdominal cavity is outlined by 
gas from a perforated viscus. The 
median umbilical ligament and 
falciform ligament are sometimes 
included in the description of this 
sign, as representing the sutures. 
 
Which football is used as the model ball varies according to the 
nationality of the author. Rugby, Australian rules and American 
football all have balls that fit the bill. Soccer is clearly not 
appropriate. 
The Rigler's sign, 
also known as 
the double wall 
sign, is seen on an 
x-ray of the 
abdomen when air 
is present on both 
sides of the 
intestine, i.e. 
when there is air 
on both the 
luminal and 
peritoneal side of 
the bowel wall. 
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Pneumoperitoneum: Conventional Radiograph. A. Supine abdominal radiograph of 
a patient with a perforated gastric ulcer demonstrates visualization of both sides of the bowel wall (Rigler 
sign) (arrowheads), free air outlining the falciform ligament (arrow), free air outlining the edge of the 
liver (curved arrow), and free air outlining the pericolic gutters (asterisk). B. Erect chest radiograph of a 
different patient shows a crescent-shaped band of gas (arrow) between the liver (L) and the diaphragm. 
Pneumoperitoneum was caused by a perforated sigmoid colon diverticulitis. 
Pneumoperitoneum: 
CT. A collection of air 
(arrow) is seen within 
the peritoneal space 
between the liver (L) 
and the diaphragm 
(arrowhead). This is a 
prime area to search 
to detect small 
amounts of free 
intraperitoneal air on 
CT. This patient had a 
torn jejunum as a 
result of trauma from 
a motor vehicle 
collision. 
Free air under the 
diaphragm (asterisk). Free intra-abdominal air 
(Supine AXR). Note Rigler’s 
sign (arrowheads). 
Pneumoperitoneum. Left lateral decubitus film. Note the presence 
of free air (arrow) between the lateral margin of the liver (L) and the rib cage. Pneumoperitoneum. Free air anterior to the liver (asterisk). 
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Peritoneal air (Supine AXR). Extensive 
intraperitoneal (asterisk) and 
retroperitoneal free air following ERCP. 
Note a biliary stent in situ (black 
arrowhead). The inferior margin of the 
liver is outlined in the intraperitoneal 
compartment (white arrowhead), with 
the kidneys (arrows) and psoas 
muscles (curved arrow) outlined in the 
retroperitoneal compartment. 
Pneumoretroperitoneum. Free air within the retroperitoneum(arrows). 
Calcificações Vasculares 
• Calcificações mais comum em aorta e vasos 
ilíacos de idosos; aneurismas calcificados 
semelhantes a anéis acometem mais comumente 
a aa. esplênica ou renal. 
 
• Tipicamente são vistas como linhas paralelas de 
calcificação correndo ao longo do curso das 
estruturas arteriais. 
• Se o paralelismo é perdido, deve-se suspeitar de 
aneurisma. 
 
• A artéria esplênica frequentemente é vista como 
um vaso com calcificação contorcida no 
quadrante superior esquerdo. 
Abdominal Aortic 
Aneurysm. Conventional 
radiograph demonstrates an 
aneurysm of the abdominal 
aorta evidenced by wide 
separation of calcifications 
in the aortic wall 
(arrowheads). Calcification 
in the wall overlying the 
spine may be difficult to 
visualize. A radiograph 
taken with the patient in 
left posterior oblique 
position will project the 
aorta away from the spine 
and make visualization of 
aortic wall calcifications 
easier. 
Splenic artery calcification (arrows). Note the incidental pacemaker 
lead (arrowhead). Vascular calcification (arrowheads) and seminal vesical (arrows) 
calcification. 
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Calcification of multiple injection sites (arrow). Note the sterilisation clips 
within the pelvis 
Flebólitos 
• Trombos calcificados (benigno) em veias. São 
redondos ou ovais de até 5 mm, com 
radiotransparência central. 
• Geralmente ocorrem na pelve e podem 
simular cálculo uretérico. 
 
 
Pelvic phleboliths are 
normally identified on 
X-ray imaging for any 
unrelated medical 
indications to find any 
suspected 
complication, such as 
ureteric stone. Since 
these stones appear 
small in size, almost 
like a dot of 
calcification, on the 
image it is difficult to 
detect if it is in the 
urinary tract or the 
vein. 
Hematoma 
• Podem deixar uma área residual de 
calcificação. 
• Hematomas pós-injeção intramuscular podem 
calcificar e podem projetar-se sobre a pelve 
ou abdome inferior. Geralmente são bem 
definidos, circulares ou ovais. 
Multiple calcified phleboliths (arrowheads). 
Linfonodos calcificados 
(Linfonodos mesentéricos) 
• Mais comum em doenças granulomatosas; 
calcificações mosqueadas entre 10 e 15 mm. 
Mais comumente em lnn. mesentéricos. 
 
• Linfonodos pós-ínflamatórios podem calcificar. 
• Linfonodos calcificados não são evidência de 
doença ativa nos linfonodos. 
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Large calcified mesenteric node (arrowhead). 
Cálculos biliares e vesícula biliar• Cerca de 15% dos cálculos possuem Ca2+ 
suficiente para serem radiopacos. As 
calcificações na parede da vesícula biliar 
(vesícula biliar em porcelana) apresentam 
uma configuração oval e semelhante a placas, 
amoldando-se ao tamanha e forma da 
vesícula. O leite de bile de Ca2+ biliar é uma 
suspensão de cristais dentro da vesícula. 
Porcelain Gallbladder. Cone-
down radiograph of the right 
upper quadrant of the 
abdomen demonstrates 
calcification in the wall of the 
gallbladder (arrow). This 
finding is indicative of 
chronic obstruction of the 
cystic duct, chronic 
gallbladder inflammation, 
and an increased risk of 
gallbladder carcinoma. 
A porcelain gallbladder refers to extensive calcium 
encrustation of the gallbladder wall. The term 
porcelain gallbladder has been used to emphasize 
the blue discoloration and brittle consistency of the 
gallbladder wall at surgery. 
 
C+ portal venous phase 
Milk of Calcium Bile. Conventional radiograph 
(above) shows milky substance in gallbladder 
(white arrow) with multiple gallstones floating on 
top (black arrow). The CT scan (below) 
demonstrates the same milk of calcium in the 
dependent part of the gallbladder (white 
arrow) while the stones occupy the upper part 
(yellow arrow). . 
Imaging Findings 
• Dense opacification of the 
gallbladder lumen seen on CT or 
conventional radiography 
• Always associated with 
cholelithiasis or 
choledocholithiasis 
• May form fluid-fluid level in 
conventional radiographs 
exposed with horizontal beam 
Multiple small gallstones 
(arrow). 
Solitary gallstone (arrow). Note the posterior acoustic shadowing. 
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Gallstone within the neck of gallbladder (arrow). 
Calcified gallstones. Axial T2 MRI 
shows mutlpile hypointense foci 
seen within the gallbladder 
(arrow) indicating the stones. 
Large impacted gallstone within the distal 
common bile duct (arrowhead). 
 
Gallstone impacted within the distal common 
bile duct (arrowhead) 
on ERCP. 
 
 
Endoscopic retrograde 
cholangiopancreatography (ERCP): a 
combined endoscopic/fluoroscopic procedure 
outlines the biliary tree 
with similar effect to an MRCP, but it has the 
advantage of allowing 
therapeutic procedures such as 
sphincterotomy with stone removal and 
biliary stent placement. 
Cálculos urinários 
• 85% são visíveis em radiografias; 
• De pontilhados até alguns cm; posição mais 
posterior que cálculos biliares; 
• Mais comuns em áreas de estreitamento: 
junção uteropélvica, abertura pélvica e junção 
vesicoureteral. 
• Cálculos vesicais são solitários ou múltiplos e 
costumam ser laminados, podem ser de 
qualquer tamanho e geralmente estão 
próximos à linha mediana da pelve. 
Staghorn Calculus (coral calculus). Conventional radiograph 
reveals a large calculus occupying the collecting system of the 
left kidney and assuming its shape. Staghorn calculi (S) are 
usually composed 
of struvite and form in the presence of chronic urinary 
infection. 
Calcified tuberculous right 
psoas abscess (asterisk).Note 
the expansion 
and bowing of the psoas 
outline, with lateral 
displacement of the right 
kidney. 
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TB autonephrectomy. IVU 
demonstrates a densely 
calcified, 
non-enhancing, small right 
kidney. The appearances 
are characteristic 
of long-standing renal 
tuberculosis. 
Peripheral calcification in a right renal cyst (arrow). 
Hydatid disease of the left kidney. A large peripherally calcified cyst 
(asterisk), containing internal septations, is seen expanding the left kidney. 
Medullary sponge kidney. Hyperechoic medullary pyramids (arrows) 
seen in US. 
Nephrocalcinosis in 
medullary sponge kidney. 
Tomogram from an 
IVU series. Extensive 
stippled calcification can be 
seen within several 
medullary pyramids 
(arrows). 
Staghorn calculus 
within a 
hydronephrotic right 
kidney (arrow). Note 
the posterior acoustic 
shadowing typical of 
calculi in general. 
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Large bilateral staghorn calculi. 
Note that this is a ‘control’ film 
from an IVU series and not a 
postcontrast radiograph. 
Obstructed right kidney 
caused by a calculus just 
beyond the 
pelviureteric junction 
(arrow). 
Left renal tract obstruction, with a 
standing column of contrast, 
caused 
by a left vesicoureteric junction 
calculus (arrow). 
Obstructed left kidney. Renal tract CT 
shows the left kidney is 
hydronephrotic. The obstructing 
calculus is clearly identified, 
surrounded by a cuff of ureteric wall, 
within the proximal ureter 
(arrowhead). 
Bladder Calculi. Numerous calculi (arrows) in the bladder are evident on this 
conventional radiograph of the pelvis. The large prostate (P, between arrowheads), 
responsible forurinary stasis leading to stone formation, makes a mass impression on 
the layering stones. Also evident are atherosclerotic calcifications in the iliac arteries 
(curved arrows). 
Large bilobed bladder calculus (arrow). 
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Chronic large bladder calculus with concentric rings 
• Granulomas hepáticos e esplênicos: 
habitualmente múltiplos, pequenos e 
densos. Focos cicatrizados de tuberculose, 
histoplasmose ou outra doença 
granulomatosa. 
• Apendicólitos e enterólitos: concreções no 
interior da luz intestinal. Redondos ou ovais 
com lâminas concêntricas. Enterólitos são 
mais comuns no cólon, sendo cálcio 
depositado sobre material não digerível. 
• Glândulas suprarrenais calcificadas: 
hemorragia suprarrenal (recém-nascido), 
tuberculose e doença de Addison. 
Calcificação mosqueada, nas suprarrenais, 
em ambos os lados da primeira vértebra 
lombar. 
Adrenal Calcifications. Conventional radiograph of the abdomen in a 4-
year-old demonstrates calcification of both adrenal glands (arrows) 
resulting from bilateral adrenal hemorrhage as an infant. 
• Calcificação pancreática: pancreatite crônica 
induzida por álcool e à pancreatite 
hereditária. Causadas por cálculos 
pancreáticos; habitualmente grosseiras e de 
tamanho variável. 
• Cistos calcificados: rins, baço, fígado, 
apêndice e cavidade peritoneal. As 
calcificações na parede são curvilíneas ou 
em anel. 
• Calcificações do tecido mole: observadas 
em estados de hipercalcemia, calcinose 
idiopática e em hematomas antigos. A 
cisticercose produz calcificações 
características em “grão de arroz” nos 
músculos. 
• Conteúdo intestinal: objetos deglutidos 
• Calcificações peritoneais: nodulares ou 
semelhantes a lâminas, resultam 
(geralmente), de diálise peritoneal, 
peritonite anterior ou carcinomatose 
peritoneal. 
Pancreatic Calcifications. Coarse and punctate calcifications (arrow) extend 
upward across the left upper quadrant in this patient with chronic alcoholic 
pancreatitis. Calcifications in the pancreatic head (arrowhead) are obscured by 
the spine. 
Calcified Renal Cyst. Scout radiograph for an excretory urogram 
shows the rim calcification (arrow) characteristic of wall 
calcification in a renal cyst. 
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Tumoral Calcifications. 
Radiograph of the abdomen 
demonstrates cloudlike 
calcifications in the 
distribution of peritoneal 
recesses. These 
calcifications were caused 
by intraperitoneal spread of 
a papillary serous 
cystadenocarcinoma of the 
ovary. 
• Calcificação costocondral: calcificação 
das junções costocondrais em costelas 
inferiores podem projetar-se em parte 
da AXR. Tipicamente em homens, a 
calcificação é paralela à borda da 
cartilhagem, enquanto em mulheres é 
central. 
• Calcificação de mioma: miomas 
uterinos degenerados podem calcificar, 
resultando em um corpo calcificado 
redondo e lobulado, projetando-se 
sobre a pelve feminina. 
• Processos transversos de vértebras 
lombares: geralmente aparecem mais 
densos na AXR que os demais processostranversos, podendo serem confundidos 
com cálculos uretéricos, visto que os 
ureteres sobrepõe-se aos quatro 
processos tranversos inferiores. 
Costochondral calcification (asterisk) and splenic artery (arrow) 
calcification. Large calcified uterine fibroid (arrowhead). 
CASOS 
Caso 01 
 
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What's the most likely diagnosis? 
A. Small bowel obstruction 
B. Ascites 
C. Mesenteric ischemia 
D. Fibroids 
 
Final diagnosis 
• B. Ascites, supine abdomen. Supine view of 
the abdomen shows central displacement of 
the loops of bowel, 
a uniform grayness to the abdomen, loss of 
any definition of the edge of the spleen or liver 
and displacement of the bowel loops out of 
the pelvis, all suggestive of ascites. 
Caso 02 
• 27 year-old with right lower quadrant pain 
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What is the most likely diagnosis? 
A. Crohn Disease 
B. Ureteral Calculus 
C. Tuberculosis 
D. Appendicolith 
E. Carcinoid 
Appendicolith with Appendicitis. Upper: Frontal close-up of right lower quadrant show a 
laminated stone in the region of the appendix consistent with a calcification that has formed 
in a viscous (white arrow). 
Lower: Coronal reconstruction with close-up of right lower quadrant shows a dilated 
appendix with a thickened wall and surrounding infiltration of the fate (yellow arrow) 
containing an appendicolith (red arrow). 
Caso 03 
 
What's the most likely diagnosis? 
• A. Pancreatitis 
• B. Gallstones 
• C. Adrenal adenoma 
• D. Renal vein thrombosis 
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Gas in Gallstones 
• CT of the abdomen demonstrates two 
radiolucencies in gallbladder (top image) and 
an additional lucency in the gallbladder on the 
lower image 
Caso 04 
• 59 year-old male with change in bowel habits 
 
What's the most likely diagnosis? 
A. Carcinoma of the colon 
B. Bilateral renal calculi 
C. Cirrhosis 
D. Myelolipomas 
E. Bilateral adrenal calcifications 
Bilateral adrenal calcifications. A coronal 
reformatted (above) and axial CT scan 
(below) of the upper abdomen show 
bilateral calcifications (red and white circles) 
in both adrenal glands. The adrenal glands 
are not enlarged. These calcifications wer 
found incidentally and are most likely due to 
previous adrenal hemorrhage. The liver (L), 
spleen (S) and kidneys (K) are labeled. 
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Caso 05 
• 71 year-old male with right lower quadrant 
pain 
What is the most likely diagnosis? 
A. Cirrhosis 
B. Liver lacerations 
C. Metastases from colon carcinoma 
D. Budd-Chiari syndrome 
E. Pseudomyxoma peritonei 
Pseudomyxoma peritonei. Axial 
contrast-enhanced CT images of the 
abdomen and pelvis demonstrate 
lobulated, low-attenuation soft tissue 
masses scalloping the border of the liver 
(left) and a mass in the right lower 
quadrant representing the primary 
appendiceal tumor. 
Caso 06 
• A 52-year-old man, active smoker with chronic 
obstructive lung disease, was admitted with 
pneumonia and influenza. Treated in intensive 
care unit with mechanical ventilation for nine 
days. 
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Routine chest radiograph taken 7 
days after extubation 
Routine chest radiograph taken 7 days 
after extubation 
What is the most likely diagnosis? 
 
Final Diagnosis 
• Pneumoperitoneum secondary to mechanical 
ventilation 
Caso 07 
• A 70 year old man presented with a history of 
abdominal pain and a tender mass on 
examination. 
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What is the most likely diagnosis? 
 
Aortic aneurysm 
• AXR: 
– Calcification of the aortic wall is a common finding in atherosclerosis. 
– Loss of parallelism of the aortic wall suggests aneurysmal dilatation. 
– Rarely vertebral body erosions may be seen with long-standing 
aneurysms. 
– In the acute scenario, loss of the psoas outline is associated with 
retroperitoneal rupture. 
• CECT: 
– CT is used as part of elective surgical planning in determining the 
anatomy of the AAA, particularly in relation to visceral vessels such as 
the renal arteries. 
– Retroperitoneal fibrosis associated with an AAA may be seen as a 
surrounding soft tissue mass. 
– In the acute setting, CT is the investigation of choice, often 
demonstrating the precise site of rupture and is very sensitive to 
intraperitoneal and retroperitoneal haemorrhage. 
– Rarer complications such as aorto-caval or aorto-enteric fistulae, and 
occlusion, can be detected. 
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Imaging Findings 
• Ruptured infrarenal abdominal aortic aneurysm 
 
• Plain abdominal radiograph shows calcification in the right lateral wall of 
the aneurysm (black arrowhead), whilst the right psoas margin (black 
arrow) is preserved the left psoas margin is obliterated. Calcification in the 
mesenteric lymph nodes is also noted (white arrow) 
 
• Axial CT reveals a large abdominal aortic aneurysm with an intraluminal 
thrombus (arrowhead). Detection of the soft tissue mass indicates a 
haematoma whereas extravasation of contrast material (arrow) shows 
active leakage. 
 
• CT abdomen (coronal reconstruction) demonstrates the aneurysm with 
active leakage of contrast material. 
 
• CT abdomen (sagittal reconstruction) also shows the aneurysm with a 
large intraluminal thrombus on the anterior wall. 
Aortic aneurysm. Calcification in the left lateral 
wall of the aneurysm (arrowheads). 
 
Ruptured aortic aneurysm. The arrowheads 
denote the breach in the wall of 
the aneurysm (A), with extensive associated 
retroperitoneal haemorrhage (H). 
Referências 
• BRAMBS, Hans-Juergen. Gastrointestinal Imaging (Direct Diagnosis in Radiology). Thieme, 2012. 
• BRANT, William E.; HELMS, Clyde A. (Ed.). Fundamentals of diagnostic radiology. Lippincott 
Williams & Wilkins, 2012. 
• JUHL, John H.; CRUMMY, Andew B.; KUHLMAN, Janet E. Interpretação radiológica. Interpretação 
radiológica, 2000. 
• FAIZ, Omar; BLACKBURN, Simon; MOFFAT, David. Anatomy at a Glance. John Wiley & Sons, 2011. 
• WEBB, Wayne Richard; BRANT, William E.; MAJOR, Nancy M. Fundamentals of body CT. Elsevier 
Health Sciences, 2006. 
 
• GAILLARD, F. Appendicolith; Radiopaedia. org. 2014. 
• William Herring. LEARNING RADIOLOGY, 2014 
 
• Dr Omar Bashir, Mr M Duxbury, Mr N Keeling. Department of Surgery West Suffolk Hospitals NHS 
Trust Bury St Edmunds UK (2005, Dec 13). Ruptured Abdominal Aortic aneurysm, {Online}. URL: 
http://www.eurorad.org/case.php?id=3696 DOI: 10.1594/EURORAD/CASE.3696 
• Nowak BJ, Kazlas L, Wasilewski SP (2013, May 19). Nonsurgical pneumoperitoneum, {Online}. URL: 
http://www.eurorad.org/case.php?id=10960 DOI: 10.1594/EURORAD/CASE.10960