CT abdomen and pelvis

■ General indications:
 Assessment of vague abdominal symptoms (pain,
colics,distenstion,...)
 Varifecation of a lesion discovered by other
diagnostic modalities as US, barium,IVP,…
 Staging of extraabdominal malignancies
(breast cancer, bronchogenic ca.,...)
● Assessment of patients with lymphoma
● Assessment of abdominal masses

■ Specific indications:
Assessment of certian intraabdominal organ (liver, spleen,
pancreas, kidneys, suprarenal, aorta, IVC, pelvic organs,…)
Examples:
 Diagnosis and staging of intraabdominal malignancies
 Blunt or penetrating abdominal trauma
 Diagnosis of intraabdoiminal vascular lesions (aortic
aneurysm, IVC thrombosis,...) (CT angiography)
 Diagnosis of pelvic lesions: inflammatory or neoplastic

Technique of examination
Patient’s preparation: For adequate examination of the
abdomen and pelvis by CT, sometimes we need to opacity the
gastrointestinal tract by an orally administrated contrast material
[gastrographin 38%] .. The contrast material is diluted by water to
a concentration of 2-4% and taken orally by the patient at
intervals to opacity the Gl tract from the stomach to the anus.
 The amount of contrast material and the intervals of
intake are subject to great variations
 Oral contrast is not usually given in the diagnosis of some
emergency cases such as acute abdominal trauma,
acute renal colic,... It is also not given for dehydrated
children
 Oral contrast may be given for patients suspected to have
 acute viscus perforation
 acute intestinal obstrection
Patients indicated for IV contrast injection are injected with 4-5
ampules (20 ml each) as a bolus just before the start of
examination
■ Almost all patients examined by CT for abdominal or pelvic
lesions are indicated for contrast injection except some limited
circumstances [e.g acute renal colic,..]
■ Fasting for 4-6 hours prior to contrast injection is necessary.

NB Non contrast scans should be obtained before contrast

Injection when examining specific organs such as the liver,
kidney and urinary bladder.

■ CT sections are usually obtained at 10mm intervals for general

indications and most of the specific indications. 5mm sections
are obtained when assessing small organs such as the
pancreas, suprarenal glands and urinary bladder or pelvic
organs in general.

■ Using the multidetector CT [MDCT] facilities we may obtain

reconstructed images in the sagittal and coronal planes which
are very helpful in the diagnosis specially in cases of:
 Diaphragmatic lesions
 Thoracic lesions extending into the abdomen and vice
versa
 Renal and suprarenal masses
 Vascular lesions specially the aortic and iliac vessels
 Pelviabdominal masses
 Abdominopelvic lymphadenopathy
 Peritoneal and mesenteric pathology

■ MDCT angiography is also helpful in the diagnosis of vascular

lesions such as :
 Aortic lesions: arteriosclerosis ,aneurysms, dissection,..
 Renal arteries: renal artery stenosis, donors of renal
transplantation
 Mesenteric vessels: abdominal angina, vascular occlusions,
aneurysms,..
 CT portography for portal venous abnormalities: portal
hypertension, esophageal variccs, portal vein
thrombosis,..
■ Triphasic study of the liver
 Is now the accurate way to detect and diagnose
hepatic lesions
 Using the MDCT and automatic pumb injector for
contrast injection [to avoid human error]
 The patient lies supine on the CT machine
 Frontal scanogram is performed
 Precontrast scans for the hepatic area are obtained
[from the diaphragm to the iliac crest]
 Start contrast injection by the pumb, the rate of injection
is 2-4 mL/ sec.
 The injected contrast- material will reach the hepatic
artery in about 20 sec. from the start time of injection
then we scan the liver [arterial phase]
 The contrast material will reach the portal vein after
about 50 sec. from the start of injection then we scan te
liver again [portal phase]
 Then we wait for about 3 minutes and scan the liver
again [delayed phase]
 The triphasic study is now completed
- Arterial phase
- Portal phase (venous phase)
- Delayed phase

Normal Anatomy

■ Liver [Rt hypochondrium]

 Average hepatic size 15 cm cranio candal diameter i.e 15 CT

sections provided the section thickeness is 1 cm. Allow ± 1
section for respiration. The use of MDCT can avoid this
misregestration as the patient can hold his breath during the
scanning period for each phase
 The normal density of the liver is homogenous with no focal
lesions.
 Normal intra hepatic bile ducts are not usually seen on CT
scans
 Hepatic CT density is almost similar to that of the spleen after
contrast injection
 Hepatic vessels appear as tubular enhancing structures after
contrast injection
 Hepatic veins are seen in the higher sections entring the IVC
while lying in its fossa on the viseral surface of the liver
 Hepatic artery branches are not seen on regular CT scan but
can be seen in the arterial phase of the triphasic study
 The rest of vascular structures seen through out the liver
parenchyma are portal venous radicles
 The porta hepatis represents the hilum of the liver. It contains
fat, lymph nodes, CBD, hepatic artery and portal vein. All
these structures are not usually seen on regular CT scan
except for fat and portal vein.

■ Liver segments:
 Left lobe: Medial segment (MS) , lateral segment (LS)
 Rt lobe : Anteriorsegment (AS), posterior segment (PS)
Caudate lobe is present between the porta hepatis and IVC

■ Spleen [left hypochondriam]

 Average size is 12 cm cranio caudal diamiter
 More than 12 cm= splenomegaly... less than 12 cm = normal
spleen
 Density is homogenous.. no focal lesion

■ Pancreas [Retro peritonium]

 Lies obliquely in the upper abdomen, head lower than body
and tail
 Density is homogenous less than that of the liver and spleen
 Pancreatic size: head (3cm), body (2.5cm), tail(2cm)in normal
adults. Atrophic changes of the pancreas are normally seen
in old age where the pancreas is small in size and shows fatty
infiltration of its parenchyma
 The normal common pancreatic duct is not seen on regular
CT
 Splenic vein lies along the posterior border of the pancreas.
The splenic vein joins the SMV to form the portal vein in the
upper CT sections.
 The normal anatomic landmark of the pancreatic head is the
SMA and SMV
 The pancreatic head lies within the concavity of the
doudenal loop, if the loop is not adequately opacified by oral
grastrographin, it will not be distinguished from the pancreatic
head→ impression of enlarged head of pancreas.
■ Suprarenal glands[ Retroperitonium]
 Best seen in obease patients with large amount of retro
peritoneal fat
 It is sometimes difficult to identify the suprarenal glands in
children and thin patients by CT
 The suprarenal gland lies at the upper pole of each
kidney
 The left suprarenal gland is easily identified compared to
the Rt one, because the Rt suprarenal gland is closely
related to the Rt hepatic lobe
 The suprarenal gland has an inverted Y configuration
with main stem, medial limb and lateral limb

■ Kidneys [Retro peritonium]

 CT evaluation of the kidneys should include pre and post
contrast scans
 Renal size is appeoximately 12 cm x 6cm x 3cm [length,
width, thickness]
 The renal hilum contains fat, renal pelvis, artery and vein.
The left renal vein is a constant finding. It crosses the
midline in front or behind (retroaortic) the aorta to join
the IVC
 The renal outline is smooth and regular, apart from fetal
tobulations (normal variant)
 The Gerotta fascia surrounds the kidney and separates
the perirenal from the pararenal spaces. The fascia itself
is not usually seen on CT unless thickened

■ Urinary bladder [pelvis]

 CT evaluation of urinary bladder lesions should include
pre and post contrast scans
 Urinary bladder usually shows contrast fluid level [urine is
above the contrast material]
 Posterior to the urinary bladder the seminal vesicles and
rectum are seen in males, the uterine cervix and rectum
are seen in the females
 The ovaries are better assessed by ultrasound or MRI
 The ischiorectal fossa is a triangular shaped fat
containing area on either side of the anal canal
■ Abdominal muscles:
 The psoas muscle lies on either side of the vertebral
bodies
 In the pelvis the psoas blends with the iliacus muscle
which lies on the inner aspect of the iliac bone to form
the iliopsoas muscle
 The rectus abdominis muscles form the anterior
abdominal wall on either side of the midline
1- Spleen
2- Liver
3- Stomach
4-Hepatic veins
5 -Suprarenal glands
6- Upper pole of the kidney
7- Tail of pancreas
8- Body of pancreas
9- Head of pancreas
10- kidney
11- Gall bladder
12- urinary bladder
13- uterine cervix (female)
14- seminal vesicles (male)
15- Rectum
16- Ureter
17- psoas muscle
18- Rectus abdomins muscle
19 -Gluteus maximus muscle
20- Intestine
LS = lateral segment MS = medial segment
AS = anterior segment PS = posterior segment
A = aorta V = IVC SV = splenic vein SMA = superior
mesentric artery
SMV = superior mesentric vein