Radiologic Findings

Radiologic findings may first identify the presence, extent, and location of the primary process. Subcutaneous emphysema presents as gas in the fascial planes between the muscles and interstitial tissues, in contrast to gas gangrene where the gas lies within the muscles. In the hip, it may first appear about the greater or lesser trochan-ter.2,7,10,16 The first site of appearance or area of maximum development of cellulitis or subcutaneous emphysema should indicate the appropriate anatomic level and likely nature of perforation of the bowel. Radiologic studies may then confirm the cause and anatomic pathway of spread. Computed tomography may be particularly useful in this regard.17

Figure 17-4 illustrates gluteal spread from a traumatic perforation of the rectum occasioned by a barium enema study. Dissection from the pelvis toward the gluteal area is strikingly illustrated in this case by the extravasated contrast agent tracking within the fascial extension of the superior gluteal artery through the greater sciatic foramen. Indeed, the vessel is shown as a tubular filling defect within its opacified endopelvic sheath. Tenderness in the buttock was a consequence of this anatomic extension.

Figure 17-5 illustrates a similar pathway in an instance of sigmoid diverticulitis perforating to the buttock, in a patient presenting with fever and vague pain in the right buttock. Perforation of the sigmoid colon in this case is directed along the extension of the supe rior gluteal artery through the greater sciatic foramen to the right buttock. The initial symptom of pain in this site heralded the progression to a prominent gluteal abscess.

Figure 17-6 illustrates extension within the fascial investment of the piriformis muscle from perforating sig-moid diverticulitis in a patient presenting with fever and pain in the left hip. Loculated extravasation from this area along the plane of the piriformis muscle extended to the left buttock and hip.

Figure 17-7 shows a tract of gas bubbles along the piriform muscle first revealed by CT, with the fistulous communication from perforation of an occult adeno-carcinoma of the sigmoid colon confirmed by barium enema study.

Figure 17-8 illustrates an instance of the clinical and radiographic presentation of septic arthritis of the hip complicating an underlying sigmoid diverticulitis. This may be initially very misleading in the absence of soft-

tissue gas.

Figure 17-9 demonstrates clinically occult extrapelvic spread in a case of appendicitis in a patient presenting with fever and right hip pain and tenderness. Necrotic cellulitis and interstitial emphysema of the right thigh in this patient progressed via the iliopsoas muscle group from a perforated appendicitis that was not diagnosed antemortem.

Figure 17-10 reveals extension of intrapelvic malignancy into the thigh along the course of the obturator internus muscle. The outlets provided by the muscles and lymphatics in their fascial investments through the text continues on page 760

Fig. 17—4. Rectal extravasation complicating a barium enema study, with gluteal spread.

(a) Postevacuation film. Contrast agent has infiltrated the intramural and extrarectal pelvic tissues.

(b) Magnification of area outlined in a demonstrates extravasation within the tunneled fascial sheath of the superior gluteal artery progressing through the greater sciatic foramen toward the buttock.

(Reproduced from Meyers and Goodman.2)

Fig. 17—4. Rectal extravasation complicating a barium enema study, with gluteal spread.

(a) Postevacuation film. Contrast agent has infiltrated the intramural and extrarectal pelvic tissues.

(b) Magnification of area outlined in a demonstrates extravasation within the tunneled fascial sheath of the superior gluteal artery progressing through the greater sciatic foramen toward the buttock.

(Reproduced from Meyers and Goodman.2)

Diverticulitis The Sigmoid Colon

Fig. 17—5. Sigmoid diverticulitis perforating to the right buttock.

(a) Sinus tract (arrows) leads from a site of inflammatory narrowing in the sigmoid colon along the course of the superior gluteal artery to the right buttock.

(b and c) Ten days later, a follow-up study shows that the sinus tract remains evident, and there is now a large abscess cavity (arrows) deep in the gluteal muscle. (Reproduced from Meyers and Goodman.2)

Fig. 17—5. Sigmoid diverticulitis perforating to the right buttock.

(a) Sinus tract (arrows) leads from a site of inflammatory narrowing in the sigmoid colon along the course of the superior gluteal artery to the right buttock.

(b and c) Ten days later, a follow-up study shows that the sinus tract remains evident, and there is now a large abscess cavity (arrows) deep in the gluteal muscle. (Reproduced from Meyers and Goodman.2)

Fig. 17—6. Sigmoid diverticulitis perforating to the left buttock and hip.

Oblique (a) and lateral (b) projections of barium enema study demonstrate extension from inflammatory narrowing of the distal sigmoid colon along the course of the piriformis muscle (arrows). (Reproduced from Meyers and Goodman.2)

Fig. 17—6. Sigmoid diverticulitis perforating to the left buttock and hip.

Oblique (a) and lateral (b) projections of barium enema study demonstrate extension from inflammatory narrowing of the distal sigmoid colon along the course of the piriformis muscle (arrows). (Reproduced from Meyers and Goodman.2)

Fig. 17—7. Perforated sigmoid carcinoma extending to the hip.

(a) CT demonstrates fistulous tract (arrows) following the plane of the piriform muscle to the greater trochanter.

(b) Barium enema confirms communication form a perforated sigmoid colon to a large abscess cavity around the greater trochanter. (Reproduced from Jager et al.4)

Fig. 17—7. Perforated sigmoid carcinoma extending to the hip.

(a) CT demonstrates fistulous tract (arrows) following the plane of the piriform muscle to the greater trochanter.

(b) Barium enema confirms communication form a perforated sigmoid colon to a large abscess cavity around the greater trochanter. (Reproduced from Jager et al.4)

Fig. 17—8. Septic arthritis of the left hip secondary to sigmoid diverticulitis.

(a) Destruction of the hip joint due to septic arthritis.

(b) Barium enema study shows segmental narrowing of the sigmoid colon due to acute diverticulitis. Barium has entered the hip joint through a fistulous communication.

(Reproduced from Smith et al.18)

Fig. 17—8. Septic arthritis of the left hip secondary to sigmoid diverticulitis.

(a) Destruction of the hip joint due to septic arthritis.

(b) Barium enema study shows segmental narrowing of the sigmoid colon due to acute diverticulitis. Barium has entered the hip joint through a fistulous communication.

(Reproduced from Smith et al.18)

Fig. 17—9. Appendicitis perforating to the right thigh.

(a) Loculated intersitial gas lateral to the right femur (arrows). Aspiration cultured E. coli.

(b) Barium enema study demonstrates nonopacification of the appendix with a prominent defect near its confluence with the caput cecum (arrow), despite reflux obtained into the terminal ileum. These findings were proved to be due to perforated appendicitis.

(Reproduced from Meyers and Goodman.2)

Fig. 17—9. Appendicitis perforating to the right thigh.

(a) Loculated intersitial gas lateral to the right femur (arrows). Aspiration cultured E. coli.

(b) Barium enema study demonstrates nonopacification of the appendix with a prominent defect near its confluence with the caput cecum (arrow), despite reflux obtained into the terminal ileum. These findings were proved to be due to perforated appendicitis.

(Reproduced from Meyers and Goodman.2)

Fig. 17—10. Recurrence of carcinoma of the colon extending through the obturator foramen to the thigh.

(a) CT scan at the level of the symphysis pubis demonstrates the recurrent mass (M) extending from the pelvis through the obturator foramen on the right to the thigh. The normal obturator internus muscle is seen on the left (curved arrow).

(b) At a higher level, the mass continues to the ischiorectal fossa, displacing the rectum (R) to the left and lying between the rectum and the urinary bladder (B).

Fig. 17—10. Recurrence of carcinoma of the colon extending through the obturator foramen to the thigh.

(a) CT scan at the level of the symphysis pubis demonstrates the recurrent mass (M) extending from the pelvis through the obturator foramen on the right to the thigh. The normal obturator internus muscle is seen on the left (curved arrow).

(b) At a higher level, the mass continues to the ischiorectal fossa, displacing the rectum (R) to the left and lying between the rectum and the urinary bladder (B).

foramina may constitute anatomic pathways for the ex-

trapelvic spread of carcinomas and lymphomas.

Figure 17-11 demonstrates a patient initially thought to have urolithiasis with scrotal referred pain shown by CT to have a perforated retrocecal appendix with extension to the inguinal canal.

Figure 17-12 illustrates that, superiorly, extension from the subperitoneal pelvic tissues preferentially seeks out the posterior pararenal compartment of the extra-

peritoneal region of the abdomen. The characteristic features allow precise radiologic localization, as detailed in Chapter 8.

Fig. 17—11. Perforated retrocecal appendix extending to the inguinal canal.

(a) CT shows retrocecal appendix with a coprolith surrounded by an abscess (open arrow) in the anterior pararenal space. Extraperitoneal gas is present in the midline anterior to the great vessels (arrow).

(b) Perirectal gas (arrows) is associated with gas in the inguinal canal (curved arrow).

(Courtesy of Michiel Feldberg, M.D., University of Utrecht, The Netherlands.)

Fig. 17—11. Perforated retrocecal appendix extending to the inguinal canal.

(a) CT shows retrocecal appendix with a coprolith surrounded by an abscess (open arrow) in the anterior pararenal space. Extraperitoneal gas is present in the midline anterior to the great vessels (arrow).

(b) Perirectal gas (arrows) is associated with gas in the inguinal canal (curved arrow).

(Courtesy of Michiel Feldberg, M.D., University of Utrecht, The Netherlands.)

Fig. 17—12. Extraperitoneal hemorrhage from iliac artery.

Difficulty in passing the catheter through the iliac artery during attempted cardiac catheterization was encountered. Contrast agent was introduced to evaluate the cause of the difficulty, and this demonstrated local extravasation. Right lower quadrant guarding and tenderness developed. Delayed film demonstrates persistent localized extravasation (arrow) from the right external iliac artery.

A soft-tissue mass representing a large amount of blood now occupies the right abdomen. This displaces the lower pole of the kidney laterally, obstructs the ureter, and obliterates the lateral edge of the psoas muscle and the flank stripe. These features localize the hematoma to the extraperitoneal posterior pararenal compartment. (Reproduced from Meyers and Goodman.2)

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