Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include: • Splenic Rupture • Obstructive jaundice • Ovarian Torsion

1. Adult Abdominal Imaging Case Studies
Michael Avery, DO; Joshua Davis, MD; Kelsey Lena, MD
Department of Surgery & Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Kyle Cunningham, MD & Michael Gibbs MD - Faculty Editors
Abdominal Imaging Mastery Project
August 2020

2. Disclosures
▪ This ongoing abdominal imaging interpretation series is proudly co-
sponsored by the Emergency Medicine & Surgery Residency Programs
at Carolinas Medical Center.
▪ The goal is to promote widespread interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
▪ Many are providing cases and these slides are shared with all contributors.
▪ Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile and Tanzania.
▪ Cases submitted this month will be distributed next month.
▪ When reviewing the presentation, the 1st slide will show an image without
identifiers and the 2nd slide will reveal the diagnosis.

4. It’s All About The Anatomy!

5. Systematic Approach to Abdominal CTs
● Aorta Down - follow the flow of blood!
○ Thoracic Aorta → Abdominal Aorta → Bifurcation → Iliac a.
● Veins Up - again, follow the flow!
○ Femoral v. → IVC → Right Atrium
● Solid Organs Down
○ Heart → Spleen → Pancreas → Liver → Gallbladder → Adrenal →
Kidney/Ureters → Bladder
● Rectum Up
○ Rectum → Sigmoid → Transverse → Cecum → Appendix
● Esophagus down
○ Esophagus → Stomach → Small bowel

6. Systematic Approach to Abdominal CTs
● Abdominal Wall/Soft tissue Up
○ Free air, abscesses, hernias
● Retroperitoneum Down
○ Hematoma, masses
● GU Up
○ Masses
● Tissue specific windows
○ Lung
○ Bone
● Don’t forget to look at multiple planes
○ Axial, sagittal, coronal

7. CASE:
A 78 year old man with
minimal alcohol use and
no tobacco use, presented
with a 4-week history of
multiple episodes of
crampy, post-prandial
abdominal pain. Relatives
have remarked on his
jaundice and the patient
endorses darker urine and
pruritus.
CT shows diffuse biliary dilation with
9mm CBD.
Labs reveal a normal white blood cell
count, direct hyperbilirubinemia,
elevated alkaline phosphate, and mildly
elevated AST/ALT.
R and L
hepatic
ducts
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum

8. The patient underwent
a right upper quadrant
ultrasound, ERCP, and
then laparoscopic
cholecystectomy.
Following procedure,
pathology was
reviewed as benign
and at the follow-up
appointment, the
patient’s symptoms
had improved.
Diagnosis: chronic
cholecystitis with
choledocholithiasis
causing obstructive
jaundice.
Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct

9. Obstructive Jaundice
- Consider clinical history and timeline:
- Patient with a new onset 1-month history of frequent postprandial
abdominal pain with progressive jaundice
versus
- Patient with history of pancreatitis with significant alcohol use who
presents with weight loss, night sweats, and fatigue
- Must consider underlying malignancy and patient’s risk factors

10. CASE:
The patient is a 43-year-old female with chronic pancreatitis and splenic and portal vein thrombosis who was
admitted after five days of ongoing abdominal pain. Her hemoglobin drifted from 14 11.1 after two days. She
became acutely hypotensive on hospital day two and a CT scan was obtained demonstrating the following:

11. CASE:
The patient is a 43-year-old female with chronic pancreatitis, splenic and portal vein thrombosis who was admitted
after five days of ongoing abdominal pain. Her hemoglobin drifted from 14 11.1 after two days. She became
acutely hypotensive on hospital day two and a CT scan was obtained demonstrating the following:
Splenic Rupture
Hemoperitoneum

12. During her hospital stay, the patient becomes hypotensive to 90/50’s. Her hemoglobin dropped further to 6.6 and she
subsequently develops left upper quadrant pain and left shoulder pain. This physical exam finding is considered a
positive Kehr’s sign!
Diagnosis: Splenic rupture with hemoperitoneum
Splenic Rupture
Hemoperitoneum

13. Non-Traumatic Splenic Rupture
• “Infection, malignancy, metabolic
disorders, as well as vascular and
hematological diseases, of which
only single case reports have been
published in the literature, are the
usual reasons”

16. FULL TEXT LI
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Title & au
Review . 2012 Aug 14;12:11. doi: 10.1186/1471-227X-12-11.
613 cases of splenic rupture without risk factors or
previously diagnosed disease: a system atic review
F Kris Aubrey-Bassler , Nicholas Sowers
Affiliations
PMID: 22889306 PMCID: PMC3532171 DOI: 10.1186/1471-227X-12-11
Free PMC article
BMC Emerg Med
1
expand
Abstract
Background: Rupture of the spleen in the absence of trauma or previously diagnosed disease is
largely ignored in the emergency literature and is often not documented as such in journals from
other fields. We have conducted a systematic review of the literature to highlight the surprisingly
frequent occurrence of this phenomenon and to document the diversity of diseases that can
present in this fashion.
Methods: Systematic review of English and French language publications catalogued in Pubmed,
Embase and CINAHL between 1950 and 2011.
Results: We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred

17. D-19 is an emerging, rapidly evolving situation.
he latest public health information from CDC: https://www.coronavirus.gov.
he latest research from NIH: https://www-nih-gov.ahecproxy.ncahec.net/coronavirus.
NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www-ncbi-nlm-nih-gov.ahecproxy.ncahec.net/sars-cov-2/.
Advanced
Search PubMed
Save
FULL TReview . 2012 Aug 14;12:11. doi: 10.1186/1471-227X-12-11.BMC Emerg Med
National Library of Medicine
National Center for Biotechnology Information
Occurred As The Presenting Complaint 53%
Occurred Following A Medical Procedure
Colonoscopy The Most Common Procedure
18%
14%
Most Common Causes
Infectious
Hematologic
Non-Hematologic Malignancies
23%
14%
8%
Medications
Anticoagulants, TPA, recombinant G-CSF
8%
Pregnancy-Related 6%

18. One Of The Most Common Causes Of Spontaneous Splenic Rupture in the U.S. Is
Mononucleosis And One Of The Most Common Causes Worldwide Is Malaria.
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Case Reports . 2019 Sep 30;12(9):e230259. doi: 10.1136/bcr-2019-230259.
Spontaneous splenic rupture in a patient with
infectious mononucleosis
Charlotte Ruth Baker , Sid Kona
Affiliations
PMID: 31570350 PMCID: PMC6768366 (available on 2021-09-30)
DOI: 10.1136/bcr-2019-230259
Free PMC article
BMJ Case Rep
1 1
Abstract
We present a case of spontaneous, atraumatic splenic rupture secondary to Epstein-Barr virus
(EBV) infection, in a young, female patient. Splenic rupture is a rare complication of EBV infection,
but is associated with the highest mortality. Additionally, this case illustrates the diagnostic
esearch from NIH: https://www-nih-gov.ahecproxy.ncahec.net/coronavirus.
RS-CoV-2 literature, sequence, and clinical content: https://www-ncbi-nlm-nih-gov.ahecproxy.ncahec.net/sars-cov-2/.
Advanced
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FULL TE
ACTION
Case Reports . 2018 Dec 4;17(1):448. doi: 10.1186/s12936-018-2600-2.
Spontaneous splenic rupture in Plasmodium
knowlesi malaria
Chee Yik Chang , Wei Chieng Pui , Khamisah Abdul Kadir , Balbir Singh
Affiliations
Malar J
1 2 3 4
National Library of Medicine
National Center for Biotechnology Information

19. Splenic
Rupture
Grading

20. Patient is a 15 year old
female who presented to
the ED febrile with a
temperature of 101.2 and
complaints of 1 week
history of abdominal pain
with constipation.
Physical examination
revealed right lower
quadrant tenderness. CT
Abdomen/Pelvis without
contrast is shown here.
Diagnosis?

21. At first glance, the
“cystic mass” may
appear as an oversized
bladder concerning for
urinary retention,
however note the bladder
inferior to the cyst.
Radiology reported this
as a complex ovarian
cyst.
Following CT, patient
underwent surgical
cystectomy where it
appeared the ovarian cyst
had lead to adnexal
torsion. Final pathology
reported a benign mature
teratoma.

22. Mature Teratoma
• Type of ovarian germ cell tumor (OGCT) that is derived from mature differentiated
primordial germ cells of the ovary
• May be benign or malignant in nature
• Comprise approximately 20-25% of ovarian neoplasms and 5% of all malignant ovarian
neoplasms
• Arise primarily in young women between 10-30 years of age
• Complications: rupture, ovarian and/or adnexal torsion, or development of malignant
components
• What is ovarian and/or adnexal torsion?
-Complete or partial rotation of the ovary on its ligamentous supports or rotation
of the fallopian tube
-Results in impedance of blood supply  risk for loss of ovarian and/or tubal
function

23. • Treatment:
-Ovarian cystectomy for pathologic classification of cystic mass and/or staging if cyst
is found to be malignant
-Traditional treatment for ovarian/adnexal torsion is oophorectomy and/or salpingectomy,
especially if decreased venous/arterial blood flow is evident on diagnostic imaging
-Increasing evidence for conservative surgery, such as de-torsion and oophoropexy,
particularly in younger women to lessen the impact on fertility

24. Summary Of Diagnoses This Month
● Obstructive Jaundice
● Non-Traumatic Splenic Rupture
● Mature Teratoma with Adnexal Torsion

25. See You Next Month!