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: - Bladder Rupture - Small Bowel Diverticula - Type B Aortic Dissection

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
December 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. CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
CASE:
A 37-year-old male
involved in a MVC
presents with
hypotension and
complaints of lower
abdominal pain,
where a seat belt sign
is noted.
The FAST exam is
positive on the
retrovesical view.

8. CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
Potential bladder
dome injury
Free fluid near
loops of bowel
and the paracolic
gutters
Extraversion
of fluid near
the bladder
CASE:
A 37-year-old male
involved in a MVC
presents with
hypotension and
complaints of lower
abdominal pain,
where a seat belt sign
is noted.
The FAST exam is
positive on the
retrovesical view.
Diagnosis:
Intraperitoneal
bladder rupture with
abdominal free fluid.

9. Bladder Rupture
Classification
Intraperitoneal Bladder Rupture
• Occurs following a direct blow to the abdomen
• Usually involves the bladder dome
• 10-20% of injuries
Extraperitoneal Bladder Rupture
• Occurs in patients with pelvic trauma1, or
penetrating wounds
• 80-90% of injuries
1For Extraperitoneal Rupture:
5-10% of patients with pelvic trauma patients have a bladder rupture
85-95% of patients with a bladder rupture have pelvic trauma

10. Bladder Rupture
Cystography
Technique
Traditional
• Instill 400-500 cc of contrast via a Foley catheter
• Clamp the Foley and shoot an AP view
• Drain the bladder and shoot a post-void view1
CT2
• Instill contrast retrograde, clamp the Foley
• Obtain the CT and then unclamp the Foley
1The post-void view will identify extravasated contrast behind the bladder
2Standard IV contrast given for the CT will enter the bladder, but the
bladder will not be distended sufficiently to allow contrast extravasation

11. Bladder Rupture
Imaging Findings
Intraperitoneal Bladder Rupture
• Intraperitoneal contrast extravasation, often
seen between loops of bowel
Extraperitoneal Bladder Rupture
• Contrast extravasation confined to the pelvis

12. EAST 2019 Practice
Management
Guidelines
Recommendation:
• Use CT cystography the preferred method1
• Four studies demonstrate similar sensitivities
to conventional plain-film cystography:
1. Deck AJ. J Urol 2000; 64:421-22.
2. Peng MY. AJR Am J Roentgenol 1999; 173:1269-72.
3. Quagliano PV. J Trauma 2006; 61:410-21.
4. Chan DP. AJR Am J Roentgenol 2006; 187:1296-1302.
1Yeung LL. Journal of Trauma & Acute Care Surgery 2019; 88:326.

13. Intraperitoneal Bladder Rupture

14. Extraperitoneal Bladder Rupture

15. Bladder Rupture
Management
Intraperitoneal Bladder Rupture
• Open or laparoscopic repair
Extraperitoneal Bladder Rupture
• Foley catheter drainage
https://youtu.be/EWM5K8tJPSo
Laparoscopic repair example

16. Gallbladder
CBD and PD
CASE:
A 73-year-old man with a
history of hypertension,
cardiomyopathy,
hyperlipidemia, and
bilateral pulmonary
emboli (on apixaban)
presents to the ED after
concerning findings seen
on outpatient chest x-ray.
He has a normal exam and
a leukocytosis to 14,000
and otherwise normal labs.
What acute findings do
you see on the CT scan of
the abdomen & pelvis?

17. Gallbladder
CBD and PD
Jejunal
pneumatosis
Intraperitoneal
free air
CASE:
A 73-year-old man with a
history of hypertension,
cardiomyopathy,
hyperlipidemia, and
bilateral pulmonary
emboli (on apixaban)
presents to the ED after
concerning findings seen
on outpatient chest x-ray.
He has a normal exam and
a leukocytosis to 14,000
and otherwise normal labs.
CT findings are shown.
There is no evidence of
viscous perforations or
extravasation.

18. CASE CONTINUED:
73-year-old man with
perforated small bowel
from presumed jejunal
diverticulum.
Non-operative
management with
antibiotics is initiated.
Upper GI contrasted
study demonstrates left
upper quadrant luminal
extravasation.
GI workup ultimately
with a diagnosis of
jejunal diverticulum and
patient defers further
workup.

19. Small Bowel Diverticula
• Rare occurrence with an incidence of 0.06-1.3%.
• Associated with motility disorders. Colonic diverticula often concurrent.
• Most commonly involves the duodenum followed by the jejunum and ileum.
• Can present with perforation, obstructive symptoms, acute pain.
• In stable patients a contained perforations can be considered for non-
operative management though surgical exploration is the definitive
approach.
Akbari ME, Atqiaee K, Lotfollahzadeh S, Moghadam AN, Sobhiyeh MR. Perforated jejunal diverticula- a rare cause of acute abdominal pain: a case
report. Gastroenterol Hepatol Bed Bench. 2013;6(3):156-158.
Gurala D, Idiculla P, S, Patibandla P, Philipose J, Krzyzak M, Mukherjee I: Perforated Jejunal Diverticulitis. Case Rep Gastroenterol 2019;13:521-525. doi:
10.1159/000503896

20. CASE:
A 55-year-old male
presents to the emergency
department complaining of
2-3 days of sharp
substernal chest pain, non-
positional in nature, with
intermittent numbness and
paresthesias of the left
hand.
On initial presentation the
patient is tachycardic with
heart rate of 120’s and
hypertensive at 162/96
mmHg. CT imaging is
subsequently obtained.
Diagnosis?

21. CASE:
A 55-year-old male
presents to the emergency
department complaining of
2-3 days of sharp
substernal chest pain, non-
positional in nature, with
intermittent numbness and
paresthesias of the left
hand.
Diagnosis:
Type B Aortic Dissection
As seen in the imaging,
there is evidence of the
dissection extending into
the abdominal aorta.
View from CT angiography of the
chest. The origin of the dissection
is at the descending aorta.

22. Aortic Dissection
• Tear in the intima of the aorta, allowing blood to enter into the wall of the aorta, thus
creating a false lumen
• The creation of a false lumen can ultimately block blood flow to the true lumen of the
aorta, resulting in decreased blood flow to vital organs
• If left untreated, an aortic dissection can be fatal within the first 24-48 hours
• Risk factors include hypertension, genetic disorders affecting the blood vessel wall
(Marfan Syndrome, Ehlers Danlos Syndrome), atherosclerosis, cocaine use, and trauma
• Most commonly occur in men and the average age of onset is 60 years old
• Stanford Classification System:
Type A Dissection: involves the ascending aorta
Type B Dissection: involves the descending aorta only

24. Aortic Dissection Treatment
Management of hemodynamics:
• Heart rate control: Diltiazem 0.25 mg/kg IV loading dose followed by 5 mg/hr infusion
titrated by 5 mg/hr (max dose 15 mg/hr) or Esmolol 500 mcg/kg IV loading dose followed
by 50 mcg/kg/min infusion titrated by 50 mcg/kg/min (max dose 300 mcg/kg/min)
• Blood pressure control: Labetalol 20 mg IV loading dose followed by 2 mg/min infusion
titrated by 0.5 mg/min (max dose 8 mg/min) or Nicardipine 5 mg/hr IV infusion titrated
by 2.5 mg/hr (max dose 15 mg/hr)

25. Aortic Dissection Treatment
Type A Dissection:
• Open surgical repair which includes excision of the intimal tear, obliteration of entry into
the false lumen, reconstitution of the aorta with synthetic vascular graft, and repair or
replacement of the aortic valve.
• Endovascular stent grafting may also be performed for Type A dissections with ischemic
compromise.
Type B Dissection:
• Historically Type B dissections have been managed medical and treatment with open
repair or endographs has been reserved for those who develop complications related to the
dissection, such as malperfusion or extension of dissection into the abdominal aorta.
• There is growing evidence that Type B dissections are best managed with endovascular
repair at centers where this procedure is done regularly.

26. THE PRESENT A ND FUTURE
J A CC REV IEW TOPIC O F THE W EEK
Optimal Treatment of Uncomplicated
Type B Aortic Dissection
JACC Review Topic of the W eek
Rami O. Tadros, MD,a
Gilbert H.L. Tang, MD, MSC, MBA,b
Hanna J. Barnes, BA,a
Idine Mousavi, BA,a
Jason C. Kovacic, MD, PHD,c
Peter Faries, MD,a
Jeffrey W. Olin, DO,c
Michael L. Marin, MD,a
David H. Adams, MDb
JACC JOURNAL CME/ MOC/ ECME
This article has been selected as the month’s JACC CME/MOC/ECME
activity, available online at http://www.acc.org/jacc-journals-cme by
selecting the JACC Journals CME/MOC/ECME tab.
Accreditation and Designation Statement
The American College of Cardiology Foundation (ACCF) is accredited by
the Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
The ACCF designates this Journal-based CME activity for a maximum
of 1AMA PRA Category 1Credit(s)Ô. Physicians should claim only the credit
2. Carefully read the CME/MOC/ECME-designat ed article available on-
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3. Answer the post-test questions. A passing score of at least 70% must be
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J OU RN A L OF THE A MERI CA N CO L L EGE OF CA RDI OL OGY V OL . 7 4 , N O. 11, 2 0 19
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PUB L I SH ED B Y EL SEV I ER

31. Summary Of Diagnoses This Month
● Bladder rupture
● Small bowel diverticula
● Type B aortic dissection

32. See You Next Month!