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: - Hepatic Abscess - Colo-renal Fistula - Splenic Artery Aneurysm Rupture

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
January 2021

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 #1:
The patient is a 50-year-
old male with a past
medical history of liver
transplant secondary to
alcoholic cirrhosis with a
DCD1 Donor. The patient
presented to the hospital
with abdominal pain,
fevers and body aches.
Diagnosis?
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
1DCD = Donation After
Circulatory Death.

8. CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
Intrahepatic
Abscess
Peripheral
Enhancement
Patent Portal System
CASE #1:
The patient is a 50-year-
old male with a past
medical history of liver
transplant secondary to
alcoholic cirrhosis with a
DCD1 Donor. The patient
presented to the hospital
with abdominal pain,
fevers and body aches.
Diagnosis?
Intrahepatic Abscess
1DCD = Donation After
Circulatory Death.

9. Common Hepatic Abscess Types

10. Imaging Findings of Hepatic Abscesses
• Peripherally enhancing lesions
• Centrally hypoattenuating lesions
• “Double Target Sign”
• “Cluster Sign”

11. The “double target sign” is an imaging feature of liver abscesses on contrast enhanced CT
scans, in which a central, fluid-filled low attenuation lesion is surrounded by a high attenuation
inner rim (abscess membrane) and a low attenuation outer ring (liver parenchyma).

12. The “cluster sign” is a feature of pyogenic hepatic abscesses. It is an aggregation of multiple
low attenuation liver lesions in a localized area to form a solitary larger abscess cavity.

16. Hepatic Abscess After Liver Transplant

19. CASE #2:
65-year-old man with
untreated atrial fibrillation
and diabetes presents to the
ED with several days of
dyspnea, fevers, and
generalized malaise.
Urinalysis and white blood
cell count are normal. The
only lab abnormalities are
mildly elevated CRP and
hyperglycemia.
Chest X-Ray suggests left
multifocal pneumonia.
CT angiography chest and
CT abdomen and pelvis are
obtained. CT angiography
chest shown first…

20. CASE #2 continued:
CT angiography chest
demonstrates scattered
consolidations consistent
with diagnosis of
multifocal pneumonia.
The patient is COVID [+]
by PCR.

21. CASE #2 continued:
Representative images
from the CT abdomen and
pelvis.
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum

22. CASE #2 continued:
The CT abdomen and
pelvis demonstrates a new
left colorenal fistula near
the splenic flexure.
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum
Colon
Colorenal Fistula

23. CASE #2 continued:
Prior CT reviewed and
demonstrates left 5cm renal
cyst at splenic flexure.
Case evaluated by urology
and general surgery. Fistula
determined to be
communicating with the
ruptured cyst cavity but not
in communication with
renal collecting system.
After several days the
patient was discharged
home with oral steroids. He
will follow up with
surgery/urology after active
COVID infection.
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
CBD and PD
duodenum
Prior CT scan

24. Operative risk with COVID19 infection
• COVID19 infection is associated with significant
increase in perioperative morbidity and mortality.
• Barring emergent/urgent indications surgical
procedures/general anesthesia should be delayed in
COVID19 positive patients.
• Reference the most up to date surgical/anesthesiology
recommendations available online.

25. CASE #3:
80-year-old female with
past medical history of
hypertension,
atherosclerotic disease, and
known abdominal aortic
aneurysm presents to the
ED after experiencing a
syncopal episode at home
while ambulating. Patient
had quick return to baseline
following syncope event,
but now complains of left
upper quadrant pain.
CT Abdomen/Pelvis
obtained in the ED.
Diagnosis?

26. Note the splenic artery aneurysm
Hemoperitoneum
surrounding the
spleen and tracking
inferiorly to the left
pericolic gutter
CASE #3:
80-year-old female with
past medical history of
hypertension,
atherosclerotic disease, and
known abdominal aortic
aneurysm presents to the
ED after syncopal episode
with quick return to
baseline. Patient now
complaining of left upper
quadrant pain.
CT Abdomen/Pelvis
obtained in the ED.
Diagnosis?
Splenic artery aneurysm
rupture
Patient emergently taken to
OR for ligation of aneurysm
and splenectomy.

27. Splenic Artery Aneurysm Rupture
• Splenic artery defined as aneurysmal when the splenic artery dilates > 1 cm or
diameter is > 50% compared to the normal vessel diameter
• Splenic artery aneurysm is the most common visceral artery aneurysm reported
• Prevalence of splenic artery aneurysm in the general population: < 1%
• Risk factors: portal hypertension, atherosclerosis, liver transplantation,
pregnancy, and connective tissue disorders (Marfan or Ehler-Danlos Syndrome)
• Imaging Modalities: CT angiography abdomen and pelvis
• Splenic artery aneurysm rupture is associated with relatively high mortality rate,
ranging 25-40%

28. Calcified
Splenic
Artery
Aneurysm

29. Treatment
• Treatment: intervention advised when aneurysm reaches diameter > 2 cm or clinical
course complicated by aneurysmal rupture
-Open surgical approach: Gold standard approach for splenic artery aneurysm repair
-Resection of aneurysm with interposition bypass considered for aneurysms located
in the proximal to mid-splenic artery without rupture
-If splenic aneurysm rupture occurs, urgent laparotomy and control of hemorrhage
with aneurysm ligation +/- splenectomy should be performed
-Endovascular approach: stent graft, aneurysmal coiling, embolization
(rupture in hemodynamically stable patient)
-Splenectomy with distal pancreatectomy may be necessary when aneurysmal
walls are severely inflamed with adherence to tail of pancreas and concurrent rupture

31. Summary Of Diagnoses This Month
● Hepatic abscess
● Colorenal fistula with concurrent COVID-19 infection
● Splenic artery aneurysm rupture

32. See You Next Month!