This document summarizes an adult abdominal imaging case study series from Carolinas Medical Center. It discusses three cases presented in the series: 1) A 36-year-old female with a perforated gastric ulcer. 2) A 63-year-old man with left lower extremity pain and ulcers diagnosed with May-Thurner syndrome. 3) An 11-year-old female with abdominal pain and difficulty urinating diagnosed with hematocolpos secondary to an imperforate hymen. The document provides brief discussions of the diagnoses, relevant anatomy, risk factors, and management considerations. It encourages systematic review of abdominal CT scans and sharing of case studies between departments and internationally.

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
October 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:
Patient is a 36-year-old
previously healthy female
who presented with 4 days of
epigastric pain that
became diffuse
abdominal pain with
unrelenting nausea

8. CASE:
Significant pain was elicited
on examination and CT scan
revealed concern for free fluid
and possible perforation.
Diagnosis:
Perforated gastric ulcer,
prepyloric
Fluid and
thickened
gastric wall
Free air
Free air
Free fluid in pelvis

9. Types of Gastric Ulcers
• Type I – lesser curve low along body of
stomach; due to ↓ mucosal protection
• Type II – 2 ulcers (lesser curve and
duodenal); similar to duodenal ulcer
with high acid secretion
• Type III – pre-pyloric ulcer; similar to
duodenal ulcer with high acid secretion
• Type IV – lesser curve high along cardia of
stomach; ↓ mucosal protection
• Type V – ulcer associated with NSAIDs

10. Risk Factors
and
Characteristics
• Risk factors: male, tobacco, alcohol,
NSAIDs, H. pylori, uremia, stress (burns,
sepsis, and trauma), steroids, chemotherapy
• 80% on lesser curvature of the stomach
• Hemorrhage is associated with higher
mortality than duodenal ulcers
• Symptoms: epigastric pain radiating to the
back; relieved with eating, but recurs 30
minutes later; melena or guaiac-positive
stools

11. Management of Ulcer Disease
• Supportive measures
• Acid suppressive therapy
• IV proton-pump inhibitor(PPI)
• In patients with other peptic-ulcer-related complications (gastric outlet obstruction,
penetration, perforation), high-dose twice-daily PPI treatment is reasonable
• The duration of treatment is based on the ulcer location and underlying etiology
• Discontinue NSAIDs
• Evaluation for H. pylori
• H. pylori testing (eg, biopsy urease test, urea breath test) in the setting of ulcer
bleeding or PPI use may result in false-negative results, so repeat testing is required
for patients whose initial tests are negative
• A urea breath test for H. pylori performed as soon as the patient has resumed oral
feedings is a reasonably sensitive predictor of H. pylori infection.

12. Free Air Under The Diaphragm: Some Cases Obvious, Others Subtle

13. Normal Diaphragmatic Contour On CXR

15. Free Air

17. Free Air

19. Free Air

21. Free Air

22. CASE:
Patient is a 63-year-old man
with history of
poorly controlled
hypertension who presented
with acute on chronic left
lower extremity (LLE) pain,
and non-healing LLE ulcers
on the shin and medial
malleolus. He has equal
palpable extremity
pulses bilaterally on
examination.
​CT scan shows compression
of left iliac vein.
Diagnosis?

23. Diagnosis:
May Thurner Syndrome
Aorta
Left common iliac
artery*
Left common iliac
vein

24. May Thurner Syndrome
• May Thurner syndrome is classically described as left common iliac vein compression between
the vertebral body (posteriorly) and the right common iliac artery (anteriorly).
• It’s very difficult to appreciate complicated vascular anatomy on static CT images. Practice
scrolling through scans in multiple views to identify normal aortic and main branch anatomy.
* This patient had a circuitous aorta and vena cava causing the anatomical variation of
the left iliac artery to compressing the left iliac vein.​
• Patient can present with acute or chronic symptoms of iliocaval venous obstruction or DVTs
with pain, swelling, skin color changes, and possible symptoms of unilateral chronic venous
stasis (ulcers).
• Treatment varies from compression therapy, anticoagulation, and endovenous interventions
such as stenting or catheter directed thrombolysis.

25. CASE:
Patient is a 11-year-old
previously healthy female
who presents for a two-day
history of suprapubic
abdominal with associated
subjective fever. The patient
also endorses a one-week
history of difficulty with
urination and constipation.
A bedside transabdominal
ultrasound was completed
in the Emergency
Department, along with a
CT Abdomen/Pelvis.
Diagnosis?

26. Bladder
Hematocolpos
Diagnosis:
Hematocolpos secondary to
imperforate hymen
Notice the complex fluid
within the a severely dilated
vaginal vault
As many patients can
experience, hematocolpos
can lead to displacement of
the bladder and
rectosigmoid colon, leading
to constipation and
difficulty urinating.

27. Imperforate
Hymen
• Congenital disorder where the hymen, a thin
membrane, covers the whole opening of the
vagina
• Most common type of blockage of the vagina
• Incidence ranges 1:1,000 to 1:10,000 females
• Often diagnosed in adolescent girls when
menstrual blood accumulates in the vagina
• Patients can present with abdominal pain, back
pain, difficulty urinating, or painful bowel
movements. In a pubescent girl, lack of a first
menstrual period may be the first sign.
• Treatment: complete hymenectomy

28. Summary Of Diagnoses This Month
● Perforated gastric ulcer
● May Thurner Syndrome
● Hematocolpos secondary to imperforate hymen

29. See You Next Month!