1) The document discusses several adult abdominal imaging case studies presented by physicians from Carolinas Medical Center and Levine Children's Hospital. 2) It provides an overview of the ongoing abdominal imaging interpretation project, which is co-sponsored by emergency medicine and surgery residency programs and shares cases internationally. 3) The document reviews a systematic approach to reviewing abdominal CT scans, focusing on following blood flow and anatomical structures from top to bottom and right to left.

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
Septemeber 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:
The patient is a 19-year-
old male with 3-4 days
of periumbilical and
right lower quadrant
pain who was seen in
ED and significant
tenderness to palpation,
along with leukocytosis.
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum

8. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
Appendicolith
Inflamed appendix
Dilated
appendix
Appendicolith
Abdominal
fluid
collection
Given his significant
pain, and CT findings,
the patient was taken to
the OR for a
laparoscopic
appendectomy.
Diagnosis: Acute
Perforated
Appendicitis

9. Acute Perforated Appendicitis: To Operate or Not

10. Management of Acute
Appendicitis

11. A 48-year-old women presents with abdominal
pain for 4 days.
• Pain initially diffuse, then sharp migration
localized to the right lower quadrant
• On exam patient is not septic, non-
peritonitic
• Labs showed neutrophilic leukocytosis and
mild acute kidney injury. Urinalysis
suggested questionable infection.
• CT with IV contrast shows 2 mm
obstructing stone at the the ureterovesical
junction
• Treated with outpatient antibiotics, urology
follow up, and medical expulsive therapy.
Right
hydronephrosis
with perinephric
inflammatory fat
stranding
Dilated right ureter
IVC
Infrarenal
Aorta
Diagnosis: obstructive uropathy

12. Intrauterine
device
Stone at
UVJ
Bladder
Stone at
ureterovesic
al junction
(UVJ)
Rectum
Delayed nephrogram
(difference in renal
parenchymal enhancement)

13. CASE:
A 65-year-old male presents to
the emergency department with
gradually worsening abdominal
distention over the last 5 days
with associated nausea and
emesis. The patient states that
he has not had a bowel
movement in the last 3 days.
Initial vital signs reveal that he
is afebrile, normotensive, and
non-tachycardic.

14. Physical examination reveals significant
abdominal tenderness on palpation, and he is
tympanitic to abdominal percussion. The
following imaging is obtained, revealing
significant colonic distention.
Diagnosis: Ogilvie Syndrome

15. Ogilvie Syndrome
• Acute colonic-pseudo obstruction
• Signs and symptoms of large bowel obstruction in the absence of a
mechanical cause
• More common in men
• Patients typically over the age of 60
• Usually involves the cecum and right hemicolon, although distention can
extend to the rectum
• Complications: colonic ischemia and perforation

17. Management
• Rectal Exam
-Rule out distal obstruction secondary to fecal impaction
-Potential to trigger motility of the paralyzed colon segment
• Conservative management
-NPO, intravenous fluids, nasogastric tube placement
• Failed 48-72 hours of conservative therapy and/or evidence of
peritonitis with > 12 cm colonic distention
-IV neostigmine therapy
• Fail neostigmine or have contraindications to treatment
-Colonic decompression

18. Summary Of Diagnoses This Month
● Acute perforated appendicitis
● Obstructive uropathy
● Ogilvie syndrome

19. See You Next Month!