Dr. Morgan Penzler is an Emergency Medicine Resident and Drs. Raza Ahmad and Ansley Ricker 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 cases include: - Nephrolithiasis - Infected Iliac Aneurysm - Pancreatic Masses

1. Adult Abdominal Imaging Case Studies
Raza Ahmad, MD, Morgan Penzler, MD, Ansley Ricker, MD
Departments of Surgery & Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Kyle Cunningham, MD & Michael Gibbs MD - Faculty Editors
Abdominal Imaging Mastery Project
August 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. It’s All About The Anatomy!

4. 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

5. 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

6. CASE #1:
An 84-year-old female
with a past medical
history dementia,
CAD, CVA, and a
chronic a indwelling
foley presents with
one day of altered
mental status. Labs
were significant for an
elevated creatinine of
1.29, urinalysis
showed >100 RBCs,
>100 WBCs, large
leukocyte esterase. CT
imaging was obtained.
Diagnosis?
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD

7. CASE #1:
The patient’s CT scan
demonstrated multiple
bilateral renal calculi
with several large
ureteral stones on the
left with moderate
hydronephrosis.
Urology
recommended
placement of left
nephrostomy tube to
alleviate the
obstruction, in the
setting of sepsis
secondary to the
presence of an
infected stone.
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
Moderate Hydronephrosis
22 mm Ureteral
Stone
Bilateral Renal
Stones

8. Nephrolithiasis
• Most common in adults 30-50 years with
typical presentation consisting of acute onset
of severe pain, nausea and vomiting
• Hematuria present in 85% of patients
• Non-contrast CT has highest sensitivity and
specificity for the diagnosis, can see
hydronephrosis, stranding of perinephric fat,
and collecting system dilation
• Management: analgesics, antiemetics, IV
fluids, medical expulsion therapy (tamsulosin
typically) and antibiotics if there are
concerns for infection
• Typically stones 5-6 mm in diameter will
pass in 7-30 days

9. Back to our case
• Urology was consulted for significant stone burden and ureteral obstruction
• A left percutaneous nephrostomy tube placement was recommended to
alleviate the anatomic obstruction
• Due to the patient’s significant medical comorbidities, history of present
illness and clinical features of sepsis, the patient’s family ultimately made
the decision of comfort care and nephrostomy tube placement was deferred.

11. Percutaneous Nephrostomy Tubes
• A form of nephrostomy where percutaneous access and catheter placement
to the kidney is obtained under radiological guidance
• Indications: urinary tract obstruction, need for urinary diversion in cases
of ureter injury or leak, access for stent placement, diagnostic testing
• Procedure:
• The patient is positioned in the prone position
• Pre-operative 3rd generation cephalosporin antibiotics are given pre-operatively
• 18-gauge needle used to puncture the renal calyx under fluoroscopic (or ultrasound)
guidance of fluoroscopy and a Seldinger technique is used to insert a guidewire,
dilator and ultimately an 8 French pigtail drain
• Typically exchanged every 3 months
• Complications: bleeding, pneumothorax, bowel injury, urine leak, spleen
or liver injury, catheter obstruction, catheter displacement

12. CASE #2:
A 62-year-old male presents to the ED with
right flank pain. He has had intermittent right
flank pain for the last 3 years. There is no
history of trauma. Since then, he has had
intermittent attacks of pain which usually
improved with sitting up and walking. Over
the last year the attacks have increased in
frequency and for the last 3 weeks he has
had constant right flank pain. He has been in
the Emergency Department 3 times.
Today his right flank pain was 10/10, up to
the ribs. There is no history of fevers or
chills, no nausea or vomiting. He has
uncontrolled HTN and a history of cocaine
and alcohol abuse.

14. Aorto-Iliac
Bifurcation
Fluid Collection
Pseudoaneurysm
Infected Fluid
Aneurysmal Sac

15. Pseudoaneurysm
• False aneurysm—an abnormal dilation of an artery due to a
weakened vessel wall
• Can be associated with perforation of the vascular wall causing
bleeding into surrounding tissue
• The physical exam may reveal a painful and pulsatile mass and/or
bruit on auscultation

16. CT findings
• A hypoattenuating (non-contrast) or hyperattenuating (contrast-
enhanced) smooth-walled sac adjacent to an artery, usually with a
contiguous communicating segment
• Infected aneurysms can have adjacent soft tissue stranding, adjacent
fluid collection +/- gas as well as reactive lymphadenopathy

18. Management of Pseudoaneurysms
• Ultrasound-guided instillation of thrombin
• Arterial embolization
• Endovascular stenting
• Surgical resection

19. Back to the case
• Vascular Surgery was consulted
• Bilateral common iliac stenting and arterial embolization of right
hypogastric artery (as this was feeding the sac) was performed
• The patient was also treated with long-term antibiotics

20. CASE #3:
A 77-year-old female
presenting with 2
weeks of PO
intolerance, choking,
abdominal pain,
distention, bloating
and emesis. She
denied fevers, chills,
jaundice, or changes
in her bowel habits.
She also reports a 100
pound non-volitional
weight loss over the
past year.
Diagnosis?

21. CASE #3:
Pancreatic cancer with
associated gastric
outlet obstruction.
The patient was
admitted to the
Hepatobiliary Surgery
service for the
following work-up:
diagnostic laparoscopy
with GJ bypass to
relieve obstruction and
port placement for
chemotherapy.
An EUS with FNA
revealed invasive
adenocarcinoma.
Pancreatic Mass Invading The
Duodenum And Vasculature. Dilated Stomach Due To
Gastric Outlet Obstruction
Clips From Previous
Cholecystectomy

22. CT Findings
● Pancreatic mass with local vascular and duodenal invasion (which is not
amendable to upfront surgical resection)
● Dilated stomach from pancreatic mass obstruction the level of the
duodenum
● Surgical clips placed from patient’s previous laparoscopic
cholecystectomy

23. Pancreatic Adenocarcinoma
● Most common symptoms: pain, jaundice, weight loss
● Workup: RUQ ultrasound to evaluate dilated bile ducts and/or the
pancreatic mass, ERCP to further visualize the biliary tree and pancreatic
duct along with stent placement if obstruction is present, EUS for biopsy
of pancreatic mass for tissue diagnosis along with assessing vasculature
and other structural involvement, CT abdomen/pelvis pancreas protocol
scan to further characterize the pancreatic mass, CT chest for staging,
tumor markers that include CA 19-9, AFP, and CEA
● Categorized: resectable vs. unresectable based on distant metastasis and
encasement of local vasculature

32. The Rest of the Story
● HPB Surgery admitted the patient
● EUS by Advanced GI for tissue diagnosis of pancreatic adenocarcinoma
● CT chest showed right paratracheal and right hilar adenopathy,
indeterminate for metastases. Further review of the CT abdomen/pelvis
revealed right hepatic lobe lesions concerning for metastases
● HPB Surgery performed diagnostic laparoscopy that was negative for
obvious peritoneal metastasis. A port was place to begin chemotherapy,
and a gastrojejunostomy was performed to relieve gastric outlet obstruction
● A Whipple would have been performed at this time if the pancreatic mass
was deemed to be resectable during the initial imaging

33. ● Hematology/Oncology initiated chemotherapy began
● The patient represented to ED with biliary obstruction, and she
underwent IR placement of a PTC
● A liver lesion biopsy that confirmed distant metastatic of pancreatic
adenocarcinoma
● The patient continues receiving palliative chemotherapy
The Rest of the Story

34. Summary Of Diagnoses This Month
● Nephrolithiasis
● Infected iliac aneurysm
● Pancreatic masses

35. See You Next Month!