Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: November Cases

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
November 2021

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.

Systematic Approach to Abdominal CT Interpretation
● 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

CASE #1:
A 79-year-old female
with a history of sick
sinus syndrome and
pacemaker placement,
anti-phospholipid
antibody syndrome
(on warfarin), and
recurrent diverticulitis
presented to the
Emergency
Department with
severe left lower
quadrant pain.
What Is The Arrow
Pointing At?

CASE #1:
Diagnosis?
Diverticulitis with a
fistula between the
small bowel and large
bowel, along with a
small bowel
obstruction (SBO)
secondary to
thickened bowel wall
thickening.
Contrast Entering
The Large Bowel
From The Small
Bowel

Complicated Diverticulitis
“Complicated diverticulitis” is defined as a case of diverticulitis with any
of these associated findings:
• Abscess
• Phlegmon
• Perforation
• Fistula
• Significant bleeding
• Obstruction

Intra-Abdominal Fistulas
Definition:
A fistula is an abnormal communication between two epithelial surfaces.
Types:
Most common: enterocutaneous, enteroenteric, enterovaginal, enterovesicular
Causes:
Surgical procedure, diverticular disease, Crohn’s disease, radiation, foreign
body

Management
Non-operative:
• Medical treatment of the symptoms and possible complications, i.e.:
skin excoriation, dehydration, and site infection…
• Maximizing medical treatment of the underlying disease (e.g.: Crohn’s)
to support the general patient’s overall condition
Operative:
• The basic principle of the surgical approach is to excise the involved
segment of the bowel and the fistula.

Operative Considerations
• Intraoperatively the sigmoid colon is usually tethered to the pelvis, fixed
to bladder wall or vagina and/or uterus in females.
• Fistula can be divided using sharp or blunt dissection.
• It is not necessary to close a vaginal or bladder defect, it will heal once
the portion of the colon has been removed. There is no need to excise
the fibrotic area in the wall of the bladder or vagina to healthy tissue
unless there is a concern for malignancy.
• Consider coverage with an omental flap.

Back To Our Case!
• The patient was noted to have had the fistula on prior CT scans and there
was no significant interval change
• She was kept NPO with bowel rest until there was return of normal bowel
function and then her diet was advanced as tolerated
• Ultimately the case was managed non-operatively and outpatient GI follow-
up was arranged for colonoscopy to further characterize the fistula

Please See More Slides Included In Appendix 1.

CASE #2:
52-year-old male who
presented to our ED
after concern for
suicide attempt by
jumping off a bridge.
There was concern
that the patient may
also have been struck
by a car. Vital signs
showed a systolic
blood pressure of 70.
Patient was stabilized
with a massive
transfusion protocol
and was transferred to
the CT scanner for
further evaluation. Pubic Symphysis Diastasis
ED Pelvis X-Ray

CASE #2:
52-year-old male who
presented to our ED
after concern for
suicide attempt by
jumping off a bridge.
There was concern
that the patient may
also have been struck
by a car. Vital signs
showed a systolic
blood pressure of 70.
Patient was stabilized
with a massive
transfusion protocol
and was transferred to
the CT scanner for
further evaluation.
Diagnosis?

CASE #2:
Diagnosis?
Right sacral fracture,
pubic symphysis
diastasis concerning
for open book pelvic
fracture, small
amount of contrast
extravasation anterior
to right sacral
fracture.
Contrast Extravasation
Right Sacral Fracture
Pubic Symphysis
Diastasis

Back To Our Case!
• The massive transfusion protocol initiated in the emergency department,
the patient was given 2 units pRBCs, 2 units FFP, 1L LR
• A pelvic binder was placed in the trauma bay
• Multiple other injuries were identified including a femur fracture, radial
fracture, rib fractures, and an intracerebral hemorrhage
• The patient ultimately required IR guided embolization for injury to
branches of the left internal iliac artery

Pelvic Ring Trauma: Management Essentials
Step #1: Define The Injury Pattern
Step #2: Early Goal Directed Resuscitation
Step #3: Pelvic Immobilization
Step #4: Advanced Resuscitative Measures
Step #5 Definitive Hemorrhage Control

A Therapeutic Emphasis On
 Early goal-directed resuscitation
 Aggressive treatment of trauma-induced coagulopathy
 Use of external compression binders
 Advanced resuscitative measures:
1. REBOA
2. Pre-peritoneal packing
 Early angiographic embolization

• Several pelvic fracture classification systems exist
• For the acute care provider, the most practical scheme defines pelvic
fractures based on the mechanism of injury
• How does the fracture pattern alter “pelvic volume?”
• Increases in pelvic volume create a potential space for hemorrhage
Lateral Compression Injury1 50% - 60%
Antero-Posterior (AP) Compression Injury2 20% - 30%
Vertical Shear Injury2 <10%
1Pelvic volume generally preserved
2Pelvic volume increased
Step #1: Define The Injury Pattern

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the need for hemorrhage control intervention-Results of an AAST multi-institutional study.
Prospective, multicenter observational trial of trauma patients with pelvic trauma presenting in shock to 11
Level-I Trauma Centers. ”Shock” was defined as either a BP <90 mmHg or a HR >120 bpm + a base deficit >5.
Results:
• Lateral compression injuries were the most common pattern in 163 patients included in the analysis
• The overall in-hospital mortality was 30%
• The fracture patterns most commonly associated with the need for hemorrhage control intervention
were: (1) vertical shear injuries, (2) severe AP compression injuries, and (3) open pelvic fractures.
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For More Pelvic Fractures Imaging Studies From
Carolinas Medical Center Please See Appendix 2

• Aggressive resuscitation using optimal transfusion ratios (1:1:1) is vital
• Immediate administration of TXA
• Keep the patient warm to prevent coagulopathy
• Monitor serial serum lactates to assess resuscitation
Step #2: Early Goal-Directed Resuscitation

• Application of an external pelvic binder is a rapid and effective method
of stabilizing the pelvic ring, preventing movement of fracture
fragments, and reducing pelvic volume.
• Placement should be at the level of the femoral trochanters.

Pre-Binder Post-Binder

Resuscitative Endovascular Balloon Occlusion Of The Aorta (REBOA)

Pre-Peritoneal Packing

Step #5: Definitive Hemorrhage Control
Motorcycle Crash
A 45-Year-Old Is Involved In A
Highspeed Collision.
ED Vitals: HR 130’s, BP 78/52
eFast (-), ED Chest X-Ray (-)
Lactate 7.8 mmol/L
After Pelvic Binding, A STAT
Abdominal CT Reveals No Solid
Organ Injury And Right-Sided Pelvic
Contrast Extravasation. He Is Taken
For An Urgent Pelvic Angiogram.
ED Pelvis: AP Compression Injury

Pelvic Angiography Reveals Contrast Extravasation At The Internal Pudendal Artery.
Contrast Blush Vascular Coils Deployed

Pelvic Angiography Reveals Contrast Extravasation At The Internal Pudendal Artery.

Post-Angiogram Pelvis X-Ray
Vascular Coils Deployed Pelvic Binder

CASE #3:
47-year-old female
with a history of HTN
and DM presenting
with several days of
worsening crampy,
intermittent
abdominal pain.
Recently hospitalized
for enteritis and
hydration. She
describes pain as
sharp, diffuse,
intermittent, and
obstipated for 2 days.
WBC 19K, lactate 2.6.
Diagnosis?

CASE #3:
The patient was
suffering from acute
mesenteric ischemia.
She was found to have
an aortic thrombus
with infarcts to the
small bowel, bilateral
kidneys, and spleen.
The small bowel had
associated ischemic
changes present.
Narrowing of the SMV given
acute stretching of bowel
into the subcutaneous tissue
Bowel floating in
subcutaneous tissue
Injury to the
abdominal wall
musculature
Aortic Thrombus
Ischemic Enteritis &
Bowel Wall
Infarction
Splenic Infarct
Renal Infarct

CT Findings In Our Patient
• Intraluminal aortic thrombus
• Ischemic enteritis/bowel wall infarction with associated pneumatosis
• Bilateral renal cortical infarctions
• Splenic infarctions
• Incidental 2.9 cm right adrenal mass, likely adenoma

Acute Mesenteric Ischemia
• Risks: conditions that reduces perfusion of the intestines or predisposes to
mesenteric arterial embolism, arterial thrombosis, venous thrombosis, or
vasoconstriction. Mortality can exceed 60%!
• Abdominal pain is the most common presenting symptom. The classic
clinical description is: ”Pain out of proportion to the exam."
• Early diagnosis is essential. CT angiography is the initial test for patient
suspected of having mesenteric ischemia.
• The goal of treatment is to restore intestinal poor flows rapidly as possible
after initial supportive management.

Back To Our Case!
• General Surgery took the patient to the OR for diagnostic laparoscopy
converted to exploratory laparotomy found to have ischemic necrosis of
small bowel status post 10cm resection with anastomosis.
• Taken to the ICU and hematology/cardiology were consulted to assess
the source of aortic thrombus. Subsequent work-up was negative for
definitive diagnosis of hypercoagulability, so it was thought to be due to
oral contraceptive pill use.
• Placed on heparin drip while in ICU. Converted to clopidogrel and
apixaban prior to discharge for which she continues indefinitely.

See You Next Month!
Click Ahead For
Appendices 1, 2, 3!

The EAES/SAGES Guidelines Concerning The Epidemiology, Diagnosis, Emergency Department Treatment And Emergency
Surgery Of Acute Diverticulitis Are Included.
Appendix 1

More Pelvic Fractures Case Examples
From Carolinas Medical Center
Appendix 2

AP Compression Injury With Pelvic Binder
Case 1

Lateral Compression Injury
Case 2

Lateral Compression Injury
Case 5

Appendix 3

Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: November Cases

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