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: - Traumatic Abdominal Hernia - Hemorrhagic Ovarian Cysts - Small Bowel Obstruction - Aortic Thrombus

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
September 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. CASE #1:
A 59-year-old female
stepped in front of a
dump truck that she
thought had stopped.
Her exam was notable
for normal vitals and a
diffusely tender
abdomen with a large
ventral Morrell’s
lesion. Her surgical
history is relevant for
a previous C section.
Diagnosis?

6. CASE #1:
The diagnosis is a
traumatic abdominal
hernia. This is
notably different from
a chronic abdominal
hernia in that there is
injury to the
abdominal wall and
bowel floating in the
subcutaneous tissue
without a hernia sac.
The superior
mesenteric vein
(SMV) is narrowed, as
it is acutely stretched
as the bowel contents
are pulled out of the
abdomen.
Narrowing of the SMV given
acute stretching of bowel
into the subcutaneous tissue
Bowel floating in
subcutaneous tissue
Injury to the
abdominal wall
musculature

7. CT Findings
• Traumatic large midline ventral hernia containing transverse colon and small bowel.
• Marked stretching and attenuation of the SMV and portal vein secondary to
mesenteric vascular structures pulled into the hernia sac as described above.
• Grade IV left lobe liver laceration with no active extravasation or significant
hematoma.
• Probable subtle lower pole Grade I splenic laceration with some perisplenic
hematoma and no active contrast extravasation.
• No evidence of gross hemoperitoneum.

8. Traumatic Abdominal Hernias
• Traumatic abdominal wall hernias (TAWHs) are uncommon. It remains
controversial whether such patients require urgent laparotomy and surgical repair.
• The mechanism of injury should be considered when deciding if a patient with a
TAWH requires surgery.
• Clinically apparent anterior TAWHs have a high rate of associated injuries
requiring urgent laparotomy. For this patient, her associated Morrell’s lesion and
Grade IV liver injury with pre-hospital hypotension (responsive to fluids) was an
indication for immediate laparotomy.
• Occult TAWHs diagnosed only by computed tomography may not require urgent
laparotomy or hernia repair, and a delayed closure may be considered.

10. The Rest of the Story
• Our patient was taken emergently to the operating room for exploratory
laparotomy, coagulation hepatorrhaphy, abdominal washout, drain placement x2,
ABThera WVAC placement. She was then taken to the ICU for continued
resuscitation and ongoing care of her open abdomen.
• She was taken back to the operating room the following day for reopen
laparotomy with abdominal washout, primary fascial closure, and subcutaneous
wound vac placement. She was taken back to the ICU after surgery for continued
resuscitation.
• She was taken back to the operating room for a 3rd time the following day for
subcutaneous layer closure. She discharged home on hospital Day 15 after her
other injuries were addressed.

11. Other Injuries
● Grade I splenic laceration
● Grade IV left lobe liver laceration
● Right maxillary sinus and orbital floor fractures
● Small right pneumothorax
● Bilateral rib fractures: right 1-7 and left 4-6
● Right clavicular fracture
● Left scapular fracture
● Left distal humerus fracture
● Right distal fibula and midfoot fractures
Orthopedic Surgery,
Plastic Surgery, and
the Surgical
Stabilization of Rib
Fractures Team were
consulted and
managed her
numerous injuries
appropriately.

12. CASE #2:
A 32-year-old female
with a past medical
history of ovarian
cysts, portal venous
thrombosis, Protein C
and S deficiency on
anticoagulation,
presents for sudden
onset of abdominal
pain and right
shoulder pain that
began a few hours
prior to presentation.
She has a normal heart
rate, but initial blood
pressure of 72/40.
Diagnosis?
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD

13. CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
Hemoperitoneum
Contrast
Extravasation
Cyst With Contrast
Extravasation
CASE #2:
CT of the abdomen
and pelvis
demonstrated a 4.3 x
2.8 x 3.3 cm right
sided ovarian cyst
with evidence of
nearby contrast
extravasation into the
right pelvis
concerning for a
ruptured
hemorrhagic cyst
with associated
hemoperitoneum.

14. A CT of the abdomen
and pelvis from 3
months prior
demonstrated a 4 cm
left ovarian cyst with a
fluid level suggesting
possible hemorrhage
into the cyst cavity.

16. Hemorrhagic Ovarian Cysts
• Typically occurs due to excessive bleeding into corpus luteum at the time of
ovulation. Rupture can lead to hemoperitoneum
• Most usually resolve within 8 weeks
• Those on anticoagulation or those with bleeding disorders (Hemophilia A
and B, vonWilibrand Disease, etc.) are at a higher risk for bleeding and
complications
• Ultrasound is the typical imaging modality used to diagnose hemorrhagic
ovarian cysts
• Observation is a good option in hemodynamically stable patients without
severe abdominal pain
• Laparoscopy should be performed if there is a large amount of free fluid in
the pelvis, if the patient has severe abdominal pain, or if hemodynamic
instability is present

18. Key points: Hemoperitoneum on CT scans
• Will first see in the most dependent
portions of the abdomen (hepatorenal
fossa) and pelvis (pelvic cul-de-sac)
• Blood has higher attenuation that
most other body fluids, CT
appearance depends on age, extent, a
and fluid location
• Un-clotted blood is usually 30-45 HFU,
clotted blood 60-90 HFU
• Often hemoperitoneum can be
managed non-surgically, however
evidence of active extravasation
requires emergent surgery or
angiographic embolization

19. Back to our patient
• Th patient was taken to the operating room by OB/GYN for a diagnostic
laparoscopy
• 2.5L of hemoperitoneum was evacuated
• Patient received a total of 2 units of packed red blood cells
• A right sided ovarian cyst appeared intact without evidence of rupture, left
sided adnexa and ovary appeared normal
• Right cyst ruptured occurred during manipulation and this was excised
• No obvious source of bleeding was identified, but hemostasis was achieved
• The patient was transferred to surgical ICU for observation

20. CASE #3:
A 48-year-old female
with HTN, type II
DM, HLD and oral
contraceptive use
who presented to the
ED with several days
of abdominal pain,
nausea/vomiting,
inability to tolerate
oral liquids, and
obstipation.
Diagnosis?
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD

21. CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
CASE #3:
A 48-year-old female
with HTN, type II
DM, HLD and oral
contraceptive use
who presented to the
ED with several days
of abdominal pain,
nausea/vomiting,
inability to tolerate
oral liquids, and
obstipation.
Diagnosis?

22. CASE #3:
A 48-year-old female
with HTN, type II
DM, HLD and oral
contraceptive use
who presented to the
ED with several days
of abdominal pain,
nausea/vomiting,
inability to tolerate
oral liquids, and
obstipation.
Diagnosis?
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
Cortical Kidney
Infarcts
Intramural
Aortic Thrombus

23. CASE #3:
A 48-year-old female
with HTN, type II
DM, HLD and oral
contraceptive use
who presented to the
ED with several days
of abdominal pain,
nausea/vomiting,
inability to tolerate
oral liquids, and
obstipation.
Diagnosis?
Aortic Thrombosis,
Renal Infarct, Small
Bowel Obstruction
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
Distally
Decompressed
Bowel
Transition Point
Pneumatosis

24. Small Bowel Obstruction CT Findings
• Dilated fluid-filled small bowel loops >2.5 cm from outer wall to outer wall
• Normal caliber or collapsed loops distally
• Thickened and increased attenuation of the bowel wall
• Pneumatosis intestinalis:
• Air in the bowel wall—This should never be there and is a sign of ischemia!

25. Perfusion Defects on CT
• Thrombus or clots appear as a “hypodense” intraluminal structure
with no enhancement after intravenous contrast.
• Remember, “hypodense” means a darker structure compared to
contrast enhancing lighter structures

26. Back to the Case!
• Our patient was taken emergently to the OR and was found to have a
small bowel obstructions secondary to interloop adhesions and
several dark lesions consistent with a thrombo-embolic phenomena
• This caused ischemia leading to a jejunal perforation into her
mesentery requiring a small bowel resection and anastomosis
• Given her scattered clots, she was worked up for a hypercoagulability
disorder by the Hematology team. Ultimately no hereditary disorders
were identified, and her hypercoagulability was attributed to her
chronic oral contraceptive (OPC) use!
• She was managed with a heparin drip and transitioned to oral
anticoagulants for 6 months, and was told to discontinue her OCPs.

28. Key Points
• Both venous or arterial thrombosis are unrelated to duration of use
or past use of combined oral contraceptives.
• The risk of arterial thrombosis induced by oral contraceptive use is
more pronounced in smokers and women with hypertension,
diabetes, and hypercholesterolemia.
• All types of thrombosis have strongly age-dependent, and therefore
risks and effects of risk factors increase with age.

29. Summary Of Diagnoses This Month
● Traumatic Abdominal Hernia
● Hemorrhagic Ovarian Cysts
● Small Bowel Obstruction, Aortic Thrombus, scattered kidney infarcts

30. See You Next Month!