Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident 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 on: ▪ Traumatic diaphragmatic hernia ▪ Internal hernia after Roux-en-y ▪ Inguinal hernia

1. Adult Abdominal Imaging Case Studies
Isolina R. Rossi, MD & Brian P. Shreve, 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
December 2019

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. 42 male presents
after a motor
vehicle collision.
Diagnosis?

8. Left-sided
traumatic
diaphragmatic
hernia!

9. Left-sided
traumatic
diaphragmatic
hernia.
Stomach
herniated into
the left chest!

11. Etiology
• Traumatic diaphragmatic hernias:
• Occurs in 5% of major trauma victims
• Penetrating injury (10–19%)
• Blunt thoracic-abdominal trauma (5%)
• 88% - 95% are left-sided
• Liver protective on the right side
• Left-sided herniation:
• Stomach, small bowel, omentum
• Right-sided herniation:
• Liver or omentum
• higher morbidity/mortality related to tears of the IVC or hepatic vein

12. Clinical Presentation
• Chest pain
• Shortness of breath
• Decreased breath sounds on the affected side
• Bowel sounds in the chest

13. Diagnosis
• Chest X-ray:
• Hemidiaphragm elevation
• Hollow viscus gas above the diaphragm
• Ipsilateral loss of lung volume
• CT scan:
• Rarely a defect in the diaphragm can be identified
• Herniation into the chest
• Diagnostic laparoscopy:
• Most sensitive test to identify diaphragmatic injury, also allows for
laparoscopic repair

14. Management
• Open repair
• Abdominal approach
• Thoracic approach
• Laparoscopic repair
• Mesh may be required if a tension-free repair cannot be achieved

15. 62 year old female with a
history of subtotal
gastrectomy with Roux-en-y
reconstruction presents
with acute onset of severe
abdominal pain and a
leukocytosis.
Diagnosis?

16. When a gastrectomy is
performed, the intestines
must be rerouted for
appropriate drainage. The
duodenum cannot be
mobilized without
devascularizing it, so it is
reconnected to drain
further down the jejunum
to create a “roux en y”
configuration.

17. Notice the “swirl sign”
which signifies twisting
of the mesentery.

18. The biliopancreatic limb
is massively dilated and
fluid filled

19. At the jejunojunal staple
line, notice that there is
dilation proximally and it
is decompressed distally

20. An internal hernia can occur at
the defect created in the
mesentery during the
jejunojejunostomy creation.

23. Quick Facts
• Hernias in Roux-en-y patients are more likely to be internal hernias
as compared to those caused by adhesions
• 4.5% of patients will experience an internal hernia after their
operation (1 in 20!)
• Can happen at any time, average 225 days after their operation
(range 2-490 days)
• Can be acute or chronic in nature- duration of symptoms 1-180
days
• CT only right 64% of the time, likely due to inexperience looking at
images from Roux-en-y patients, hence the importance of the next
article

25. Seven Signs of Internal Hernia after Roux-en-Y
1. Swirled appearance of mesenteric fat or vessels at the root of the mesentery
2. Small-bowel obstruction
3. Clustered loops of small bowel
4. Mushroom shape of the herniated mesenteric root with crowding and stretching
of the mesenteric vessels
5. Tubular or round shape of distal mesenteric fat closely surrounded by bowel
loops
6. Small bowel other than duodenum passing posterior to the superior mesenteric
artery (SMA)
7. Right-sided location of distal jejunal anastomosis

26. One of the reviewers was a third year resident, showing that these
signs can be identified by a novice

27. 75M presents with swelling
in his left groin, abdominal
pain, nausea and vomiting.
Diagnosis?

28. Inguinal Hernia

29. Notice the hernia
sac that is bowel
containing and
tracks into the
scrotum.

31. Inguinal Hernias
● Account for 75% of all abdominal wall hernias
● Lifetime risk:
○ 27% in men
○ 3% women
● Risk of strangulation is low in all age groups <0.5%

32. Surgical Approach?
● Mesh vs. sutured?
○ Recurrence less common in hernias repaired with mesh
○ Hazard ratio 0.25
● Open vs. laparoscopy?
○ Laparoscopy: Results in longer operative time, quicker return to
baseline activities
○ Open: Increased postoperative pain and complications
● Infertility <2.0% for all ages, increased in cases of recurrent repairs

33. Summary Of Diagnoses This Month
▪ Traumatic diaphragmatic hernia
▪ Internal hernia after Roux-en-y
▪ Inguinal hernia

34. See You Next Month!