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: ● Chilaiditi syndrome ● Retroperitoneal hematoma ● Rectus sheath hematoma

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
January 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. 74M chest x-ray after
trauma.
Diagnosis?

8. 74M chest x-ray after
trauma.
Diagnosis?
Chilaiditi syndrome
Notice the transposition of
the colon over the right
hemidiaphragm.

9. Here is the accompanying
lateral chest x-ray. Again
demonstrated is the elevated
right hemidiaphragm with
large bowel occupying that
space. Notice the intact
diaphragm, making this a
separate entity from
herniation as discussed in last
months cases.

10. Here is a look of the
accompanying CT Abdomen
that was obtained. Notice the
colon’s position anterior to the
liver.

11. The anterior
position of the
colon is again
noted on the
sagittal and
coronal views.

13. Chilaiditi Syndrome
● It is often mistaken for pneumoperitoneum.
● Chilaiditi Syndrome vs. Chilaiditi Sign is based on whether or not the patient is symptomatic.
● Common symptoms:
○ Emesis
○ Abdominal pain/distention
○ Constipation
● Extremely rare: 0.025%- 0.28% of the population
● No age or sex predominance.

14. Chilaiditi Syndrome
● Strict criteria for diagnosis:
○ Right hemidiaphragm elevated above the liver by bowel.
○ Bowel must be distended to appear as pseudo-pneumoperitoneum.
○ Liver depressed below the margin of the left hemidiaphragm .
● Causes:
○ Increased colonic mobility
○ Decreased hepatic volume
○ Phrenic nerve palsy
○ Obesity
● Treatment:
○ Primarily non-operative (74%), most resolve after bowel decompression.
○ Operative intervention was needed if associated with ischemia from obstruction
or volvulus.

15. 48M CNS lymphoma
presents with AMS and
hypotension, L hip pain
prior to presentation.
Normal platelets and INR
but on therapeutic lovenox
shots.
Diagnosis?

16. 48M CNS lymphoma
presents with AMS and
hypotension, L hip pain
prior to presentation.
Normal platelets and INR
but on therapeutic lovenox
shots.
Diagnosis?
Retroperitoneal
Hematoma

17. Accompanying
sagittal and coronal
views

19. ● Surgical intervention: only necessary after failed IR management
and for neural decompression.
● Mortality: 7 days - 5.6%, 30 days - 10.1%, 6 month - 19.1%
○ No statistically significant difference in mortality for
anticoagulated vs. non-anticoagulated patients.

20. 48F h/o renal transplant
with acute onset right
lower quadrant pain.
Diagnosis?

21. 48F h/o renal transplant
w/acute onset RLQ pain
Diagnosis?
Rectus sheath hematoma

22. Accompanying coronal
and sagittal views

24. Risk Factors
● Female (2:1 predominance)
● Advanced age - 68 years old on average (probably from increased
anticoagulation in the older population)
● Anticoagulation (⅔ of all patients)
● Trauma (even minor trauma)
○ Cough was #1 cause- this is how our patient presented in this case

28. ● Few patients (~17%) needed operative intervention, most of which was performed by IR with only one
case with a surgical approach.
● Medical management with transfusion (80%) was adequate in most cases.
● 70% of cases were managed in the ICU.

29. Summary Of Diagnoses This Month
● Chilaiditi syndrome
● Retroperitoneal hematoma
● Rectus sheath hematoma

30. See You Next
Month!