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: • Necrotizing Enterocolitis (NEC) • Spontaneous Intestinal Perforation (SIP) • Intestinal Atresia

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
June 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. 2 week old premature ex-
32 week neonate who
presents with abdominal
distention and feed
intolerance. KUB shown
here.
Diagnosis?

8. 2 week old premature ex-
32 week neonate who
presents with abdominal
distention and feed
intolerance. KUB shown
here.
Necrotizing Enterocolitis
(NEC)!
Notice:
Portal venous gas
and
Intraluminal pneumatosis
intestinalis
Left lateral decubitus film
obtained to rule out free
air.

9. Necrotizing Enterocolitis (NEC)
- Bacterial translocation into intestinal wall
- Increased incidence in premature infants, peak incidence at 31
weeks of gestational age
- When concerned for perforation in neonate, obtain lateral
decubitus or cross table lateral x-ray to assess for free air
- Clinical signs: abdominal distention, food intolerance, bloody
stools

10. - Translocation of bacteria across intestinal wall.
- Related to altered local bacterial flora (ie dysbiosis)
and breakdown of mucosal protective barriers.
- Conflicting schools of thought whether breast milk
vs formula alters the risk of NEC by providing
different nutrients to the pre-term microbiome.

11. - Despite popular opinion that breast milk provides protection
against NEC, this meta-analysis showed no benefit of donor breast
milk vs formula in preterm infants.
- While some studies show a cost savings when considering donor
milk cost with the cost of NEC treatment, the use of donor milk in
preterm infants has not been validated as no alteration in risk for
NEC development has been confirmed.

12. 3 day old premature ex-
31 week neonate who
presents with abdominal
distention and feed
intolerance. KUB shown
here.
Diagnosis?

13. 3 day old premature ex-
31 week neonate who
presents with abdominal
distention and feed
intolerance. KUB shown
here.
Spontaneous Intestinal
Perforation
Massive
pneumoperitoneum

14. Spontaneous Intestinal Perforation
- Isolated location of intestinal perforation
- Increased survival compared to NEC
- Massive pneumoperitoneum:
- Football sign = massive pneumoperitoneum leaves outline
of falciform ligament on KUB
- Obtain cross table/lateral for NICU
Image from Alshahrani, M.A., Aloufi, F.F., Alabdulkarim, F.M. et al. The football sign. Abdom Radiol 42, 2769–2771 (2017).

15. - Mortality decreases with increasing birth weight.
- Mortality in all birth weight groups was higher for NEC vs SIP.
- Indomethacin and steroid use were noted to be more frequent in SIP for this
study.

16. 3 day full term infant
with po intolerance and
abdominal distention.
KUB shown here.
Note the massively
dilated stomach vs loop
of small bowel?
Which further imaging is
necessary?

17. 3 day full term infant
with po intolerance and
abdominal distention,
KUB shows dilated
stomach.
Proceed with Upper GI
series to assess anatomy.
Must rule out
malrotation!
Normal gastroduodenal
anatomy, note outline of
massively dilated loop of
bowel and normal gastric
filling!

18. 3 day full term infant
with po intolerance and
abdominal distention,
UGI shows dilated loop
of small bowel and
concern for distal
obstruction.
Proceeded with contrast
enema to evaluate distal
anatomy for obstruction.
Note abrupt cut off at
transverse colon.
Diagnosis?

19. 3 day full term infant
with po intolerance and
abdominal distention,
upper and lower GI
imaging reveals distal
obstruction with
proximal dilation and
distal decompression.
Intestinal Atresia!

20. Intestinal Atresia
- Can occur at any length along the intestine
- Proximal (Duodenal), Mid (Jejuno-ileal), Distal (Colonic)
- Requires surgical intervention.
- Largest concern is subsequent short-gut syndrome if large
segments of bowel require resection, although this is rare.
- Neonates might be able to pass meconium, will have po
intolerance, and often abdominal distention (although proximal
atresias may not present with distention!)

21. - Assuming no short-gut physiology, outcomes usually depend on
presence of concomitant congenital abnormalities.
- Duodenal atresias are thought to be congenital as opposed to
distal atresias are vascular events that result in necrotic and
malformed intestine/mesentery.
- Studies suggest that use of vasoactive medications and cigarette smoking
increase risk of intestinal atresia by 4x.

22. Summary Of Diagnoses This Month
● Necrotizing Enterocolitis (NEC)
● Spontaneous Intestinal Perforation (SIP)
● Intestinal Atresia

23. See You Next
Month!