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: • Splenic Laceration • Necrotizing Pancreatitis • Hepatic Abscess

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
May 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. 60 year old female presents to
the Emergency Department
with abdominal pain after
colonoscopy yesterday. Pain in
left upper quadrant, radiating to
left shoulder. Tolerating PO.
Diagnosis?

8. 60 year old female presents to
the Emergency Department
with abdominal pain after
colonoscopy yesterday. Pain in
left upper quadrant, radiating to
left shoulder. Tolerating PO.
Diagnosis?

9. 60 year old female presents to
the Emergency Department
with abdominal pain after
colonoscopy yesterday. Pain in
left upper quadrant, radiating to
left shoulder. Tolerating PO.
Diagnosis?
Grade 3 splenic laceration with
active extravasation
Patient was initially treated with
an embolization. This was
complicated by a splenic
abscess which was ultimately
managed with splenectomy.

10. Now, Since Our Patient Developed An
Iatrogenic Splenic Injury During A Colonoscopy,
We Will Discuss:
• The most recent colorectal cancer screen guidelines
• The complication of splenic injury during colonoscope
• Splenic injury management

12. Colorectal Cancer Screening
• Recent updates to guidelines
• Average risk:
• Initial screening age moved from 50 to 45
• Screen until age 75
• Age 76-85 based on person’s preferences, life expectancy, overall health,
and prior screening history.
• Over 85 years old no screening recommended
• Considered average risk if following criteria met:
• No personal history of colorectal cancer or certain polyps
• No family history of colorectal cancer (including FAP, Lynch syndrome)
• No personal history of inflammatory bowel disease
• No personal history of abdominal radiation for treatment of prior cancer

13. Colorectal Cancer Screening Methods
• Stool based tests:
• Highly sensitive fecal immunochemical test (FIT) yearly
• Highly sensitive guaiac fecal occult blood test yearly
• Multi-targeted stool DNA test every three years
• Visual exams of the colon:
• Colonoscopy every 10 years
• CT colonography every 5 years
• Flexible sigmoidoscopy every 5 years

16. Splenic Injury Epidemiology
• Colonoscopy is extremely safe and complications are rare with the
most common being hemorrhage (1%) and perforation (0.1%).
• Splenic injury is underreported and has an estimated incidence of
0.00005 and 0.017 %.
• Authors of this study estimated a rate of 0.02% with a
mortality of 5%.
• More common in females (76.5%) than males (23.5%)
• Presumed mechanisms:
• Direct trauma to the spleen
• Excessive splenocolic ligament traction
• Decrease in the relative mobility between the spleen and the colon

17. Splenic Injury Risk Factors
• 10.8% on anticoagulation
• 10% with history of inflammatory bowel disease
• 48% prior intra-abdominal surgery (17% colorectal operation)
• Routine screening 29.5% vs diagnostic study 70.5%
• 66% no difficulty noted during procedure

18. Splenic Injury Presentation/Management
• 2/3 of patients presented within 24 hours post procedure
• Complaints:
• Left upper quadrant pain- 58%
• Abdominal pain and dizziness- 17%
• Diffuse abdominal pain- 15%
• Dizziness- 10%
• Kehr sign positive in 56% of patients
• 70% of patients with > 3gm/dL drop in hemoglobin
• 11% of patients discharged at initial visit
• CT with 100% diagnostic sensitivity
• Management:
• 70% with splenectomy vs. 90% non-operative or embolization

19. 49-year-old female presents to
the Emergency Department
with altered mental status and
inability to tolerate PO after
recent discharge for treatment
of pancreatitis.
Diagnosis?

20. 49-year-old female presents to
the Emergency Department
with altered mental status and
inability to tolerate PO after
recent discharge for treatment
of pancreatitis.
Diagnosis?

21. Splenic infarction
Pancreatic Necrosis
49-year-old female presents to
the Emergency Department with
altered mental status and
inability to tolerate PO after
recent discharge for treatment
of pancreatitis.
Diagnosis?
Necrotizing pancreatitis (acute
necrotic collection) with splenic
infarction.

23. Initial Acute Pancreatitis Management
• Aggressive fluid resuscitation in the initial phase
• Lactated ringers is the preferred fluid for resuscitation.
• Must be cautious with fluid resuscitation due to high risk of pulmonary edema, heart
failure and abdominal compartment syndrome.
• 10-15ml/kg with higher rates of mechanical ventilation, abdominal compartment
syndrome and mortality compared to a 5-10ml/kg strategy.
• Adequate pain management
• Poorly controlled pain with negative effect on microvascularization also possibly
induces necrosis.
• Typically IV analgesics, epidural anesthesia shown benefits in a few trials but evidence is
limited.
• Nutrition
• Enteral is preferred route.
• No difference in nasogastric vs. nasojejunal feeding!

26. Necrotizing Pancreatitis
• Occurs in 5-10% of pancreatitis patients
• Infection occurs in 3 to 4 weeks but can occur earlier
• Infection diagnosed by gas on CT scan or by positive culture from
fine need aspiration
• FNA with high rates of false negatives
• FNA w/culture can help guide antibiotic selection
• No studies showing the benefit of routine FNA

27. ● Other rare indications for operative
intervention include; abdominal
compartment syndrome, acute bleeding,
bowel necrosis.
● Asymptomatic walled off necrosis
regardless of size does not need
intervention.
● Current guidelines recommend delaying
intervention for 3 to 4 weeks.
● Recent trials show benefit of intervention
before 4 weeks when using an endoscopic
transluminal step-up approach with
improvement in organ failure, low mortality
and no increase in other complications.

28. Acute Pancreatitis Complications
• Pancreatic fistulae
• Close spontaneously with a median of 70 days
• Stenting of fistula with similar rates of closure compared to a non-
interventional approach but on average over shorter time duration
• Disconnected pancreatic duct syndrome
• 30-50% of patients with necrotizing pancreatitis
• Managed with temporary or permanent stenting
• Causes recurrent fluid collections
• Long term can cause recurrent acute or chronic pancreatitis in the areas of
excluded gland
• Exocrine and endocrine pancreatic insufficiency
• Exocrine- 27.5% of patients ~36 months after index admission
• Endocrine- 23% of patients
• Both reduced with minimally invasive intervention vs. open necrosectomy

29. Acute Pancreatitis Complications
• Splanchnic vein thrombosis
• 16-18% of patients
• Typically asymptomatic and rarely causes complications
• Anticoagulation is controversial, no difference in re-cannulation rates,
increased risk of bleeding into necrotic collections
• Pseudoaneurysms
• Secondary to necrosis or operative intervention
• Splenic artery 35-50%
• Gastroduodenal and pancreaticoduodenal arteries 20-25%
• Mortality 34-52% after rupture - Requires embolization with or without
stenting

30. 47-year-old female presents to
the Emergency Department
with umbilical abdominal pain
for 3 days and fever after recent
travel to Africa.
Diagnosis?

31. 47 year old female presents to
the Emergency Department
with umbilical abdominal pain
for 3 days and fever after recent
travel to Africa.
Diagnosis?

32. 47-year-old female presents to
the Emergency Department
with umbilical abdominal pain
for 3 days and fever after recent
travel to Africa.
Diagnosis?
Intrahepatic abscess secondary
to Klebsiella pneumoniae. Also
tested positive for Hepatitis B.

34. Invasive K. pneumoniae
disease
● Emerging phenomena identified
in the late 1980s in Asia.
● Almost all reported cases were
community acquired.
● Diabetes mellitus identified as a
risk factor.
● Likely due to translocation from
the GI tract.
● Higher incidence of pathogenic
strains in stool from Asian
countries as compared to the
US or Europe, possible
explanation of geographic
distribution of cases.

35. Clinical Presentation
• Clinical features
• Most common- fever, chills, abdominal pain
• ¼ of patients presented with nausea and vomiting
• Laboratory evaluation:
• Leukocytosis and thrombocytopenia
• Elevated CRP, glucose, and LFTs
• CT scan was more sensitive than US in identifying abscesses- typically
in right lobe
• Metastatic disease associated with this syndrome
• Not always present on admission, diagnosed within 3 days of admission
• CNS- Meningitis, endophthalmitis (85% with permanent visual impairment)
• Pulmonary- septic pulmonary emboli, empyema
• MSK- Osteomyelitis, subcutaneous or muscular abscess, necrotizing fasciitis

36. Management
• Strict glycemic control appears to decrease the incidence of
metastatic disease.
• Treated with double coverage in USA, typically metronidazole and
3rd generation cephalosporin.
• ESBL rare but if detected treated with carbapenems.
• Antibiotic duration guided by clinical response.
• Percutaneous drainage recommended but may require hepatic
resection in critically ill patients.

37. Summary Of Diagnoses This Month
● Splenic laceration
● Necrotizing pancreatitis
● Hepatic abscess due to K. pneumoniae

38. See You Next
Month!