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: Enterovesical Fistula Abdominal Aorta Aneurysm Aortic Dissection

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
November 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! (sagittal cuts most useful)
 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. 38 year old male with no
past medical history
presents with abdominal
pain for 3 months and
“urinating corn and
lettuce” for the last
several weeks.
Diagnosis?

8. Enterovesical
fistula

10. Etiology
Diverticulitis 50-70%
Malignancy 20%
Crohn’s Disease 10%
Inflammatory
(Other)
Appendicitis, Meckel’s diverticulum, fungal infections,
tuberculosis, syphilis
Iatrogenic Cystoplasty, prostatectomy, laparoscopic inguinal
hernia, radiation
Foreign Body Catheters, dropped gallstones
Penetrating Trauma

11. Clinical Presentation
Recurrent urinary track infections 70-80%
Pneumaturia 60%
Faecaluria 40%
Urinary flow from rectum 15%
Other:
 Hematuria
 Changes in bowel habits
 Hematochezia
 Orchitis

12. Diagnosis
 Blood analysis is not useful
 Urinalysis will be abnormal but non-specific (85% of cases)
 Will have fecal debris
 Culture will grow fecal flora
 Charcoal test:
 Ingestion of charcoal and monitoring for blackened urine
 100% sensitive
 Poppy Seed test:
 50mg of poppy seeds
 Inspection of urine for next 48 hours
 Detection rate- 100%

13. Diagnosis
Imaging:
• Barium enema- sensitivity 20-35%
• Cystography- beehive sign is pathognomonic
• CT- Most sensitive (60-80%)
• Benefit of identifying underlying pathology
• MRI- Limited by time and cost
• No contrast needed

14. Diagnosis
Cystoscopy:
• Recommended by some as first line procedure in work-up
• Fails to identify fistula in 50% of patients
Colonoscopy:
• Poor at identifying fistulas
• Important in cases of underlying malignancy as etiology
• Sensitivity 11-89%

15. Management
Non-operative:
• 2% spontaneous closure rate; 75% of patients will develop infectious
complications
Endoscopic management:
• Fistulas <1cm can be closed with stents, clips, or fibrin glue
Operative:
• Primary resection anastomosis vs Hartmann Procedure
• High complication and perioperative mortality rate, due to the
associated medical comorbidities and underlying cause
• 5-year mortality rate- 60%

16. 69 year old male with a
history of hypertension,
peripheral vascular
disease, and smoking
who presents for
evaluation of 2 months
of back pain.
Diagnosis?

17. 7.9 cm AAA!

18. Aneurysm sac
with clot and
aortic wall
breakdown
material

19. Coronal Saggital

20. Transverse UltrasoundSaggital Ultrasound

21. • Prevalence: 5-10% of men 65-79 years old
• High mortality after rupture
• 80% in those reaching the hospital
• 50% in those with surgical repair
• Elective repair recommended if over 5.5 cm

24. 56 year old male
presents to emergency
department with
shortness of breath and
tearing chest pain
shooting to his back.
Diagnosis?

25. 56 year old male
presents to emergency
department with
shortness of breath and
tearing chest pain
shooting to his back.
Diagnosis?
Notice a widened
mediastinum

26. Aortic Dissection!
Intimal flap
creates a false
lumen from
thoracic to
abdominal aorta.

28. • Risk factors: connective tissue disorder, hypertension, trauma,
smoking
• Type A is a surgical emergency, Type B can be managed medically and
now with endovascular repair to prevent complications
• General goal: HR < 70 beats/min, SBP <120 mm Hg
• 40% of medically managed type B dissections will require surgical
intervention due to aneurysmal transformation

29. Complicated Type B Dissection
• Complicated dissection
require emergent
intervention
• Complicated: dissection
extends to branching vessels
to cause organ ischemia or
aortic rupture

30. Summary Of Diagnoses This Month
▪ Enterovesical fistula
▪ AAA
▪ Aortic Dissection

31. See You Next Month!