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: Gastric bubble pattern, nonspecific bowel gas pattern, post-operative ileum, constipation, free air under the diaphragm.

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
September 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. Benign Abdominal X-ray Imaging
 This month we will review common benign abdominal imaging
findings.
 Abdominal X-rays are usually referred to as KUB (kidney ureter
bladder).
 We present 4 simple cases with benign X-ray findings and will
discuss the findings.

6. 42M POD1
after umbilical
hernia repair.
POD = Post-Operative Day.

7. Normal
gastric
bubble.
Large
gastric
bubble.
42M POD1
after umbilical
hernia repair.

8. Large gastric bubble.
Nasogastric tube placed
for decompression. It is
curled in the fundus.
Massively distended stomach.
Nasogastric tube needs to be
advanced another 4 cm. The tip lies
just past the gastroesophageal
junction.

9. The Gastric Bubble
 Not to be confused with pneumoperitoneum!
 Present on 70% of chest X-rays.
 Very distended stomach can cause respiratory insufficiency and
abdominal pain.
 If a chest X-ray for respiratory insufficiency shows a large gastric
bubble in a postoperative patient, an NGT should be placed for
decompression.

10. 73F presents for
evaluation of
new onset
diarrhea with
fevers at home.

11. A “nonspecific bowel gas
pattern” is a term to describe
no obvious pathology.
Note that the small
bowel does not appear
distended and no air
fluid levels can be seen.
Note that the colon is
gas filled.. again, we
know this is colon
because of the haustra.

12. The Nonspecific Bowel-Gas Pattern
 When the abdominal x-ray does not have obvious pathology, the
radiologist describes it as “nonspecific bowel-gas pattern.”
 Always important to over read your own images - look for air under
the diaphragm.
 The amount of bowel gas in the abdomen is variable and represents
mainly swallowed air.

13. In a small sample size these authors found that there was a statistically significant
difference between the meaning of the term to radiologists and referring physicians
and recommend the term be abandoned.

14. 87F POD3 after lower
anterior resection
who has abdominal
distention and
nausea.

15. Note the small
bowel is identifiable
by the plicae
circulares outline.
Large bowel
haustra are
noticeable as going
all the way across
the bowel width.
Feces can be
appreciated in
the left colon.
An “ileus” implies that the
instestine has delayed
motility. We expect to see
air in both the colon and
the small intestine.

16. The Post-Operative Ileus
 In the post-operative period motility returns in order from earliest to
latest: small bowel within 24h, stomach within 48h and colon within
72h.
 No action is necessary for postoperative ileus, although an NGT can be
placed in the setting of nausea and vomiting.
 Few practices have been shown to minimize the length of post-
operative ileus: mu opioid antagonist and early enteral feeding have
been shown to increase return of bowel function.

17. 4 year old boy
presents to the ED
for evaluation of
abdominal pain.

18. Significant
amount of stool
within the right
colon.

19. Constipation
-50% of children with abdominal pain diagnosed with constipation and
this should be an incidental finding.
-Constipation is a clinical diagnosis and imaging should be used
sparingly.
-As demonstrated in the image, it is very similar to the “nonspecific
bowel gas pattern,” but radiopaque material can be seen between the
bowel walls.

21. Relying on a imaging of constipation makes you more likely to miss significant pathology!

22. Let’s Distinguish These
Benign Bowel Gas Patterns
From Free Air!

23. Free air.

24. Free air.
Companion CT Image: Perforation Of The Distal Esophagus.

25. Free air.
Perforation Of The Right Colon.

26. Free air. Free air.
Perforated Duodenal Ulcer

27. Diagnoses Of The Month
 Gastric bubble pattern
 Nonspecific bowel gas pattern
 Post-operative ileus
 Constipation
 Free air under the diaphragm

28. See You Next Month!