Drs. Kylee Brooks and Parker Hambright are Emergency Medicine Residents and Drs. Alexis Holland and William Lorenz are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham, Brent Matthews, 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. This month’s cases include: • Iatrogenic Esophageal Perforation • Emphysematous Cystitis • Meckel’s Diverticulum • Paraesophageal Hernia

1. Adult Abdominal Imaging Case Studies
Kylee Brooks, MD2, Parker Hambright, MD2, Alexis Holland MD1,
William Lorenz, MD1
Departments of Surgery1 & Emergency Medicine2
Carolinas Medical Center & Levine Children’s Hospital
Kyle Cunningham, MD1 & Brent Matthews, MD1 - Faculty Editors
Michael Gibbs, MD2 - Lead Editor
Abdominal Imaging Mastery Project
Presentation #27

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. It’s All About The Anatomy!

4. Systematic Approach to Abdominal CT Interpretation
● 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

5. CASE #1:
A 70-year-old female
with past medical history
of stroke, atrial
fibrillation, and
dysphagia secondary to
an esophageal mass
presents to the ED from
her gastroenterologist’s
clinic for abdominal pain
following an endoscopy.
Diagnosis?

6. Pneumoperitoneum
Diaphragm
Rigler Sign: the bowel wall is
visualized on both sides due to
intraluminal & extraluminal air.
CASE #1:
A portable upright chest
x-ray demonstrates free
air under the diaphragm,
indicative of
pneumoperitoneum.

7. CASE #1:
The patient continued to demonstrate stable vital signs so a CT-esophagram was obtained.
What are the pertinent findings?

8. Esophageal Mass
Pneumoperitoneum
Paraoesophageal Free Air
No Extravasated
Esophageal Contrast
CASE #1:
The patient continued to demonstrate stable vital signs so a CT-esophagram was obtained.
What are the pertinent findings?

9. Learning Point: Free air is often more readily identified
using a CT lung window than a CT abdominal window as
demonstrated by our patient’s images.
Abdominal Abdominal
Lung
Lung

10. Learning Point: Free air is more readily identified using lung windows rather than soft tissue windows.
A CT window is the range of Hounsfield units (HU) that will be represented as various shades of gray on
the image. Matter with HU greater than the window are represented as white and matter with HU less
than the window are represented as black. Lung windows range from -1350HU to +150HU, while
soft tissue windows range from -150HU to +250HU.
Air has a density of 1000HU falling within the range of HU of the CT lung window. This permits air to be
more readily contrasted from surrounding structures when the lung window is used.

11. Iatrogenic Esophageal Perforation
Causes
• Complication of endoscopy in 70% of cases
• Also: complication of NGT insertion, endotracheal intubation, TEE
Pathophysiology
The most common location of the perforation is at the pharyngoesophageal
junction, where the esophageal wall is the weakest
Mortality
• Overall mortality >20%
• Location and mortality: cervical > abdominal > thoracic
• Presence of an esophageal mass and delays in making the diagnosis are
associated with increased mortality

12. Iatrogenic Esophageal Perforations
Consider endoscopic esophageal clipping or
esophageal stenting if <1.5cm clean
perforation with minimal systemic symptoms
Early diagnosis (<24h) or delayed diagnosis (>24h) with contained leak
Perforation contained to mediastinum
No esophageal mass or obstruction
No evidence of sepsis or respiratory compromise
Resuscitation: IV crystalloid fluids, broad-spectrum antibiotics, nasogastric decompression, and NPO
Nonoperative
Operative
Nutrition: Consider nasogastric tube vs percutaneous gastrostomy tube vs total parenteral nutrition
Primary closure +/- buttressing of repair
Esophagectomy
T-Tube Drainage
*Approach determined by presence/absence of esophageal
obstruction, location of injury, and surgeon preference
Yes
No

13. Treatment Algorithm

14. Back To Our Patient…
The CT esophagram demonstrated pneumoperitoneum, pneumomediastium, and an
esophageal mass at the gastroesophageal junction.
Due to the perforation extending beyond the mediastinum and associated mass, the
patient underwent operative repair with an urgent laparoscopic esophagogastrectomy
with re-anastomosis.
The site of perforation was identified as immediately proximal to the esophageal mass.
Pathology identified the mass as an esophageal adenocarcinoma.
A gastrojejunostomy tube was placed. The patient has since been initiated on enteral
nutrition and subsequent upper GI series demonstrates no evidence of recurrent leak.

15. CASE #2:
A 65-year-old male
presents with 10 days of
generalized weakness,
confusion, poor oral
intake, abdominal pain,
nausea and multiple
episodes of urinary
incontinence.
Vital Signs:
HR 116, BP 111/70, Afebrile
Diagnosis?

16. CASE #2:
CT cystogram reveals
bladder wall thickening
and emphysema (→)
with at least two sites of
bladder wall perforation
consistent with
emphysematous cystitis.
Contrast agent is seen
tracking along course of
emphysema into
posterior peritoneum
(⇒).

17. CASE #2:
CT shows
emphysematous cystitis
and bladder rupture
with air tracking into
mesentery and
abdominal wall soft
tissues. Air is also seen
within the right renal
collecting system with
mild right-sided
hydronephrosis and air
within the right ureter. Air Within The
Right Renal
Collecting
System
Labs: WBC of 33.5, lactate 3.9, anion gap 28, glucose 456, BUN 133, Creatinine 3.94.

18. Emphysematous Cystitis
• Rare but life-threatening necrotizing infection characterized by gas
within the bladder and bladder wall
• Caused by gas-producing pathogens such as E. coli, Klebsiella
pneumoniae, Proteus mirabilis, Enterobacter and streptococcus species1
• Risk factors: diabetes mellitus, bladder outlet obstruction, neurogenic
bladder, female sex
• 7-20% mortality2
150% of patients with emphysematous cystitis have concomitant bacteremia
2Higher mortality rate with involvement of kidneys and renal parenchyma

19. Emphysematous Cystitis
Clinical Presentation:
• 7% present with asymptomatic pneumaturia
• Most present with classic symptoms of urinary tract infection (dysuria,
frequency, hesitancy, hematuria)
• Presentation can escalate to acute abdomen on exam or septic shock
Diagnosis:
• Radiologic evidence of gas within the bladder wall without evidence of
bladder fistula or history of iatrogenic pneumaturia

20. Emphysematous Cystitis
Management:
• Broad spectrum antibiotics
• Bladder drainage and decompression
• Control of diabetes
• Surgical intervention reserved for severe cases or those refractory to
medical management

21. Back To Our Patient…
General Surgery and Urology were consulted and the patient was admitted to the ICU.
He underwent emergency surgery overnight for partial cystectomy, cystorrhaphy,
rectosigmoid colon resection left in discontinuity with wound vac placement.
He subsequently became hemodynamically unstable requiring vasopressor support and
remained intubated and sedated postoperatively.
Neurologically, the patient remained unresponsive and the decision was made to pursue
comfort care. The patient expired shortly thereafter.
Cause of death: septic shock.

22. CASE #3:
47-year-old male who
presented to the
emergency department
with large volume
melanotic stool and
dizziness.
Diagnosis?

23. CASE #3:
A CT-A of the abdomen
and pelvis reveals a
tubular blind pouch
ending off of the small
bowel. There is no
contrast extravasation.
Tubular
Structure
Ending In A
Blind Pouch.

24. The Case Continues
• The patient is evaluated by GI with EGD/Colonoscopy. There are no
signs of active bleeding
• Surgical consult was obtained a suspicion for Meckel’s Diverticulum
• Surgery obtained a 99mTc Pertechnetate Meckel Diverticulum Scan1.
1The gastric mucosa also has an affinity for technetium and will take it up.

25. CASE #3:
99mTc Pertechnetate
Meckel Diverticulum
Scan reveals focal uptake
in the RLQ with similar
dynamics to gastric
mucosa, consistent with
a Meckel’s Diverticulum.
Heterotopic
Uptake In
The RLQ
Uptake Of
The Gastric
Mucosa

26. The Case Continues
• The patient was taken to the OR for diagnostic laparoscopy, which
revealed a blind ending tubular structure on small bowel
• There was a small bowel resection of the involved segment with re-
anastomosis
• Pathology confirm Meckel’s diverticulum with heterotopic gastric
mucosa

27. Meckel’s Diverticulum
• Incomplete obliteration of vitelline duct
• Presentation:
• Asymptomatic
• GI bleed
• Diagnostic evaluation options:
• CT-angiography
• Meckel’s Scan- 99 technetium pertechnetate
• Capsule endoscopy if the patient is stable and a prep is possible.

28. Meckel’s Diverticulum: Management
Symptomatic
• Diagnostic laparoscopy vs
Exploratory laparotomy
• Diverticulectomy if it will not
narrow the small intestine lumen
• Small bowel resection with
anastomosis
Asymptomatic
• Found on imaging: no further
action needed
• Found on operation: surgeon
discretion

29. CASE #4:
62-year-old male with a
history of GERD, who
presents to the ED with
dysphagia, regurgitation,
and worsening reflux.
Vital Signs:
97.2, HR 67, BP 139/70.
Diagnosis?

30. CASE #4:
62-year-old male with a
history of GERD, who
presents to the ED with
dysphagia, regurgitation,
and worsening reflux.
Herniation Of The
Stomach Into The Chest.

31. 62-year-old male with a history of GERD, who presents to the ED with dysphagia,
regurgitation, and worsening reflux, with herniation of the stomach.

32. Classification Of Hiatal Hernias
Type I: Sliding Hernias
• Gastroesophageal junction (GEJ)
slides through the esophageal hiatus
into the mediastinum
• No true hernia sac
Paraesophageal Hernias
Type II – gastric fundus herniates
through the hiatus alongside the GEJ
but the GEJ remains in normal position
Type III – displaced GEJ into the thorax
with a hernia sac containing the fundus
or body of the stomach into the thorax
Type IV – defined by other organs in
addition to the stomach prolapsing into
the chest:
• Colon or small bowel
• Spleen
• Pancreas

34. UGI Showing
Stomach Above
The Diaphragm
UGI Showing
Stomach Above
The Diaphragm

35. Hiatal & Paraesophageal Hernias
Risk Factors:
• Genetic/familial predisposition
• Obesity
• Connective tissue disorders
Presentation:
Can present as an acute obstruction secondary to gastric or bowel
volvulus = surgical emergency!

36. Hiatal & Paraesophageal Hernias
Presentation:
• Nausea, vomiting, regurgitation
• Dysphagia, postprandial fullness, bloating
• Chest pain
• Shortness or breath, cough, aspiration
More symptomatic with more abdominal contents in the chest!

37. Hiatal & Paraesophageal Hernias
Diagnosis:
CT imaging
Pre-Operative Evaluation:
• Upper GI
• Manometry
• Upper endoscopy

38. Hiatal & Paraesophageal Hernias
Surgical Treatment
• Type I does not require Rx
• Symptomatic Type II-IV hernias
benefit from repair if the patient
can tolerate surgery
Complications Of No Treatment
• Barrett’s esophagus
• Esophageal carcinoma
• Perforation
• Volvulus
Medical Management: high dose antacid + proton pump inhibitor + H2 Blocker

39. Hiatal & Paraesophageal Hernias
Surgical Considerations:
1. Open vs. Laparoscopic/Robotic PEH Repair
2. Reduce the herniated contents
3. Close the hiatus with suture +/- mesh placement
4. Fundoplication: wrap the fundus of the stomach around the esophagus to prevent reflux
• Nissen vs. Partial (Toupet or Dor)
• Nissen: full 360 degree wrap to recreate lower esophageal sphincter
• Partial: 270 degree wrap to prevent dysphagia that can occur with a full wrap

40. Back To Our Patient…
The patient underwent laparoscopic paraesophageal hernia repair with mesh + Toupet
partial fundoplication
A postoperative esophagram + UGI confirmed repair and ruled out a leak
The patient discharged once he was tolerating clear liquids
The patient’s diet was advanced to blenderized liquids at home and then slowly
reintroduce regular food over the next couple weeks with bread and meat being the
last things added back.

41. Summary Of Diagnoses This Month
• Iatrogenic Esophageal Perforation
• Emphysematous Cystitis
• Meckel’s Diverticulum
• Paraesophageal Hernia

42. See You Next Month!