Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

0

Share

Download to read offline

Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: July Cases

Download to read offline

Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents 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. This month’s topics include:
• Malignant Bowel Obstruction
• Liver Laceration
• Sigmoid Volvulus

  • Be the first to like this

Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: July Cases

  1. 1. Adult Abdominal Imaging Case Studies Michael Avery, DO; Joshua Davis, MD; Kelsey Lena, 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 July 2020
  2. 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. 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. 4. It’s All About The Anatomy!
  5. 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. 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. 7. 54-year-old women presents with several months of weight loss, vague abdominal pain, oral intolerance, and increasing nausea / vomiting. Diagnosis?
  8. 8. 54-year-old women presents with several months of weight loss, vague abdominal pain, oral intolerance, and increasing nausea / vomiting. Obstructing cecal adenocarcinoma. CT shows RLQ mass (left) with decompressed ascending colon (right) and diffusely dilated small bowel. Colonoscopy confirms diagnosis.
  9. 9. Malignant Bowel Obstruction - Initial approach is standard fluid resuscitation and correction of severe electrolyte derangements. - Placement of nasogastric tube if clinically indicated. - Contacting appropriate consultants for further work up as indicated.
  10. 10. Patient is an 8 year old male who fell directly on handlebars and developed epigastric pain. Presented to the ED as a Pediatric Trauma Code 2 Diagnosis?
  11. 11. Patient is an 8 year old male who fell directly on handlebars and developed epigastric pain. Presented to the ED as a Pediatric Trauma Code 2 Grade 3 hepatic liver laceration! Moderate perihepatic and pelvic blood products
  12. 12. Liver Lacerations and Hepatic Injuries from Trauma - In blunt abdominal trauma, the liver is injured ~5% (range 1- 10%) of the time - Patients can present with right upper quadrant pain, right shoulder tip pain (from diaphragmatic irritation), hypotension and shock • CT is the investigation of choice for evaluating liver trauma. • Lacerations appear as irregular linear/branching areas of hypoattenuation
  13. 13. Grading Liver Lacerations AAST Injury Scoring Scale
  14. 14. • Nonoperative management of blunt hepatic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury • Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy • Adjunctive therapies such as angiography, percutaneous drainage, endoscopy/ ERCP and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries
  15. 15. Patient is a 80 yo male who presented to the ED febrile with an altered mental status and was concurrently in atrial fibrillation with RVR. Physical examination revealed distended, but nontender abdomen. KUB shown here. Diagnosis?
  16. 16. 80 yo male – febrile, altered mental status and evidence of atrial fibrillation with RVR. Physical examination with distended, but nontender abdomen. Sigmoid Volvulus Note massively dilated loop of bowel Plain Abdominal X-Ray diagnostic in majority of cases. Imaging reveals an “omega” or “horseshoe” sign.
  17. 17. Sigmoid Volvulus • Condition in which the sigmoid colon wraps around itself and its own mesentery, resulting in a closed-loop obstruction • Accounts for 2-5% of colonic obstructions in the Western countries and 20-50% of obstruction in Eastern countries with highest incidence in the 4th-8th decades of life • Results in mucosal ischemic injury  bacterial translocation and bacteremia  colonic gangrene • Etiology is multifactorial, however, there appears to be an association with advanced age and colon redundancy as well as dolichomesentery • Presentation: abdominal pain and distention, constipation, nausea, vomiting, anorexia, and hematemesis
  18. 18. Treatment -Nonoperative management: colonoscopy with decompression -Operative management: sigmoidopexy, percutaneous endoscopic colostomy, or detorsion and sigmoid resection with primary anastomosis -Surgical treatment preferred due to high recurrence rate (55-90%) and morality rates (~40%)
  19. 19. Summary Of Diagnoses This Month ● Malignant Bowel Obstruction ● Liver Laceration ● Sigmoid Volvulus
  20. 20. See You Next Month!

Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents 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. This month’s topics include: • Malignant Bowel Obstruction • Liver Laceration • Sigmoid Volvulus

Views

Total views

2,619

On Slideshare

0

From embeds

0

Number of embeds

2,431

Actions

Downloads

8

Shares

0

Comments

0

Likes

0

×