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Adult Abdominal Imaging Case Studies
Michael Avery, DO, Joshua Davis, MD, Kelsey Lena, MD,
Brent Matthews, MD
Departments ...
Disclosures
▪ This ongoing abdominal imaging interpretation series is proudly co-
sponsored by the Emergency Medicine & Su...
Process
▪ Many are providing cases and these slides are shared with all contributors.
▪ Contributors from many Carolinas M...
It’s All About The Anatomy!
Systematic Approach to Abdominal CTs
● Aorta Down - follow the flow of blood!
○ Thoracic Aorta → Abdominal Aorta → Bifurca...
Systematic Approach to Abdominal CTs
● Abdominal Wall/Soft Tissue Up
○ Free air, abscesses, hernias
● Retroperitoneum Down...
CASE #1:
A 70-year-old female
with a history of
abdominoperineal
resection with VRAM
flap reconstruction
and a right-sided...
CBD
SMV
SMA
duodenum
Portal vein
CBD and PD
Fecalization of small bowel contents Decompressed distal loop of
the small bow...
Parastomal Hernias
• The incidence of parastomal hernias varies and are highest for end-
colostomies; estimated to occur in 4-48% of patients...
• Upon the construction of an end-colostomy, the use of prophylactic,
synthetic non-absorbable mesh is strongly recommende...
CASE #2:
A 21-year-old male with
no significant medical
history presented to the
ED with 24 hours of
increasing left groin...
Inguinal hernia
defect
Hernia extending into
inguinal canal and scrotum
Sigmoid colon and omentum
entrapped in hernia sac
...
Hernia Types:
Inguinal:
• Above the inguinal ligament
• Direct and indirect
Femoral:
• Below the inguinal ligament
Epidemi...
Inguinal Hernias
• Protrusion of abdominal cavity contents through the inguinal canal:
-Present with swelling and/or pain ...
Sliding Inguinal
Hernia
• A sliding hernia is a protrusion
through an abdominal wall of a
retroperitoneal organ. The
frequ...
CASE #3:
A 62-year-old female
with a past medical
history of ventral hernia
repair with mesh
presented to the ED
with abdo...
Significant gas containing density
fluid collection in the right anterior
abdominal wall
Inferior to the abscess is a
righ...
Abdominal Wall Abscess
• Purulent skin and soft tissue infection
• Clinical features include surrounding erythema, fluctua...
Abdominal
Wall Abscess
Treatment
• Bedside incision and drainage:
-Abscesses < 5 cm in diameter
-Packing for immunocomprom...
• Analysis demonstrated that the lowest surgical site infection (SSI) rate belonged to non-smokers with BMI < 24.2 kg/m2
(...
Summary Of Diagnoses This Month
● Parastomal hernia with mechanical obstruction
● Incarcerated inguinal hernia
● Abdominal...
See You Next Month!
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: May Cases
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: May Cases
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: May Cases
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: May Cases
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Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: May Cases

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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 also offers additional expert guidance by Dr. Brent Matthews

This month’s topics include:
Parastomal hernia
Obstruction
Incarcerated inguinal hernia
Abdominal wall abscess secondary to infected mesh framework

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

  1. 1. Adult Abdominal Imaging Case Studies Michael Avery, DO, Joshua Davis, MD, Kelsey Lena, MD, Brent Matthews, MD Departments of Surgery & Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Kyle Cunningham, MD & Michael Gibbs MD - Faculty Editors Abdominal Imaging Mastery Project May 2021
  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. CASE #1: A 70-year-old female with a history of abdominoperineal resection with VRAM flap reconstruction and a right-sided end colostomy, presents to the ED with several days of decreased ostomy output and 6- 12 hours of abdominal pain. The physical exam demonstrated a firm bulge by the stoma. CT imaging is obtained. Diagnosis? CBD SMV SMA duodenum Portal vein CBD and PD
  8. 8. CBD SMV SMA duodenum Portal vein CBD and PD Fecalization of small bowel contents Decompressed distal loop of the small bowel Transverse colon Sigmoid colon end colostomy CASE #1: The patient’s CT scan demonstrated a parastomal hernia with a mechanical obstruction. The hernia was not reducible. Ultimately, the patient went to the operating room for parastomal hernia repair. Note: The patient end colostomy was right- sided as the VRAM flap was harvested from the left side.
  9. 9. Parastomal Hernias
  10. 10. • The incidence of parastomal hernias varies and are highest for end- colostomies; estimated to occur in 4-48% of patients undergoing this procedure. • Risk factors: obesity, wound infection, and conditions causing increased abdominal pressure (COPD, ascites, chronic constipation). • Indications for operative fixation include symptoms of obstruction or bowel strangulation, refractory appliance leakage. • Our patient underwent a Sugarbaker repair with mesh placement (see diagram next slide). Parastomal Hernias
  11. 11. • Upon the construction of an end-colostomy, the use of prophylactic, synthetic non-absorbable mesh is strongly recommended to avoid the subsequent development of a parastomal hernia. • Suture repair of a parastomal hernia not recommended for elective repair. • The use of mesh is recommended, safe, and infrequently associated with infection. • In laparoscopic repair a Sugarbaker mesh technique is superior to a Keyhole technique; showing fewer recurrences. Summary Of Guideline Recommendations
  12. 12. CASE #2: A 21-year-old male with no significant medical history presented to the ED with 24 hours of increasing left groin and scrotal swelling. Physical examination reveals in enlarged, tender left hemi- scrotum, with overlying skin erythema. Diagnosis?
  13. 13. Inguinal hernia defect Hernia extending into inguinal canal and scrotum Sigmoid colon and omentum entrapped in hernia sac CASE #2: A 21-year-old male with no significant medical history presented to the ED with 24 hours of increasing left groin and scrotal swelling. Diagnosis? Incarcerated left inguinal hernia with colon and omentum entrapped in the hernia sac.
  14. 14. Hernia Types: Inguinal: • Above the inguinal ligament • Direct and indirect Femoral: • Below the inguinal ligament Epidemiology: • The lifetime risk is 27% in men and 3% in women. Femoral hernias are more common in women. • Indirect hernias twice as common as direct hernias. • A family history increases the risk 8- fold.
  15. 15. Inguinal Hernias • Protrusion of abdominal cavity contents through the inguinal canal: -Present with swelling and/or pain in the groin -7:1 male-to-female ratio • Divided into two categories based on anatomy: -Indirect -Hernia lateral to inferior epigastric vessels -Males: anterior to the spermatic cord; females: follows the round ligament -Direct -Hernia medial to the inferior epigastric vessels • Complications: incarceration, strangulation, bowel obstruction
  16. 16. Sliding Inguinal Hernia • A sliding hernia is a protrusion through an abdominal wall of a retroperitoneal organ. The frequency of sliding hernias is estimated at 6-8% of all elective inguinal hernia repairs. • The sliding inguinal hernia is a rare finding. The risk of injury of the sliding organ in minimal. If a tension free technique is used, the risk of recurrence is similar to that of patients with non-sliding inguinal hernia.
  17. 17. CASE #3: A 62-year-old female with a past medical history of ventral hernia repair with mesh presented to the ED with abdominal pain and vomiting. Physical examination reveals abdominal tenderness and erythema at the site of the prior hernia repair. Due to concern for acute kidney injury, a CT abdomen/pelvis without contrast was obtained. Diagnosis?
  18. 18. Significant gas containing density fluid collection in the right anterior abdominal wall Inferior to the abscess is a right lower quadrant abdominal wall hernia containing distended loops of small bowel CASE #3: A 62-year-old female with a past medical history of ventral hernia repair with mesh presented to the ED with abdominal pain and vomiting. Diagnosis? Abdominal wall abscess. The patient was taken to the operating room where 3 liters of purulent material was drained, and an infected mesh was identified and excised.
  19. 19. Abdominal Wall Abscess • Purulent skin and soft tissue infection • Clinical features include surrounding erythema, fluctuance, and/or a tender nodular region with surrounding induration • Soft tissue ultrasound can differentiate between between abscess and cellulitis: -Cellulitis: cobblestoning -Abscess: cobblestoning + fluid collection with “swirl” • CT imaging can be obtained if there is concern for a subsequent abscess communicating with the intra-abdominal cavity
  20. 20. Abdominal Wall Abscess Treatment • Bedside incision and drainage: -Abscesses < 5 cm in diameter -Packing for immunocompromised or diabetic patient -Loop drainage with vessel ties or a Penrose drain as an alternative • Formal surgical incision and drainage with subsequent wash-out performed on patients with larger anterior abdominal wall abscesses • Antibiotic coverage: MRSA (vancomycin or Bactrim) + Gram negatives (piperacillin tazobactam)
  21. 21. • Analysis demonstrated that the lowest surgical site infection (SSI) rate belonged to non-smokers with BMI < 24.2 kg/m2 (1.9%), and the highest SSI to smokers with BMI > 42.3 kg/m2 (12%). • Between the values above, there was a stepwise increase in SSI rate as BMI increased, while smoking added additional risk in each group. • Immunosuppressive drugs use, urgent repair, and postoperative surgical site infection are predictive of mesh infection. • Risk factors of prosthesis explantation are PTFE mesh, onlay mesh position, and associated enterotomy in the same procedure.
  22. 22. Summary Of Diagnoses This Month ● Parastomal hernia with mechanical obstruction ● Incarcerated inguinal hernia ● Abdominal wall abscess secondary to infected mesh framework
  23. 23. 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 also offers additional expert guidance by Dr. Brent Matthews This month’s topics include: Parastomal hernia Obstruction Incarcerated inguinal hernia Abdominal wall abscess secondary to infected mesh framework

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