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Adult Abdominal Imaging Case Studies
Michael Avery, DO; Joshua Davis, MD; Kelsey Lena, MD
Department of Surgery & Emergenc...
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:
50-year-old male with
a past medical history
of exploratory
laparotomy who
presents with
constipation, nausea,
and d...
CASE:
50-year-old male with a past
medical history of exploratory
laparotomy who presents with
constipation, nausea, and
a...
Internal Hernias
• Protrusion of visceral contents through a congenital or acquired
defect in the peritoneum or mesentery ...
Internal Hernias
• Clinical features
• Abdominal pain
• Nausea and vomiting
• Abdominal distention and constipation
• Diag...
Internal Hernia Treatment
• Conservative management
• Indications
• No evidence of hemodynamic instability
• No evidence o...
CASE:
42-year-old man with previous
open appendectomy who
presents with third recurrent
small bowel obstruction after
rece...
CASE:
Patient underwent upper
endoscopy on same admission
for management of small bowel
obstruction.
Endoscopy demonstrate...
Management
overview:
• When reviewing CTs for bowel obstructions,
identify transition points as areas of decompressed
bowe...
CASE:
Patient is a 58-year-old male
with a history of recurrent
diverticulitis who presents for a
3 day history of diffuse...
Diagnosis:
Colonic perforation secondary
to acute diverticulitis
The colonic perforation is
involving the mid-descending
c...
Colonic
Perforation
• Commonly due to diverticulitis, neoplasm, non-
iatrogenic trauma mechanisms, and iatrogenic
mechanis...
Colonic
Perforation
Treatment
• Intravenous fluid bolus and initiation of broad
spectrum antibiotic therapy
-Metronidazole...
Summary Of Diagnoses This Month
● Internal hernia
● Small bowel obstruction secondary to neoplasm
● Colonic perforation
See You Next Month!
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Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: November 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’s topics include:
- Internal Hernia
- Small Bowel Obstruction Secondary to Neoplasm
- Colonic Perforation

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Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: November 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 November 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. CASE: 50-year-old male with a past medical history of exploratory laparotomy who presents with constipation, nausea, and diffuse abdominal pain for 2 days. Leukocytosis of 13.1 present in the emergency department. Diagnosis?
  8. 8. CASE: 50-year-old male with a past medical history of exploratory laparotomy who presents with constipation, nausea, and abdominal pain in the setting of a leukocytosis of 13.1. Diagnosis: Internal hernia Small bowel obstruction Herniation of fat Mesenteric Edema, stretching of mesenteric vessels
  9. 9. Internal Hernias • Protrusion of visceral contents through a congenital or acquired defect in the peritoneum or mesentery within the abdominal cavity • Patients with a history of Roux-en-Y gastric bypass or live transplant are especially at risk of internal hernia formation • Incidence of <1% • Most common content of internal hernia is small bowel loops
  10. 10. Internal Hernias • Clinical features • Abdominal pain • Nausea and vomiting • Abdominal distention and constipation • Diagnostic Features • Distended bowel loops in an abnormal location • Crowding of small bowel loops within a potential hernia sac • Mesenteric engorgement, twisting, stretching or crowding • Evidence of obstruction
  11. 11. Internal Hernia Treatment • Conservative management • Indications • No evidence of hemodynamic instability • No evidence of sepsis or peritonitis • Surgery: • Either open or laparoscopic • Procedure: reduction of the hernia and closure of the peritoneal or mesenteric defect • Indications • Evidence of hemodynamic instability • Evidence of sepsis or peritonitis • No signs of improvement on conservative management
  12. 12. CASE: 42-year-old man with previous open appendectomy who presents with third recurrent small bowel obstruction after recent discharge. CT scan shows gastric wall thickening/enhancement and diffusely dilated small bowel with right lower quadrant transition point. Diagnosis?
  13. 13. CASE: Patient underwent upper endoscopy on same admission for management of small bowel obstruction. Endoscopy demonstrated non- bleeding gastric body mass with pathology of poorly differentiated gastric adenocarcinoma and gastritis with H. pylori infection. Eventual exploratory laparotomy demonstrated diffuse peritoneal metastasis. Right lower quadrant transition point Gastric thickening and wall enhancement Dilated small bowel with air fluid levels
  14. 14. Management overview: • When reviewing CTs for bowel obstructions, identify transition points as areas of decompressed bowel contiguous to areas of dilated bowel. • Multiple, frequent presentations with recurrent bowel obstructions need further workup to identify underlying pathology (i.e., mechanical/adhesive disease, potential carcinoma, etc). • Gastric adenocarcinoma carries high mortality with 31% 5-year survival rate.1 • Patient’s need staging CT chest/abdomen/pelvis and will benefit from early port placement if chemo is to be pursued. Rawla P, Barsouk A. Epidemiology of gastric cancer: global trends, risk factors and prevention. Prz Gastroenterol. 2019;14(1):26-38. doi:10.5114/pg.2018.80001
  15. 15. CASE: Patient is a 58-year-old male with a history of recurrent diverticulitis who presents for a 3 day history of diffuse abdominal pain with associated nausea and unrelenting vomiting. Patient is diaphoretic on examination with vital signs revealing heart rate 130 bpm, blood pressure 84/52 mm Hg, and oxygen saturation 95% on room air. Diagnosis?
  16. 16. Diagnosis: Colonic perforation secondary to acute diverticulitis The colonic perforation is involving the mid-descending colon posteriorly. Additionally, notice the abundant amount of extraluminal stool.
  17. 17. Colonic Perforation • Commonly due to diverticulitis, neoplasm, non- iatrogenic trauma mechanisms, and iatrogenic mechanisms (1) -Incidence in colonoscopy: 1/1400 procedures • Clinical manifestations depend on nature of contents released (stool or gas), ability of surrounding tissues to contain those contents, and patient’s ability to mount an inflammatory response (1) • Symptomatic presentation can range for general abdominal pain to septic shock. As such, a broad work-up is typically required • Complications include peritonitis, abscess formation, and fistula formation
  18. 18. Colonic Perforation Treatment • Intravenous fluid bolus and initiation of broad spectrum antibiotic therapy -Metronidazole + Cefazolin or Ceftriaxone • Indications for abdominal exploration include radiologic evidence of perforation PLUS one of the following: sepsis, diffuse peritonitis, bowel ischemia, or complete/closed loop bowel obstruction (1) • Perforation is small  simple suture via laparoscopic approach • Perforation larger with evidence of devascularization of the colonic wall  colon resection Nassour I, Fang SH Gastrointestinal perforation. JAMA Surg 2015;150:177
  19. 19. Summary Of Diagnoses This Month ● Internal hernia ● Small bowel obstruction secondary to neoplasm ● Colonic perforation
  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: - Internal Hernia - Small Bowel Obstruction Secondary to Neoplasm - Colonic Perforation

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