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.
Adult Abdominal Imaging Case Studies
Isolina R. Rossi, MD & Brian P. Shreve, MD
Department of Surgery & Emergency Medicine...
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...
42 male presents
after a motor
vehicle collision.
Diagnosis?
Left-sided
traumatic
diaphragmatic
hernia!
Left-sided
traumatic
diaphragmatic
hernia.
Stomach
herniated into
the left chest!
Etiology
• Traumatic diaphragmatic hernias:
• Occurs in 5% of major trauma victims
• Penetrating injury (10–19%)
• Blunt t...
Clinical Presentation
• Chest pain
• Shortness of breath
• Decreased breath sounds on the affected side
• Bowel sounds in ...
Diagnosis
• Chest X-ray:
• Hemidiaphragm elevation
• Hollow viscus gas above the diaphragm
• Ipsilateral loss of lung volu...
Management
• Open repair
• Abdominal approach
• Thoracic approach
• Laparoscopic repair
• Mesh may be required if a tensio...
62 year old female with a
history of subtotal
gastrectomy with Roux-en-y
reconstruction presents
with acute onset of sever...
When a gastrectomy is
performed, the intestines
must be rerouted for
appropriate drainage. The
duodenum cannot be
mobilize...
Notice the “swirl sign”
which signifies twisting
of the mesentery.
The biliopancreatic limb
is massively dilated and
fluid filled
At the jejunojunal staple
line, notice that there is
dilation proximally and it
is decompressed distally
An internal hernia can occur at
the defect created in the
mesentery during the
jejunojejunostomy creation.
Quick Facts
• Hernias in Roux-en-y patients are more likely to be internal hernias
as compared to those caused by adhesion...
Seven Signs of Internal Hernia after Roux-en-Y
1. Swirled appearance of mesenteric fat or vessels at the root of the mesen...
One of the reviewers was a third year resident, showing that these
signs can be identified by a novice
75M presents with swelling
in his left groin, abdominal
pain, nausea and vomiting.
Diagnosis?
Inguinal Hernia
Notice the hernia
sac that is bowel
containing and
tracks into the
scrotum.
Inguinal Hernias
● Account for 75% of all abdominal wall hernias
● Lifetime risk:
○ 27% in men
○ 3% women
● Risk of strang...
Surgical Approach?
● Mesh vs. sutured?
○ Recurrence less common in hernias repaired with mesh
○ Hazard ratio 0.25
● Open v...
Summary Of Diagnoses This Month
▪ Traumatic diaphragmatic hernia
▪ Internal hernia after Roux-en-y
▪ Inguinal hernia
See You Next Month!
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December Cases
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December Cases
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December Cases
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December Cases
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December Cases
Upcoming SlideShare
Loading in …5
×
Upcoming SlideShare
What to Upload to SlideShare
Next
Download to read offline and view in fullscreen.

0

Share

Download to read offline

Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December Cases

Download to read offline

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:
▪ Traumatic diaphragmatic hernia
▪ Internal hernia after Roux-en-y
▪ Inguinal hernia

Related Books

Free with a 30 day trial from Scribd

See all
  • Be the first to like this

Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December Cases

  1. 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 December 2019
  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. 42 male presents after a motor vehicle collision. Diagnosis?
  8. 8. Left-sided traumatic diaphragmatic hernia!
  9. 9. Left-sided traumatic diaphragmatic hernia. Stomach herniated into the left chest!
  10. 10. Etiology • Traumatic diaphragmatic hernias: • Occurs in 5% of major trauma victims • Penetrating injury (10–19%) • Blunt thoracic-abdominal trauma (5%) • 88% - 95% are left-sided • Liver protective on the right side • Left-sided herniation: • Stomach, small bowel, omentum • Right-sided herniation: • Liver or omentum • higher morbidity/mortality related to tears of the IVC or hepatic vein
  11. 11. Clinical Presentation • Chest pain • Shortness of breath • Decreased breath sounds on the affected side • Bowel sounds in the chest
  12. 12. Diagnosis • Chest X-ray: • Hemidiaphragm elevation • Hollow viscus gas above the diaphragm • Ipsilateral loss of lung volume • CT scan: • Rarely a defect in the diaphragm can be identified • Herniation into the chest • Diagnostic laparoscopy: • Most sensitive test to identify diaphragmatic injury, also allows for laparoscopic repair
  13. 13. Management • Open repair • Abdominal approach • Thoracic approach • Laparoscopic repair • Mesh may be required if a tension-free repair cannot be achieved
  14. 14. 62 year old female with a history of subtotal gastrectomy with Roux-en-y reconstruction presents with acute onset of severe abdominal pain and a leukocytosis. Diagnosis?
  15. 15. When a gastrectomy is performed, the intestines must be rerouted for appropriate drainage. The duodenum cannot be mobilized without devascularizing it, so it is reconnected to drain further down the jejunum to create a “roux en y” configuration.
  16. 16. Notice the “swirl sign” which signifies twisting of the mesentery.
  17. 17. The biliopancreatic limb is massively dilated and fluid filled
  18. 18. At the jejunojunal staple line, notice that there is dilation proximally and it is decompressed distally
  19. 19. An internal hernia can occur at the defect created in the mesentery during the jejunojejunostomy creation.
  20. 20. Quick Facts • Hernias in Roux-en-y patients are more likely to be internal hernias as compared to those caused by adhesions • 4.5% of patients will experience an internal hernia after their operation (1 in 20!) • Can happen at any time, average 225 days after their operation (range 2-490 days) • Can be acute or chronic in nature- duration of symptoms 1-180 days • CT only right 64% of the time, likely due to inexperience looking at images from Roux-en-y patients, hence the importance of the next article
  21. 21. Seven Signs of Internal Hernia after Roux-en-Y 1. Swirled appearance of mesenteric fat or vessels at the root of the mesentery 2. Small-bowel obstruction 3. Clustered loops of small bowel 4. Mushroom shape of the herniated mesenteric root with crowding and stretching of the mesenteric vessels 5. Tubular or round shape of distal mesenteric fat closely surrounded by bowel loops 6. Small bowel other than duodenum passing posterior to the superior mesenteric artery (SMA) 7. Right-sided location of distal jejunal anastomosis
  22. 22. One of the reviewers was a third year resident, showing that these signs can be identified by a novice
  23. 23. 75M presents with swelling in his left groin, abdominal pain, nausea and vomiting. Diagnosis?
  24. 24. Inguinal Hernia
  25. 25. Notice the hernia sac that is bowel containing and tracks into the scrotum.
  26. 26. Inguinal Hernias ● Account for 75% of all abdominal wall hernias ● Lifetime risk: ○ 27% in men ○ 3% women ● Risk of strangulation is low in all age groups <0.5%
  27. 27. Surgical Approach? ● Mesh vs. sutured? ○ Recurrence less common in hernias repaired with mesh ○ Hazard ratio 0.25 ● Open vs. laparoscopy? ○ Laparoscopy: Results in longer operative time, quicker return to baseline activities ○ Open: Increased postoperative pain and complications ● Infertility <2.0% for all ages, increased in cases of recurrent repairs
  28. 28. Summary Of Diagnoses This Month ▪ Traumatic diaphragmatic hernia ▪ Internal hernia after Roux-en-y ▪ Inguinal hernia
  29. 29. See You Next Month!

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: ▪ Traumatic diaphragmatic hernia ▪ Internal hernia after Roux-en-y ▪ Inguinal hernia

Views

Total views

2,266

On Slideshare

0

From embeds

0

Number of embeds

2,127

Actions

Downloads

5

Shares

0

Comments

0

Likes

0

×