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

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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:
• Intrauterine Pregnancy and Trauma
• Ruptured hemorrhagic cyst
• Ovarian teratoma
• Pelvic Inflammatory Disease

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Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: February 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 February 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. 32-year-old female in a motor vehicle collision presents with altered mental status and inability to provide a history. Her abdominal exam is unremarkable. A CT scan of abdomen and pelvis is shown here. Diagnosis?
  8. 8. 32-year-old female in a motor vehicle collision presents with altered mental status and inability to provide a history. Here are FAST Images. Diagnosis?
  9. 9. 32-year-old female in a motor vehicle collision presents with altered mental status and inability to provide a history. Intrauterine Pregnancy! Ultrasound staged at 12w6d.
  10. 10. ● Fetal risk of harm from ionizing radiation depends on the gestational age and dose of radiation. ● ACOG guidelines recommend CT imaging not be withheld if clinically necessary, with consideration of risks/benefits.
  11. 11. ● Studies suggest a 60–310 mGy threshold. ● ACOG guidelines recommend consulting a radiation physicist to assist in calculating total dose of radiation if multiple imaging studies are required.
  12. 12. 32-year-old female presented with abdominal pain and small volume of free fluid in the pelvis. She is on therapeutic anticoagulation for antiphospholipid syndrome. Diagnosis?
  13. 13. 32-year-old female presented with abdominal pain and small volume of free fluid in the pelvis. Here Is Her Ultrasound. She is diagnosed with a hemorrhagic ovarian cyst and discharged home.
  14. 14. The patient returns two weeks later with worsening abdominal pain. CT imaging reveals hemoperitoneum secondary to a ruptured ovarian cyst (in an anticoagulated patient).
  15. 15. 9-year-old female presented with acute onset of severe abdominal pain for one day, no fevers, emesis, or diarrhea. Diagnosis?
  16. 16. 9-year-old female presented with acute onset of severe abdominal pain for one day, no fevers, emesis, or diarrhea. Diagnosis?
  17. 17. 9-year-old female presented with acute onset of severe abdominal pain for one day, no fevers, emesis, or diarrhea. Here Is Her Ultrasound.
  18. 18. 9-year-old female presented with acute onset of severe abdominal pain for one day, no fevers, emesis, or diarrhea. Diagnosis: Ovarian Teratoma.
  19. 19. 28-year-old female with a history hx of pelvic inflammatory disease admitted to the hospital with fevers, anorexia, and right lower quadrant pain. Cervical cultures [+] for gonorrhea. Diagnosis?
  20. 20. 28-year-old female with a history hx of pelvic inflammatory disease admitted with fevers, anorexia, and right lower quadrant pain. Tubo-ovarian abscess and pelvic inflammatory disease. Note the IUD present within the uterus.
  21. 21. Adnexal Mass Evaluation Malignancy Risk Factors: ● Age >55 ● Family history of ovarian cancer Imaging Recommendations: ● Begin evaluation with Transvaginal Ultrasound ● If this does not provide the needed information proceed to MRI ● CT can be used to evaluate for other etiologies and associated complications (ascites, omental metastases, peritoneal implants, pelvic or periaortic lymph node enlargement, hepatic metastases, obstructive uropathy) Laboratory Evaluation: ● Urine pregnancy test ● If infection suspected; CBC, Gonorrhea and Chlamydia testing ● Further tests based on history and physical exam ● CA-125 to evaluate for malignancy- most useful in postmenopausal women
  22. 22. PID management ● Presumptive treatment for: ○ cervical motion tenderness ○ uterine tenderness ○ adnexal tenderness ● Must treat against N. gonorrhoeae and C. trachomatis (negative screening does not rule out upper tract infections). ● IUDs increase risk of PID in the first three weeks after insertion ● IUD does not need to be removed if diagnosed with PID
  23. 23. Summary Of Diagnoses This Month ● Intrauterine pregnancy ● Ruptured hemorrhagic cyst ● Ovarian teratoma ● Pelvic inflammatory disease
  24. 24. See You Next Month!

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