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Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: June 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:
• Necrotizing Enterocolitis (NEC)
• Spontaneous Intestinal Perforation (SIP)
• Intestinal Atresia

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Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: June 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 June 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. 2 week old premature ex- 32 week neonate who presents with abdominal distention and feed intolerance. KUB shown here. Diagnosis?
  8. 8. 2 week old premature ex- 32 week neonate who presents with abdominal distention and feed intolerance. KUB shown here. Necrotizing Enterocolitis (NEC)! Notice: Portal venous gas and Intraluminal pneumatosis intestinalis Left lateral decubitus film obtained to rule out free air.
  9. 9. Necrotizing Enterocolitis (NEC) - Bacterial translocation into intestinal wall - Increased incidence in premature infants, peak incidence at 31 weeks of gestational age - When concerned for perforation in neonate, obtain lateral decubitus or cross table lateral x-ray to assess for free air - Clinical signs: abdominal distention, food intolerance, bloody stools
  10. 10. - Translocation of bacteria across intestinal wall. - Related to altered local bacterial flora (ie dysbiosis) and breakdown of mucosal protective barriers. - Conflicting schools of thought whether breast milk vs formula alters the risk of NEC by providing different nutrients to the pre-term microbiome.
  11. 11. - Despite popular opinion that breast milk provides protection against NEC, this meta-analysis showed no benefit of donor breast milk vs formula in preterm infants. - While some studies show a cost savings when considering donor milk cost with the cost of NEC treatment, the use of donor milk in preterm infants has not been validated as no alteration in risk for NEC development has been confirmed.
  12. 12. 3 day old premature ex- 31 week neonate who presents with abdominal distention and feed intolerance. KUB shown here. Diagnosis?
  13. 13. 3 day old premature ex- 31 week neonate who presents with abdominal distention and feed intolerance. KUB shown here. Spontaneous Intestinal Perforation Massive pneumoperitoneum
  14. 14. Spontaneous Intestinal Perforation - Isolated location of intestinal perforation - Increased survival compared to NEC - Massive pneumoperitoneum: - Football sign = massive pneumoperitoneum leaves outline of falciform ligament on KUB - Obtain cross table/lateral for NICU Image from Alshahrani, M.A., Aloufi, F.F., Alabdulkarim, F.M. et al. The football sign. Abdom Radiol 42, 2769–2771 (2017).
  15. 15. - Mortality decreases with increasing birth weight. - Mortality in all birth weight groups was higher for NEC vs SIP. - Indomethacin and steroid use were noted to be more frequent in SIP for this study.
  16. 16. 3 day full term infant with po intolerance and abdominal distention. KUB shown here. Note the massively dilated stomach vs loop of small bowel? Which further imaging is necessary?
  17. 17. 3 day full term infant with po intolerance and abdominal distention, KUB shows dilated stomach. Proceed with Upper GI series to assess anatomy. Must rule out malrotation! Normal gastroduodenal anatomy, note outline of massively dilated loop of bowel and normal gastric filling!
  18. 18. 3 day full term infant with po intolerance and abdominal distention, UGI shows dilated loop of small bowel and concern for distal obstruction. Proceeded with contrast enema to evaluate distal anatomy for obstruction. Note abrupt cut off at transverse colon. Diagnosis?
  19. 19. 3 day full term infant with po intolerance and abdominal distention, upper and lower GI imaging reveals distal obstruction with proximal dilation and distal decompression. Intestinal Atresia!
  20. 20. Intestinal Atresia - Can occur at any length along the intestine - Proximal (Duodenal), Mid (Jejuno-ileal), Distal (Colonic) - Requires surgical intervention. - Largest concern is subsequent short-gut syndrome if large segments of bowel require resection, although this is rare. - Neonates might be able to pass meconium, will have po intolerance, and often abdominal distention (although proximal atresias may not present with distention!)
  21. 21. - Assuming no short-gut physiology, outcomes usually depend on presence of concomitant congenital abnormalities. - Duodenal atresias are thought to be congenital as opposed to distal atresias are vascular events that result in necrotic and malformed intestine/mesentery. - Studies suggest that use of vasoactive medications and cigarette smoking increase risk of intestinal atresia by 4x.
  22. 22. Summary Of Diagnoses This Month ● Necrotizing Enterocolitis (NEC) ● Spontaneous Intestinal Perforation (SIP) ● Intestinal Atresia
  23. 23. See You Next Month!

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