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Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: May 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:
• Splenic Laceration
• Necrotizing Pancreatitis
• Hepatic Abscess

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Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: May 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 May 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. 60 year old female presents to the Emergency Department with abdominal pain after colonoscopy yesterday. Pain in left upper quadrant, radiating to left shoulder. Tolerating PO. Diagnosis?
  8. 8. 60 year old female presents to the Emergency Department with abdominal pain after colonoscopy yesterday. Pain in left upper quadrant, radiating to left shoulder. Tolerating PO. Diagnosis?
  9. 9. 60 year old female presents to the Emergency Department with abdominal pain after colonoscopy yesterday. Pain in left upper quadrant, radiating to left shoulder. Tolerating PO. Diagnosis? Grade 3 splenic laceration with active extravasation Patient was initially treated with an embolization. This was complicated by a splenic abscess which was ultimately managed with splenectomy.
  10. 10. Now, Since Our Patient Developed An Iatrogenic Splenic Injury During A Colonoscopy, We Will Discuss: • The most recent colorectal cancer screen guidelines • The complication of splenic injury during colonoscope • Splenic injury management
  11. 11. Colorectal Cancer Screening • Recent updates to guidelines • Average risk: • Initial screening age moved from 50 to 45 • Screen until age 75 • Age 76-85 based on person’s preferences, life expectancy, overall health, and prior screening history. • Over 85 years old no screening recommended • Considered average risk if following criteria met: • No personal history of colorectal cancer or certain polyps • No family history of colorectal cancer (including FAP, Lynch syndrome) • No personal history of inflammatory bowel disease • No personal history of abdominal radiation for treatment of prior cancer
  12. 12. Colorectal Cancer Screening Methods • Stool based tests: • Highly sensitive fecal immunochemical test (FIT) yearly • Highly sensitive guaiac fecal occult blood test yearly • Multi-targeted stool DNA test every three years • Visual exams of the colon: • Colonoscopy every 10 years • CT colonography every 5 years • Flexible sigmoidoscopy every 5 years
  13. 13. Splenic Injury Epidemiology • Colonoscopy is extremely safe and complications are rare with the most common being hemorrhage (1%) and perforation (0.1%). • Splenic injury is underreported and has an estimated incidence of 0.00005 and 0.017 %. • Authors of this study estimated a rate of 0.02% with a mortality of 5%. • More common in females (76.5%) than males (23.5%) • Presumed mechanisms: • Direct trauma to the spleen • Excessive splenocolic ligament traction • Decrease in the relative mobility between the spleen and the colon
  14. 14. Splenic Injury Risk Factors • 10.8% on anticoagulation • 10% with history of inflammatory bowel disease • 48% prior intra-abdominal surgery (17% colorectal operation) • Routine screening 29.5% vs diagnostic study 70.5% • 66% no difficulty noted during procedure
  15. 15. Splenic Injury Presentation/Management • 2/3 of patients presented within 24 hours post procedure • Complaints: • Left upper quadrant pain- 58% • Abdominal pain and dizziness- 17% • Diffuse abdominal pain- 15% • Dizziness- 10% • Kehr sign positive in 56% of patients • 70% of patients with > 3gm/dL drop in hemoglobin • 11% of patients discharged at initial visit • CT with 100% diagnostic sensitivity • Management: • 70% with splenectomy vs. 90% non-operative or embolization
  16. 16. 49-year-old female presents to the Emergency Department with altered mental status and inability to tolerate PO after recent discharge for treatment of pancreatitis. Diagnosis?
  17. 17. 49-year-old female presents to the Emergency Department with altered mental status and inability to tolerate PO after recent discharge for treatment of pancreatitis. Diagnosis?
  18. 18. Splenic infarction Pancreatic Necrosis 49-year-old female presents to the Emergency Department with altered mental status and inability to tolerate PO after recent discharge for treatment of pancreatitis. Diagnosis? Necrotizing pancreatitis (acute necrotic collection) with splenic infarction.
  19. 19. Initial Acute Pancreatitis Management • Aggressive fluid resuscitation in the initial phase • Lactated ringers is the preferred fluid for resuscitation. • Must be cautious with fluid resuscitation due to high risk of pulmonary edema, heart failure and abdominal compartment syndrome. • 10-15ml/kg with higher rates of mechanical ventilation, abdominal compartment syndrome and mortality compared to a 5-10ml/kg strategy. • Adequate pain management • Poorly controlled pain with negative effect on microvascularization also possibly induces necrosis. • Typically IV analgesics, epidural anesthesia shown benefits in a few trials but evidence is limited. • Nutrition • Enteral is preferred route. • No difference in nasogastric vs. nasojejunal feeding!
  20. 20. Necrotizing Pancreatitis • Occurs in 5-10% of pancreatitis patients • Infection occurs in 3 to 4 weeks but can occur earlier • Infection diagnosed by gas on CT scan or by positive culture from fine need aspiration • FNA with high rates of false negatives • FNA w/culture can help guide antibiotic selection • No studies showing the benefit of routine FNA
  21. 21. ● Other rare indications for operative intervention include; abdominal compartment syndrome, acute bleeding, bowel necrosis. ● Asymptomatic walled off necrosis regardless of size does not need intervention. ● Current guidelines recommend delaying intervention for 3 to 4 weeks. ● Recent trials show benefit of intervention before 4 weeks when using an endoscopic transluminal step-up approach with improvement in organ failure, low mortality and no increase in other complications.
  22. 22. Acute Pancreatitis Complications • Pancreatic fistulae • Close spontaneously with a median of 70 days • Stenting of fistula with similar rates of closure compared to a non- interventional approach but on average over shorter time duration • Disconnected pancreatic duct syndrome • 30-50% of patients with necrotizing pancreatitis • Managed with temporary or permanent stenting • Causes recurrent fluid collections • Long term can cause recurrent acute or chronic pancreatitis in the areas of excluded gland • Exocrine and endocrine pancreatic insufficiency • Exocrine- 27.5% of patients ~36 months after index admission • Endocrine- 23% of patients • Both reduced with minimally invasive intervention vs. open necrosectomy
  23. 23. Acute Pancreatitis Complications • Splanchnic vein thrombosis • 16-18% of patients • Typically asymptomatic and rarely causes complications • Anticoagulation is controversial, no difference in re-cannulation rates, increased risk of bleeding into necrotic collections • Pseudoaneurysms • Secondary to necrosis or operative intervention • Splenic artery 35-50% • Gastroduodenal and pancreaticoduodenal arteries 20-25% • Mortality 34-52% after rupture - Requires embolization with or without stenting
  24. 24. 47-year-old female presents to the Emergency Department with umbilical abdominal pain for 3 days and fever after recent travel to Africa. Diagnosis?
  25. 25. 47 year old female presents to the Emergency Department with umbilical abdominal pain for 3 days and fever after recent travel to Africa. Diagnosis?
  26. 26. 47-year-old female presents to the Emergency Department with umbilical abdominal pain for 3 days and fever after recent travel to Africa. Diagnosis? Intrahepatic abscess secondary to Klebsiella pneumoniae. Also tested positive for Hepatitis B.
  27. 27. Invasive K. pneumoniae disease ● Emerging phenomena identified in the late 1980s in Asia. ● Almost all reported cases were community acquired. ● Diabetes mellitus identified as a risk factor. ● Likely due to translocation from the GI tract. ● Higher incidence of pathogenic strains in stool from Asian countries as compared to the US or Europe, possible explanation of geographic distribution of cases.
  28. 28. Clinical Presentation • Clinical features • Most common- fever, chills, abdominal pain • ¼ of patients presented with nausea and vomiting • Laboratory evaluation: • Leukocytosis and thrombocytopenia • Elevated CRP, glucose, and LFTs • CT scan was more sensitive than US in identifying abscesses- typically in right lobe • Metastatic disease associated with this syndrome • Not always present on admission, diagnosed within 3 days of admission • CNS- Meningitis, endophthalmitis (85% with permanent visual impairment) • Pulmonary- septic pulmonary emboli, empyema • MSK- Osteomyelitis, subcutaneous or muscular abscess, necrotizing fasciitis
  29. 29. Management • Strict glycemic control appears to decrease the incidence of metastatic disease. • Treated with double coverage in USA, typically metronidazole and 3rd generation cephalosporin. • ESBL rare but if detected treated with carbapenems. • Antibiotic duration guided by clinical response. • Percutaneous drainage recommended but may require hepatic resection in critically ill patients.
  30. 30. Summary Of Diagnoses This Month ● Splenic laceration ● Necrotizing pancreatitis ● Hepatic abscess due to K. pneumoniae
  31. 31. See You Next Month!

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