Drs. Kylee Brooks and Parker Hambright are Emergency Medicine Residents and Drs. Alexis Holland and William Lorenz are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham, Brent Matthews, 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 cases include: - Pyogenic Liver Abscess - Bladder Rupture - Sigmoid Volvulus

1. Adult Abdominal Imaging Case Studies
Kylee Brooks, MD2, Parker Hambright, MD2,
Alexis Holland MD1, William Lorenz, MD1
Departments of Surgery1 & Emergency Medicine2
Carolinas Medical Center & Levine Children’s Hospital
Kyle Cunningham, MD1 & Brent Matthews, MD1 - Faculty Editors
Michael Gibbs, MD: Imaging Mastery Project Lead Editor
Abdominal Imaging Mastery Project
Presentation #26

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. It’s All About The Anatomy!

4. Systematic Approach to Abdominal CT Interpretation
● 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

5. CASE #1:
A 51-year-old female
with a history of
gallstone pancreatitis,
status post
cholecystectomy and
debridement of walled-
off pancreatic necrosis,
presents to the ED for
weakness, abdominal
pain, and altered mental
status.
Vital Signs:
T 102, HR 118, BP 96/62.
Diagnosis?

6. CASE #1:
Abdominal imaging
reveals multiple bi-lobar,
septated hepatic fluid
collections consistent
with pyogenic abscesses.
The largest is in the right
posterior lobe measuring
8.6 x 6.1cm.
Right Lower
Lobe Abscess
Right Upper
Lobe Abscess

7. Gastroenterology Clinics of North America 2020; 49:361-377

8. Gastroenterology Clinics of North America 2020; 49:361-377
Causative Organisms
U.S.: E. coli (most common), Klebsiella, Enterobacter, Proteus. Strep/Staph (hematogenous).
Worldwide: the pathogen profile of liver abscess is highly variable by region.

11. Surgical Clinics of North America 2010; 90:679-697.

12. Back To Our Patient
• The abscesses were felt to be due to an ascending biliary infection in the
setting of severe pancreatitis requiring debridement
• The patient was resuscitated with fluids and vasopressors and empirically
treated with piperacillin-tazobactam.
• Blood cultures were positive for Streptococcus constellatus and antibiotics
were transitioned to ampicillin-sulbactam.
• Because the abscesses were not technically amenable to CT-guided
percutaneous drainage she underwent surgical drainage.
• The patient was discharge after a 2-week hospitalization on oral ampicillin-
sulbactam.

13. CASE #2:
A healthy 22-year-old
male presents to the
emergency department
after a motor vehicle
collision with shortening
and internal rotation of
his right femur and an
unstable pelvis. He is
hypotensive and
tachycardic on arrival
with a [+] FAST. A foley
was placed with return of
gross blood.
Complex Pelvic & Acetabular Fracture + Right Hip Dislocation

14. CASE #2:
A healthy 22-year-old
male presents to the
emergency department
after a motor vehicle
collision with shortening
and internal rotation of
his right femur and an
unstable pelvis. He is
hypotensive and
tachycardic on arrival
with a [+] FAST. A foley
was placed with return of
gross blood.
Diagnosis?

15. CASE #2:
CT imaging reveals
contrast extravasation
extending from the
upper aspect of the
urinary bladder into the
upper abdomen,
consistent with a
bladder dome rupture.
Contrast
Extravasation
Bladder

16. Bladder Rupture
Most cases of bladder rupture are caused by direct pelvic or abdominal
injury, occurring in 1-2% of blunt trauma patients.
Physical exam findings:
• Abdominal and pelvic pain, difficulty voiding
• 75-100% of patients have gross hematuria
Extraperitoneal 60%
Intraperitoneal 30%
Both 10%

17. Extraperitoneal Rupture
Extraperitoneal ruptures are often
associated with pelvic fractures and
are due to compressive forces causing
rupture, burst injury, sudden shearing
forces or from direct penetration by
bony fragments.
CT cystography typically shows
extravasation of contrast confined to
the peri- and pre-vesicular space but
complex injuries have shown contrast
material extending to the thigh,
scrotum/labia, penis, perineum or
anterior abdominal wall.
Management: uncomplicated cases
are typically managed with Foley
catheter drainage for 2-3 weeks.

18. Intraperitoneal ruptures typically
occur at the dome of the bladder
where it is the weakest, least
supported and meets the peritoneum.
Occurs when a full bladder is
subjected to compressive forces to
the lower abdomen.
CT cystography will show
accumulation of contrast material
within the peritoneal cavity outlining
loops of bowel and filling paracolic
gutters, subphrenic spaces and the
pouch of Douglas.
Management: surgical repair with
post-operative Foley catheter
drainage.
Intraperitoneal Rupture

19. Journal of Trauma and Acute Care Surgery 2019; 86:326-336.
1 CT cystography is the diagnostic study of choice for blunt trauma patients who are at
moderate risk (e.g.: gross hematuria) or high risk (e.g.: gross hematuria + pelvic fracture)
for bladder rupture.
2 Operative management is recommended for intraperitoneal bladder rupture.
3 Non-operative management is recommended for the management of simple1
extraperitoneal bladder rupture and operative management is recommended for complex
cases extraperitoneal bladder rupture cases.
1A “simple” extraperitoneal bladder rupture is defined as a single full-thickness tear in the bladder wall with
extravasation into the extraperitoneal space. All other more significant injuries are defined as “complex.”

20. Performing Retrograde Cystography

21. Performing Retrograde Cystography
• To adequate identify contrast extravasation, it it critical that the
bladder be adequately distended.
• For both ”traditional” and CT cystography, contrast should be instilled
into the bladder retrograde.
Adult & Children >11 Years 300-400 cc
Children 1-11 years 30 cc/kg
Children <1 year 10-20 cc/kg
Procedure
1. Place the Foley
2. Instill contrast by gravity
3. Clamp the Foley
4. Obtain images
5. Post-void images1
1When performing a traditional retrograde cystogram it is important to drain the bladder
and obtain a post-void view to identify potential contrast extravasation behind the bladder.

22. Traditional Cystogram CT Cystogram
Intraperitonea
l
Rupture
Extraperitoneal
Rupture
Intraperitoneal
Rupture
Extraperitonea
l
Rupture

23. More Cases Of Bladder Rupture From
Carolinas Medical Center

24. A healthy 5-year-old is
struck by a car while
riding her bike.
She sustains a closed
right femur fracture.
In the ED she is noted to
have gross hematuria.

25. A Healthy 5-Year-Old Is Struck By A Car While Riding Her
Bike.
CT Imaging Reveals A
Bladder Dome
Laceration (→)
Along With Free Fluid
In The Pelvis (⇒)
⇒

26. A Healthy 5-Year-Old Is Struck By A Car While Riding Her
Bike.
A Retrograde Cystogram Reveal Intraperitoneal Contrast
Extravasation
A Bladder Dome Laceration Was Repaired Surgically Without

27. 28-Year-Old Presented After A Car Crash With Abdominal Pain, And Gross
Hematuria.
Extraperitoneal
Fluid
Intraperitoneal Fluid
CT Imaging Reveals A Bladder Laceration (→) Along With

28. The patient taken to the OR for
laparoscopic bladder repair and was
noted to have an 8-cm dome laceration
(→) along with a 2nd extraperitoneal
laceration visualized through the defect
(⇒).
28-Year-Old Presented After A Car Crash With Abdominal Pain, And Gross
Hematuria.

29. A 53-year-old female
sustains a complex pelvic
fracture and left femoral
neck fracture in a car
crash.
In the ED she is noted to
have gross hematuria.

30. A 53-Year-Old Female Sustains A Complex Pelvic Fracture
And Left Femoral Neck Fracture In A Car Crash.
CT Imaging Reveals A
Bladder Dome
Laceration (→)
Along With Free Fluid
In The Pelvis (⇒)
The Patient
Underwent Operative
Repair

31. Back To Our Patient
• The patient was resuscitated in the ICU and then
taken to the OR.
• A 10-12 cm bladder dome laceration was repaired
and a JP drain and Foley catheter were placed.
• 8-days following repair a cystogram was
performed that did not reveal any evidence of
contrast extravasation.
• The Foley catheter was removed and the patient
was able to void with minimal post-void residual
volumes.
8-Days Post-Op

32. The Patient’s Pelvic Fracture Was Stabilized After The Bladder Was Repaired

33. CASE #3:
A 91-year-old male
with a history of
diverticulosis, COPD,
HTN, pancreatitis, and
heart failure presents
to the ED with
abdominal pain and
distension.
Vital Signs:
T 97, HR 67, BP 139/70.
Diagnosis?

34. CASE #3:
CT imaging shows
massive dilatation of
the ascending,
transverse, and
descending colon with
a swirl sign and
decompressed sigmoid
and rectum.
Colonic
Dilatation
Swirl
Sign

35. Sigmoid Volvulus
Presentation:
• The colon twists around the
mesenteric root causing the bowel to
fold onto itself, create a closed loop
obstruction and vascular compromise.
• Symptoms:
• Nausea, vomiting
• Abdominal distension
• Obstipation
• Sigmoid volvulus more common than
cecal volvulus
• Risk factors
• Advanced age
• Redundant, mobile colon
• The differential would include a colonic
mass causing obstruction
Diagnosis:
• Clinical picture
• KUB will show colonic dilatation
• Coffee Bean Sign – medial walls of the
bowel fold next to each other and make
the crease in the coffee bean
• Inverted U Sign – a haustral dilated bowel
in the shape of upside-down U, specific to
sigmoid volvulus
• Bird Beak Sign – smooth tapering of colon
down to the obstruction
• Northern Exposure Sign – sigmoid extends
above the transverse colon
• CT imaging will better identify the
specific point of obstruction
• Transition point + lack of rectal gas
• Water soluble enema

36. Surgical Clinics of North America 2018; 98:973-993.

37. Swirl Sign: Mesentery
Twisting On Itself
Coffee Bean Sign:
Colon
Dilation Proximal To The
Obstruction With Lack
Of
Gas Distal To The
Obstruction

38. American Journal of Radiology 2010; 194:136-143.

39. Surgical Clinics of North America 2018; 98:973-993.

40. 87-Year-Old Presenting With Abdominal Distension And Pain.
New England Journal of Medicine 2009;361:10.
Inverted U Sign Swirl Sign

41. New England Journal of Medicine 2013; 369:25.
Coffee Bean Sign Bird Beak Sign
14-Year-Old With Vomiting, Abdominal Pain and Distension.

42. BMJ Case Reports 2011; doi.10.1136/bcr.06.2011.4334
80-Year-Old With 10 Days Of Abdominal Pain, Distention, Constipation.

43. Management of Sigmoid Volvulus
• No intervention leads to bowel ischemia
and necrosis.
• Surgery is definitive treatment but is it
elective or emergent?
Endoscopic Management
If no peritonitis or signs of bowel ischemia are present,
attempt endoscopic detorsion prior to surgery:
1. Consult GI, can be attempted 1-2 times
2. Colonoscopic insufflation often untwists the bowel
3. Leave a rectal tube in place until the patient is stable.
Surgical Management
Endoscopy successful: elective sigmoid colectomy with
anastomosis vs. Hartman procedure to prevent recurrence.
Endoscopy unsuccessful: rectosigmoid resection with end
colostomy.

44. Two Cases Of Sigmoid Volvulus

45. Back To Our Patient
• The patient underwent successful colonoscopic detorsion confirmed by
plain film imaging (KUB).
• Due to patient’s age and comorbidities, the patient and family decided
to observe following decompression.
• If he were younger and healthier, we would have performed an elective
sigmoid resection with anastomosis during the index admission due to
the high risk of recurrence.

46. Summary Of Diagnoses This Month
● Pyogenic Liver Abscesses
● Bladder Rupture
● Sigmoid Volvulus

47. See You Next Month!