1. The document discusses three adult abdominal imaging case studies from Carolinas Medical Center involving abdominal wall hematoma, walled off necrosis of the pancreas, and acute aortic thrombosis. 2. For the first case, a 57-year-old female presented with an abdominal wall dog bite and was found to have a 12 cm abdominal wall hematoma with active contrast extravasation. 3. The second case was a 65-year-old female with a history of severe pancreatitis who had a follow up CT showing walled off necrosis of the pancreas. 4. The third case was a 46-year-old male with a history of Ehlers Danlos and recent cocaine usage who presented

1. Adult Abdominal Imaging Case Studies
Raza Ahmad, MD1, Morgan Penzler, MD2, Ansley Ricker, MD1
Departments of Surgery1 & Emergency Medicine2
Carolinas Medical Center & Levine Children’s Hospital
Kyle Cunningham, MD1 & Brent Matthews, MD1 - Faculty Editors
Cesar Aviles, DNP1 – Hepatobiliary Guest Editor
Michael Gibbs, MD2 – Project Lead Editor
Abdominal Imaging Mastery Project
June 2022

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 57-year-old female,
with a past medical
history of peripheral
arterial disease (PAD)
presents, to the ED
after being attacked by
a dog. The dog bit her
on her abdomen and
right thigh. The patient
is on dual-anti-platelet
therapy for her PAD.
Diagnosis?

6. Abdominal Wall Hematoma
Contrast Extravasation
CASE #1:
CT imaging reveals A
12 cm x 5 cm
abdominal wall
hematoma with active
contrast extravasation.

7. Abdominal Wall Injuries
• Seen in ± 9% of blunt trauma patients
• Spectrum: muscle strain, hematoma to traumatic abdominal wall rupture
• Physical exam findings:
• Seat belt sign: bruising or abrasion to lower abdominal wall that is associated with
serious injuries (lumbar spine fractures, pelvic fractures, splenic and bowel injuries)
• Seat belt syndrome: triad of abdominal wall contusion, hollow viscus perforation,
spinal column injury
• Radiographic findings:
• Abdominal wall contusions, hematomas, and muscle tears
• Rectus sheath hematomas
• Traumatic abdominal wall hernias are the most severe form of abdominal wall injury
• Rare: 0.17-1.5% of patients with blunt trauma
• Most often seen in the inferior lumbar triangle (Petit triangle)

8. Management of the Abdominal Wall Hematoma
• Not all are trauma related, some can be spontaneous or after other
surgical procedures (e.g.: paracentesis)
• Most can be managed conservatively with compression, observation,
trending of hemoglobin
• With active extravasation, consider embolization if the area is amenable
• Surgery targets those who are hemodynamically unstable, not amenable
to embolization, concomitant complications such as infection, wall
rupture, etc.

9. Back To Our Case!
• An abdominal binder was placed for compression
• The patient was admitted to the ICU for close monitoring
• She was given coagulation product replacement based on her
admission thromboelastogram (TEG)
• After correction of her coagulopathy, she was taken to the OR for a
washout of the abdominal wall, and a wound-vac was placed
• She completed a course of ampicillin-clavulanic acid for her dog bite

10. CASE #2:
65-year-old female with
a history of severe
pancreatitis and recent
hospitalization. While
the patient is
asymptomatic, she had
a follow up CT scan as
an outpatient
demonstrating the
following pathology.
Diagnosis?

11. CASE #2:
CT imaging reveals
walled-off necrosis
(WON) of the pancreas.
Walled Off Necrosis
(WON) Of The Pancreas
CBD
Gallbladder

12. CASE #2:
WON Of The Pancreas
is a complication of
necrotizing pancreatitis
that is seen >4 weeks
after the initial
diagnosis.
This terminology is
used as part of the
Atlanta Classification
of severe pancreatitis.
Walled Off Necrosis
(WON) Of The Pancreas
CBD
Gallbladder

14. Pathogenesis Of Pseudocyst Formation Pathogenesis Of Walled-Off Pancreatic Necrosis

15. Acute Pancreatic Fluid Collection (APFC)
• Develops in the early phases of acute
pancreatitis
• Homogeneous without a well-defined wall
• Confined to retroperitoneal fascial planes
• Can be multiple
• Most remain sterile and resolved without
intervention
Pancreatic Fluid Collections: CT Findings

16. Acute Necrotic Fluid Collection (ANFC)
• Arises in the setting of necrotizing pancreatitis
• Develops within the initial 4 weeks of disease
• Variable amount of fluid and necrotic tissue
• Poor contrast uptake + “moth eaten” appearance
• May be associated with disruption of the main
pancreatic duct
Pancreatic Fluid Collections: CT Findings

17. Pancreatic Pseudocyst (PP)
• Cystic structure surrounded by a well-defined
wall and containing amylase-rich fluid but no
debris
• May be partly or wholly intrapancreatic
• Usually takes ≥4 weeks for it to mature
Pancreatic Fluid Collections: CT Findings

18. Walled-Off Necrosis Of The Pancreas
• Usually occurs ≥4 weeks following an episode of
necrotizing pancreatitis
• Necrotic material contained within a well-
defined enhancing wall of reactive inflammatory
tissue
Pancreatic Fluid Collections: CT Findings

19. 1 Pancreatic necrosis causes substantial M&M and requiring a multidisciplinary team.
2 Antibiotics are only indicated when infection is strongly suspected. Prophylaxis is not indicated.
3 Antibiotics must effectively penetrate necrotic tissue (metronidazole, carbapenems, quinolones).
4 Drainage and/or debridement is often indicated in patients with infected necrosis.
5 Debridement should be avoided early (<2 weeks) since this is associated with increased mortality.
6 Debridement is ideally performed after 4 weeks of the initial episode of pancreatitis.
7 When performing a drainage/debridement procedure for necrotic pancreatitis and/or walled-off
necrosis (WON) of the pancreas a “step-up approach” should be used. This may involve:
• Percutaneous drainage
• Endoscopic drainage
• Open necrosectomy

21. Back to our case!
• Given the size of the walled-off necrosis and the associated compressive
biliary obstruction, she underwent an attempt at endoscopic drainage.
However, this failed because the collection was too solid to drain
• She subsequently underwent a robotic-assisted transmesenteric
pancreatic necrosectomy, and robotic cholecystectomy
• Immediately following the procedure her symptoms improved and she
was able to tolerate oral liquids. She was discharged on post-operative
day #2 with a plan for clinic follow-up

22. More Cases Of Pancreatitis From
Carolinas Medical Center

23. 54-Year-Old With Severe Necrotizing Pancreatitis
Notice Contrast Uptake In The Pancreatic Head With Decreased Uptake In The Body (→)

24. 54-Year-Old With Severe Necrotizing Pancreatitis
Subsequent WON Of The Pancreas (→) With Stent Drainage

25. 2 Pseudocysts
59-Year-Old With A History Of Recurrent Pancreatitis And Pseudocyst Formation.

26. 59-Year-Old With A History Of Recurrent Pancreatitis And Pseudocyst Formation.
The Cyst Was Drained Endoscopically Using A Cysto-Gastric Shunt

27. 64-Year-Old With A Large Pseudocyst (*) In The Setting Of Long-Standing Pancreatitis.
* *
*

28. 64-Year-Old With A Large Pseudocyst In The Setting Of Long-Standing Pancreatitis.
The Cyst Was Drained Endoscopically Using A Cysto-Gastric Shunt (→)

29. CASE #3:
46-year-old male with
a history of Ehlers
Danlos and recent
cocaine usage
presents with
peritonitis and right
lower extremity rest
pain.
Diagnosis?

30. CASE #3:
46-year-old male with
a history of Ehlers
Danlos and recent
cocaine usage
presents with
peritonitis and right
lower extremity rest
pain.
Aortic thrombus with
multiple distal emboli.

31. Aortic Thrombus

32. CT Findings In Our Patient
• Focal filling defect in the mid descending thoracic aorta presumably representing
a mural thrombus of unknown etiology.
• Right lower extremity mid to distal vascular occlusion.
• Distended proximal small bowel loops.

33. • Differentiation: Thromboembolism from aortic plaques is common, whereas
cholesterol crystal embolization is rare.
• Pathology: The material protruding from the aortic wall is typically atheromatous
plaque, with the characteristic composition consisting of a lipid pool, a fibrous
cap, smooth muscle cell and mononuclear cell infiltration, and varying degrees of
calcification. Thrombi are plaques with high proportions of lipid with a
preponderance of monocytes and macrophages.
• Risk factors for embolization: plaque thickness (>4 mm in thickness), plaque
ulceration, plaque mobility, plaque location (ascending aorta and aortic arch),
cardiovascular procedures
Aortic Thrombosis

35. Clinical Manifestations
• Acute limb ischemia
• Spinal cord syndromes that
may mimic cauda equina
• Acute abdominal pain due
to mesenteric ischemia
• Severe hypertension due to
occlusive renal ischemia
TheJournal of Emergency Medicine, Vol. 58, No. 5, pp. 802–806, 2020

36. Case Reports Describe A Range Of Clinical Presentations
J Col Phys Pakistan 2021.
J Int & Emerg Med 2019.
J Emerg Med 2020.
Spine 2011.
Vasc Endovasc Surg 2021.
Clin Nephrology 2003.
Clinical
Communications: Adult
E AORTIC THROMBUS PRESENTING AS CAUDA EQUINA SYNDROME
Emily Mayo, BMBS, BMEDSCI (HONS)* and Gareth Herdman, MBBS, FRCR†
y Trainee, Princess of Wales Hospital, Bridgend, United Kingdom and †Musculoskeletal Radiology Consultant, Radiology
Department, Princess of Wales Hospital, Bridgend, United Kingdom
ss: Emily Mayo, BMBS, BMEDSCI (HONS), Radiology Department, Princess of Wales Hospital, Coity Road, Bridgend CF31 1RQ,
United Kingdom
Background: Occlusive abdominal aortic
rare but critical clinical emergency with life-
nsequences. Clinical presentation may mimic
s, resultingin adelay in theappropriateinves-
is condition. Spinal arterial involvement is a
mplication of aortic thrombus and can result
, Keywords—aorta; thrombus; cauda equina; artery of
Adamkiewicz
INTRODUCTION
Occlusive abdominal aortic thrombus is a rare but life-
0736-4679/$ - see front matter
https://doi.org/10.1016/j.jemermed.2020.03.011
CASE REPORT
SPINE Volume 36, Number 15, pp E1042–E1045
©2011, Lippincott Williams & Wilkins
Acute Infrarenal Aortic Thrombosis Presenting
With Flaccid P
araplegia
Georgios K. Triantafyllopoulos, MSc,* Michael Athanassacopoulos, MD,* Chrysostomos Maltezos, MD,† and
Spyridon G. Pneumaticos, PhD*
Study Design. Thisstudy isa case report.
Objective. To report a case of a patient with paraplegia and
low back pain, who was diagnosed with acute infrarenal aortic
who was admitted to the orthopedic emergency department
with flaccid paraplegia and who was finally diagnosed with
acuteinfrarenal aortic thrombosis.
Case Report
Acute Thrombosis of an Infrarenal
Abdominal Aortic Aneurysm Presenting
as Bilateral Critical Lower Limb Ischemia
Vascular and Endovascular S
urgery
2021, Vol. 55(2) 186-188
ª The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1538574420954297
journals.sagepub.com/home/ves
(Acute Bilateral Leg Pain And Mottling)
(Acute Back And Leg Pain And Urinary incontinence)
(Acute Abdominal Pain With Splenic Infarction Demonstrated On CT)

37. Back To Our Case!
• The patient was taken emergently to the OR for an exploratory laparotomy with
a bowel resection of ischemic bowel. The patient was originally left in
discontinuity with an open abdomen due to hemodynamic instability. He was
later taken back for an anastomosis and closure.
• During the original operation, orthopedic surgery performed a below the knee
amputation in which they later revised to an above the knee amputation.
• The patient was started on a heparin drip and follow-up imaging showed that
the thrombus had decreased in size. Vascular surgery continues to follow the size
of the thrombus.
• Hematology evaluated patient and their work-up was negative for underlying
hypercoagulable disorders. The thrombus was ultimately deemed to be
secondary to cocaine induced vasculopathy.

38. Summary Of Diagnoses This Month
● Abdominal Wall Hematoma
● Walled Off Necrosis Of The Pancreas
● Acute Aortic Thrombosis

39. See You Next Month!