Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents 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. This month’s topics include: - Internal Hernia - Small Bowel Obstruction Secondary to Neoplasm - Colonic Perforation

1. Adult Abdominal Imaging Case Studies
Michael Avery, DO; Joshua Davis, MD; Kelsey Lena, 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
November 2020

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. 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. It’s All About The Anatomy!

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. 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. CASE:
50-year-old male with
a past medical history
of exploratory
laparotomy who
presents with
constipation, nausea,
and diffuse abdominal
pain for 2 days.
Leukocytosis of 13.1
present in the
emergency
department.
Diagnosis?

8. CASE:
50-year-old male with a past
medical history of exploratory
laparotomy who presents with
constipation, nausea, and
abdominal pain in the setting
of a leukocytosis of 13.1.
Diagnosis: Internal hernia
Small bowel obstruction
Herniation of fat
Mesenteric Edema, stretching
of mesenteric vessels

9. Internal Hernias
• Protrusion of visceral contents through a congenital or acquired
defect in the peritoneum or mesentery within the abdominal cavity
• Patients with a history of Roux-en-Y gastric bypass or live
transplant are especially at risk of internal hernia formation
• Incidence of <1%
• Most common content of internal hernia is small bowel loops

10. Internal Hernias
• Clinical features
• Abdominal pain
• Nausea and vomiting
• Abdominal distention and constipation
• Diagnostic Features
• Distended bowel loops in an abnormal location
• Crowding of small bowel loops within a potential hernia sac
• Mesenteric engorgement, twisting, stretching or crowding
• Evidence of obstruction

11. Internal Hernia Treatment
• Conservative management
• Indications
• No evidence of hemodynamic instability
• No evidence of sepsis or peritonitis
• Surgery:
• Either open or laparoscopic
• Procedure: reduction of the hernia and closure of
the peritoneal or mesenteric defect
• Indications
• Evidence of hemodynamic instability
• Evidence of sepsis or peritonitis
• No signs of improvement on conservative management

12. CASE:
42-year-old man with previous
open appendectomy who
presents with third recurrent
small bowel obstruction after
recent discharge.
CT scan shows gastric wall
thickening/enhancement and
diffusely dilated small bowel
with right lower quadrant
transition point.
Diagnosis?

13. CASE:
Patient underwent upper
endoscopy on same admission
for management of small bowel
obstruction.
Endoscopy demonstrated non-
bleeding gastric body mass with
pathology of poorly
differentiated gastric
adenocarcinoma and gastritis
with H. pylori infection.
Eventual exploratory laparotomy
demonstrated diffuse peritoneal
metastasis.
Right lower
quadrant
transition point
Gastric
thickening and
wall
enhancement
Dilated
small bowel
with air
fluid levels

14. Management
overview:
• When reviewing CTs for bowel obstructions,
identify transition points as areas of decompressed
bowel contiguous to areas of dilated bowel.
• Multiple, frequent presentations with recurrent
bowel obstructions need further workup to identify
underlying pathology (i.e., mechanical/adhesive
disease, potential carcinoma, etc).
• Gastric adenocarcinoma carries high mortality
with 31% 5-year survival rate.1
• Patient’s need staging CT chest/abdomen/pelvis
and will benefit from early port placement if
chemo is to be pursued.
Rawla P, Barsouk A. Epidemiology of gastric cancer: global trends, risk factors and
prevention. Prz Gastroenterol. 2019;14(1):26-38. doi:10.5114/pg.2018.80001

15. CASE:
Patient is a 58-year-old male
with a history of recurrent
diverticulitis who presents for a
3 day history of diffuse
abdominal pain with associated
nausea and unrelenting
vomiting.
Patient is diaphoretic on
examination with vital signs
revealing heart rate 130 bpm,
blood pressure 84/52 mm Hg,
and oxygen saturation 95% on
room air.
Diagnosis?

16. Diagnosis:
Colonic perforation secondary
to acute diverticulitis
The colonic perforation is
involving the mid-descending
colon posteriorly.
Additionally, notice the
abundant amount of
extraluminal stool.

17. Colonic
Perforation
• Commonly due to diverticulitis, neoplasm, non-
iatrogenic trauma mechanisms, and iatrogenic
mechanisms (1)
-Incidence in colonoscopy: 1/1400 procedures
• Clinical manifestations depend on nature of contents
released (stool or gas), ability of surrounding tissues
to contain those contents, and patient’s ability to
mount an inflammatory response (1)
• Symptomatic presentation can range for general
abdominal pain to septic shock. As such, a broad
work-up is typically required
• Complications include peritonitis, abscess
formation, and fistula formation

18. Colonic
Perforation
Treatment
• Intravenous fluid bolus and initiation of broad
spectrum antibiotic therapy
-Metronidazole + Cefazolin or Ceftriaxone
• Indications for abdominal exploration include
radiologic evidence of perforation PLUS one of
the following: sepsis, diffuse peritonitis, bowel
ischemia, or complete/closed loop bowel
obstruction (1)
• Perforation is small  simple suture via
laparoscopic approach
• Perforation larger with evidence of
devascularization of the colonic wall  colon
resection
Nassour I, Fang SH Gastrointestinal perforation. JAMA Surg 2015;150:177

19. Summary Of Diagnoses This Month
● Internal hernia
● Small bowel obstruction secondary to neoplasm
● Colonic perforation

20. See You Next Month!