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: • Intrauterine Pregnancy and Trauma • Ruptured hemorrhagic cyst • Ovarian teratoma • Pelvic Inflammatory Disease

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
February 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. 32-year-old female in a motor
vehicle collision presents with
altered mental status and
inability to provide a history.
Her abdominal exam is
unremarkable. A CT scan of
abdomen and pelvis is shown
here.
Diagnosis?

8. 32-year-old female in a motor
vehicle collision presents with
altered mental status and
inability to provide a history.
Here are FAST Images.
Diagnosis?

9. 32-year-old female in a motor
vehicle collision presents with
altered mental status and
inability to provide a history.
Intrauterine Pregnancy!
Ultrasound staged at 12w6d.

10. ● Fetal risk of harm from ionizing radiation depends on the gestational age and dose of
radiation.
● ACOG guidelines recommend CT imaging not be withheld if clinically necessary, with
consideration of risks/benefits.

11. ● Studies suggest a 60–310 mGy threshold.
● ACOG guidelines recommend consulting a
radiation physicist to assist in calculating total
dose of radiation if multiple imaging studies
are required.

19. 32-year-old female presented with
abdominal pain and small volume
of free fluid in the pelvis. She is on
therapeutic anticoagulation for
antiphospholipid syndrome.
Diagnosis?

20. 32-year-old female presented with
abdominal pain and small volume of
free fluid in the pelvis.
Here Is Her Ultrasound.
She is diagnosed with a hemorrhagic
ovarian cyst and discharged home.

21. The patient returns two weeks later
with worsening abdominal pain.
CT imaging reveals hemoperitoneum
secondary to a ruptured ovarian cyst
(in an anticoagulated patient).

22. 9-year-old female presented with
acute onset of severe abdominal
pain for one day, no fevers,
emesis, or diarrhea.
Diagnosis?

23. 9-year-old female presented with
acute onset of severe abdominal
pain for one day, no fevers,
emesis, or diarrhea.
Diagnosis?

24. 9-year-old female presented with
acute onset of severe abdominal
pain for one day, no fevers,
emesis, or diarrhea.
Here Is Her Ultrasound.

25. 9-year-old female presented with
acute onset of severe abdominal
pain for one day, no fevers,
emesis, or diarrhea.
Diagnosis: Ovarian Teratoma.

26. 28-year-old female with a history hx of pelvic
inflammatory disease admitted to the hospital
with fevers, anorexia, and right lower quadrant
pain. Cervical cultures [+] for gonorrhea.
Diagnosis?

27. 28-year-old female with a history hx of pelvic
inflammatory disease admitted with fevers,
anorexia, and right lower quadrant pain.
Tubo-ovarian abscess and pelvic inflammatory
disease.
Note the IUD present within the uterus.

29. Adnexal Mass
Evaluation
Malignancy Risk Factors:
● Age >55
● Family history of ovarian cancer
Imaging Recommendations:
● Begin evaluation with Transvaginal Ultrasound
● If this does not provide the needed information proceed
to MRI
● CT can be used to evaluate for other etiologies and
associated complications (ascites, omental metastases,
peritoneal implants, pelvic or periaortic lymph node
enlargement, hepatic metastases, obstructive uropathy)
Laboratory Evaluation:
● Urine pregnancy test
● If infection suspected; CBC, Gonorrhea and Chlamydia
testing
● Further tests based on history and physical exam
● CA-125 to evaluate for malignancy- most useful in
postmenopausal women

30. PID management
● Presumptive treatment for:
○ cervical motion tenderness
○ uterine tenderness
○ adnexal tenderness
● Must treat against N. gonorrhoeae and C. trachomatis (negative
screening does not rule out upper tract infections).
● IUDs increase risk of PID in the first three weeks after insertion
● IUD does not need to be removed if diagnosed with PID

31. Summary Of Diagnoses This Month
● Intrauterine pregnancy
● Ruptured hemorrhagic cyst
● Ovarian teratoma
● Pelvic inflammatory disease

32. See You Next
Month!