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: • Malignant Bowel Obstruction • Liver Laceration • Sigmoid Volvulus

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
July 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. 54-year-old women
presents with several
months of weight loss,
vague abdominal pain,
oral intolerance, and
increasing nausea /
vomiting.
Diagnosis?

8. 54-year-old women
presents with several
months of weight loss,
vague abdominal pain,
oral intolerance, and
increasing nausea /
vomiting.
Obstructing cecal
adenocarcinoma.
CT shows RLQ mass
(left) with decompressed
ascending colon (right)
and diffusely dilated
small bowel.
Colonoscopy confirms
diagnosis.

9. Malignant Bowel Obstruction
- Initial approach is standard fluid resuscitation and correction of severe
electrolyte derangements.
- Placement of nasogastric tube if clinically indicated.
- Contacting appropriate consultants for further work up as indicated.

11. Patient is an 8 year old
male who fell directly on
handlebars and developed
epigastric pain. Presented
to the ED as a Pediatric
Trauma Code 2
Diagnosis?

12. Patient is an 8 year old
male who fell directly on
handlebars and developed
epigastric pain. Presented
to the ED as a Pediatric
Trauma Code 2
Grade 3 hepatic liver
laceration!
Moderate perihepatic and
pelvic blood products

13. Liver
Lacerations and
Hepatic Injuries
from Trauma
- In blunt abdominal trauma, the
liver is injured ~5% (range 1-
10%) of the time
- Patients can present with right
upper quadrant pain, right
shoulder tip pain (from
diaphragmatic irritation),
hypotension and shock
• CT is the investigation of choice
for evaluating liver trauma.
• Lacerations appear as irregular
linear/branching areas of
hypoattenuation

14. Grading Liver Lacerations
AAST Injury Scoring Scale

15. • Nonoperative management of blunt hepatic injuries is now the treatment modality of choice in
hemodynamically stable patients, irrespective of the grade of injury
• Nonoperative management of blunt hepatic injuries should only be considered in an environment that
provides capabilities for monitoring, serial clinical evaluations, and an operating room available for
urgent laparotomy
• Adjunctive therapies such as angiography, percutaneous drainage, endoscopy/ ERCP and laparoscopy
remain important adjuncts to nonoperative management of hepatic injuries

16. Patient is a 80 yo male
who presented to the ED
febrile with an altered
mental status and was
concurrently in atrial
fibrillation with RVR.
Physical examination
revealed distended, but
nontender abdomen.
KUB shown here.
Diagnosis?

17. 80 yo male – febrile,
altered mental status and
evidence of atrial
fibrillation with RVR.
Physical examination
with distended, but
nontender abdomen.
Sigmoid Volvulus
Note massively dilated
loop of bowel
Plain Abdominal X-Ray
diagnostic in majority of
cases. Imaging reveals an
“omega” or “horseshoe”
sign.

18. Sigmoid Volvulus
• Condition in which the sigmoid colon wraps around itself and its own
mesentery, resulting in a closed-loop obstruction
• Accounts for 2-5% of colonic obstructions in the Western countries and 20-50%
of obstruction in Eastern countries with highest incidence in the 4th-8th decades
of life
• Results in mucosal ischemic injury  bacterial translocation and bacteremia 
colonic gangrene
• Etiology is multifactorial, however, there appears to be an association with
advanced age and colon redundancy as well as dolichomesentery
• Presentation: abdominal pain and distention, constipation, nausea, vomiting,
anorexia, and hematemesis

19. Treatment
-Nonoperative management:
colonoscopy with
decompression
-Operative management:
sigmoidopexy, percutaneous
endoscopic colostomy, or
detorsion and sigmoid
resection with primary
anastomosis
-Surgical treatment preferred
due to high recurrence rate
(55-90%) and morality rates
(~40%)

20. Summary Of Diagnoses This Month
● Malignant Bowel Obstruction
● Liver Laceration
● Sigmoid Volvulus

21. See You Next
Month!