Imaging of Gastrointestinal and Abdominal Emergencies in Binge Drinking  Trishna R. Shimpi, MMed, FRCR, Sumer N. Shikhare, MMed, FRCR, Raymond Chung, MBBS, FRCR, Peng Wu, MD, Wilfred C.G. Peh, MD, FRCP(Glasg), FRCP(Edin), FRCR  Canadian Association of Radiologists Journal  Volume 70, Issue 1, Pages 52-61 (February 2019) DOI: 10.1016/j.carj.2018.10.009 Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 1 Acute interstitial oedematous pancreatitis in a 45-year-old man with a recent episode of binge drinking. Axial CECT of the abdomen shows diffusely enlarged pancreas with associated peripancreatic fat stranding. Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 2 Acute necrotizing pancreatitis in a 35-year-old known alcoholic man. Axial CECT of the abdomen shows diffusely enlarged pancreas with areas of non-enhancing parenchyma, associated peripancreatic fat stranding and free fluid. Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 3 Acute necrotizing pancreatitis with superimposed infection in a 55-year-old man. Axial CECT of the abdomen shows pancreatic and peripancreatic necrotic collection with air-foci within, suggestive of superimposed infection with gas-forming organisms. Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 4 Boerhaave's syndrome in a 62-year-old man after an episode of binge drinking followed by forceful vomiting. (A) Frontal radiograph of the chest shows large left pleural effusion with underlying atelectasis. It also shows left apical pneumothorax (thick arrow), pneumomediastinum (thin arrow) and subcutaneous emphysema (arrowhead). (B) Axial CECT of the chest obtained in soft tissue (left) and lung (right) windows shows esophageal wall oedema (thick arrow), peri-esophageal fluid collections (thin arrow), left pleural effusion, pneumothorax and pneumomediastinum. (C) Fluoroscopic esophagography shows contrast leak from the distal esophagus (arrow). Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 5 Abdominal apoplexy in a 27-year-old man after an episode of binge drinking. Axial MIP (A) and coronal reformatted CECT abdomen (B) in the portal venous phase shows a large haematoma (arrowhead) in the left hypochondrium, adjacent to the greater curvature of stomach with a focus of active contrast extravasation (thick arrow), probably from a branch of short gastric artery (thin arrow). Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 6 Spontaneous intraperitoneal bladder rupture in a 32-year-old woman. (A) Axial CECT of abdomen and pelvis shows free fluid in the pelvis with hyperdense haematoma in the bladder lumen in the portal venous phase (arrowhead). (B) Axial CECT images in the delayed phase shows intraperitoneal contrast extravasation (thick arrow) and filling defects in the bladder lumen (thin arrow). Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 7 Acute gastrointestinal perforation in a 50-year-old man, a known alcoholic. Frontal radiograph of chest (A) shows free air beneath the right dome of diaphragm (arrowhead). Axial CECT of the abdomen and pelvis (B, C) shows pneumoperitoneum with pyloric antral wall thickening, enhancement, surrounding inflammatory changes and free fluid (thick arrow). There is periportal free gas sign (arrowhead). Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 8 Upper GI bleed in a 76-year-old man. Coronal reformatted CECT image of the abdomen (A) in the arterial phase shows active contrast extravasation in the gastric lumen (thick arrows). Axial CECT image in the delayed phase (B) shows pooling of contrast in the gastric lumen (thick arrows). Catheter angiography image (C) shows active contrast extravasation from a branch of left gastric artery (thick black arrow). Catheter angiography image post-left gastric embolization using glue (D) shows no active contrast extravasation. Endoscopy image (E) shows a gastric ulcer which was the source of bleed (thick arrow). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 9 Haemorrhage into a pseudocyst with secondary pseudoaneurysm in a 39-year-old man. Axial CECT of the abdomen (A) shows haematoma within the previous pseudocyst (double-ended arrow) with perfusion nidus (single arrow) anteriorly. Digital subtraction angiography (B) shows jejunal arterial haemorrhage into the pseudocyst (arrow). Post-proximal coil embolization image (C) of the involved jejunal artery (arrow) shows successful exclusion of the pseudoaneurysm. Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 10 Haemorrhage into a pseudocyst with secondary pseudoaneurysm in a 39-year-old man 3 months later. Axial CECT image (A) shows significant re-perfusion of the haemorrhagic pseudocyst/pseudoaneurysm (thick arrow) secondary to a defect (thin arrow) in the patent SMA (curved arrow). Transabdominal ultrasound image (B) shows the classical yin-yang perfusion of the pseudoaneurysm from the SMA (arrow). Digital subtraction angiography (C) shows the SMA defect (thin arrow) and early pseudoaneurysm perfusion (curved arrow). Anomalous vasculature with the common hepatic artery arising from the SMA (thick arrow) is present. (D) Successful coverage of the SMA defect by endograft deployment (thin arrow). Anomalous origin of the common hepatic artery (thick arrow) arising from the SMA, with subsequent division into the hepatic arteries and gastroduodenal artery is seen. (E) Transabdominal ultrasound image shows complete thrombosis of the pseudoaneurysm with no further perfusion (double-ended arrow). This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 52-61DOI: (10.1016/j.carj.2018.10.009) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions