Blunt Abdominal Trauma: Injury to the Epigastrium

Mária

Némethy, Harvard Medical School, Year IIIGillian Lieberman, MD

Mária Némethy, HMS IIIGillian Lieberman, MDNovember 2004

Blunt Abdominal Trauma (BAT)•

Trauma is the leading cause of death in the United States in persons under 45 years of age

Because it primarily affects the young, trauma causes more lost years of productive life than cancer and cardiovascular disease combined

Blunt trauma accounts for 2/3 of all injuries•

Majority of abdominal injuries are due to blunt trauma; 10% of trauma fatalities are due to abdominal injury

Mechanisms of injury•

Compression: direct blow or against a fixed object (seat belt, spinal column)–

Generally results in tears or subcapsular

hematomas in

solid organs–

Increased intraluminal

pressure can cause rupture of

hollow organs•

Deceleration: stretching and linear shearing between fixed and movable structures–

Rupture of supporting elements at junction between fixed and free segments of organs

Thrombosis of vessels contained within supporting elements

http://www.emedicine.com/EMERG/topic1.htm

Injuries resulting from blunt abdominal trauma

Common:–

Liver –

most commonly injured in all abdominal trauma

(blunt and penetrating)–

Spleen –

most commonly injured organ in blunt trauma

Kidney –

increasing frequency (increased detection)–

Bladder (extraperitoneal)

Rare:–

Pancreas

Adrenal

Bladder (intraperitoneal)

First, a brief review of retroperitonal anatomy.

Note the crowding of the numerous soft organs in the epigastrium, with little bony protection. Unlike small bowel, these organs are fixed in place, and so cannot move out of the path of

blunt traumatic forces.

Abdominal Retroperitoneum

Netter FH. Atlas of Human Anatomy, 2nd ed.

PancreasDuodenum(retroperitoneal)

Right kidneyLeft kidney

Inferior vena cava Abdominal aorta

Epigastric

region

Netter FH. Atlas of Human Anatomy, 2nd ed.

Right adrenal

Right kidney

Duodenum

Transverse colon

Abdominalaorta

Left adrenal

Pancreas

Left kidney

Options for evaluating BAT

Plain film–

Difficult to evaluate soft-tissue injury

May reveal free intraperitoneal

air or signs of bowel obstruction

Deep peritoneal lavage–

Rapid detection of hemoperitoneum

Invasive–

Risk of visceral and vascular injury

Options for evaluating BAT•

CT – gold standard for BAT evaluation–

MDCT: high-resolution images and reconstructions allow improved detection and management of soft-

tissue injury, hemorrhage, etc•

Ultrasound –

increasing use

Safe for unstable patients; decreased costs–

Limitations: fluid-filled bowel versus hemoperitoneum; extraperitoneal

fluid versus intraperitoneal

fluid; cystic

masses can look like fluid collections; obesity•

MRI –

not used in initial evaluation of BAT

Our Patient

JO, a 23-yr-old woman kicked in the stomach by a horse

Imaging at outside hospital suggested pancreatic injury; JO was

transferred to BIDMC for more complete evaluation

Initial plain films were normal

Images from PACS, BIDMC

CT: the diagnostic modality of choice in initial evaluation of

blunt abdominal trauma

CT: pre-contrast

Mesenteric hematoma

Blood attenuation induodenal wall

Post-contrast: Pancreatic injury

Fluid surrounding pancreas

Blood surrounding pancreatic head

Pancreatic injury in BAT•

Epi: uncommon –

seen in 0.2-12% of blunt trauma

associated visceral injuries are very common (50-90% of patients)

Mechanism: –

compression against vertebral column

shear across pancreatic neck•

Sequelae:

Ductal

leakage pancreatitis, which can

lead to pseudocysts, fistulas and abscesses (20% mortality)

Grading: based on injury to main pancreatic duct:–

minor injuries usually heal spontaneously and are treated conservatively

injuries involving main pancreatic duct require surgical intervention

CT findings in pancreatic injury•

CT sens/spec for pancreatic injury over 80%; dependence on interpreter experience and timing of evaluation

Contusion: areas of low attenuation with heterogeneous foci and diffuse enlargement of pancreas

Laceration: areas of linear, irregular low attenuation within normal parenchyma

Nonspecific: thickening of anterior pararenal

fascia; blood/fluid tracking along mesenteric vessels; fluid in lesser sac; fluid between pancreas and splenic

Image from PACS, BIDMCImage from PACS, BIDMC

Ischemic kidney

Extravasation

of IV contrast

Renal injury

Renal injuryRight kidney Left kidney

Ischemic kidney

Renal injury in BAT•

Seen in 10% of trauma patients; blunt trauma

accounts for 80% of renal injuries–

Left-sided predominance (1.3:1) –

thought to be due to

anatomic protection of right renal artery beneath inferior vena cava and duodenum

Mechanism: –

sudden deceleration/direct blow can cause renal dislocation

stretching of renal arteries can cause immediate avulsion or delayed thrombosis

Sequelae: 80% are contusions/minor lacerations that heal spontaneously; persistent bleeding or complete infarction require surgical intervention

CT findings in renal injury•

CT important in both diagnosis and patient management: provides both functional and morphologic information

Absence of contrast nephrogram

reveals devascularized

Helical CT can image specific renal artery injury•

Contusion: delayed and non-homogenous excretion of contrast material

Laceration: linear or wedge-shaped hypodensity•

Fracture: involvement of full depth of renal parenchyma + disruption of collecting system

Duodenal hematoma

Image from PACS, BIDMC

Duodenal injury in BAT•

Epi: Bowel injury seen in 4-5% of major BAT; associated non-bowel injuries in 50%–

Retroperitoneal duodenum most common site of injury

Duodenal hematomas are very uncommon!•

Mechanism:–

Compression between spine and impacting body;

Shearing at fixed points (e.g. ligament of Treitz)•

Sequelae:–

Duodenal hematoma: resolves in 1-3 weeks

Duodenal perforation: surgical intervention required

CT findings in duodenal injury

Nonspecific (perforation vs. hematoma): –

Thickening of duodenal wall

Presence of fluid in right anterior pararenal

space•

Specific to perforation: Extraluminal

gas and/or

oral contrast in right anterior pararenal

space•

Duodenal hematoma: –

Initial heterogeneous, high attenuation region in duodenal wall due to blood accumulation

Isodensity, then hypodensity

as clot resolves

Intraperitoneal

bleedingUterus

Air in rectum

Intraperitoneal

bloodin Douglas’

pouch(HU = 50)

Intraperitoneal

fluid in BAT

Is often sole finding on CT in blunt abdominal trauma

Tracks down right and left paracolic gutters into pelvic reflection of peritoneum

Large amounts of blood can accumulate in pelvis without significant hemoperitoneum

apparent in upper abdomen

CT: detection of intraperitoneal

fluid•

CT very sensitive for detecting even small amounts of intraperitoneal

fluid or hemorrhage

“Sentinel clot”

sign: with multiple sites of hemoperitoneum, blood with highest CT attenuation is in proximity of site of hemorrhage

Blood attenuation on CT:–

Free blood: 20-45 HU

Clotted blood: 40-100 HU–

Active bleeding: within 10 HU of contrast density inside adjacent major vessel

How extensive was the pancreatic injury?

…The role of MRI…

MRI: characterization of soft tissue injury

MRI is more sensitive for soft tissue anatomy and pathology

No advantage over CT in initial evaluation, but can be invaluable in characterization of subtle soft tissue injury, as in the pancreas

Role of MRCP: evaluate damage to pancreatic duct –

key factor in surgical

versus conservative treatment

Pancreatic injury: characterization with MRI

Lacerations in head of pancreas

Pancreatic headcontusion

Laceration in bodyof pancreas

Duodenal hematoma on MRI

Sequelae•

JO was admitted to BIDMC one day after the injury

Her intra-abdominal injuries were managed conservatively (MRCP did not show laceration of pancreatic duct)

PICC line was placed on day two post-injury; initial inappropriate placement corrected on day three

Follow-up CT imaging was performed 10 days after initial CT–

the findings…?

10-day follow-up: Pancreatic pseudocyst

Pseudocyst

Pancreatic tissue

Pancreatic pseudocyst

Why did the kidney not infarct completely??

Initial work-up demonstrated ischemic lower pole in left kidney

Extravasation

of IV contrast into peritoneal cavity would suggest transection

of renal

artery•

Follow-up CT indicated improved perfusion of lower renal pole

Interesting anatomy…

Bilateral accessory renal arteries

Accessory renal arteries

Transection

of inferior accessory renal artery originating from common iliac artery, leading to contrast extravasation

infarct of inferior renal pole•

Development of collateral perfusion from main renal artery and remaining accessory renal artery

Our patient’s course

JO had a stable hospital course, and was discharged home 13 days after admission

Incidental note: JO received a PICC line for parenteral

nutrition. Initial follow-up

CXR revealed inappropriate positioning of the line….

PICC line terminating in L jugular vein

The PICC line was repositioned, and subsequently revealed some more

interesting anatomy….

A Left-sided SVC!

Acknowledgements

Michael Goldfinger, MD•

Gillian Lieberman, MD

Pamela Lepkowski•

Larry Barbaras, Webmaster

References•

Becker CD, et al. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Eur

Radiol

1998;8:772-80.•

Bradley EL III, et al. Diagnosis and initial management of blunt pancreatic trauma. Ann Surg

1998;227(6):861-9.•

Bruce LM, et al. Blunt renal artery injury: incidence, diagnosis, and management. Am Surg

2001;67(6):550-5.•

WJ, et al. Traumatic fracture of the pancreas: CT characteristics. J Comp

Assist Tomography 1990;14(3):375-8.

Fischer JH, Carpenter KD, O’Keefe GE. CT diagnosis of an isolated blunt pancreatic injury. AJR 1996;167:1152.

Fuchs WA and Robotti

G. The diagnostic impact of computed tomography in blunt abdominal trauma. Clin

Radiol

1983;34:261-5.•

Klausner

JM, et al. Intramural haematoma

of the duodenum following blunt abdominal injury –

the place for conservative treatment. Injury 1986;17:131-2.•

JR, et al. Duodenal injuries caused by blunt abdominal trauma: Value of CT in differentiating perforation from hematoma. AJR 1993;160:1221-3.

Lupetin

AR, Mainwaring BL, Daffner

RH. CT diagnosis of renal artery injury caused by blunt abdominal trauma. AJR 1989;153:1065-8.

McGehee

M, et al. Comparison of MRI with postcontrast

CT for the evaluation of acute abdominal trauma. J Comp Assist Tomography 1993;17(3):410-3.

References•

McKenney

KL. Ultrasound of blunt abdominal trauma. Radiol

N Am 1999;37(5):879-93.

Mirvis

SE and Shanmuganathan

K. Abdominal computed tomography in blunt abdominal trauma. Sem

Roentgen 1992;27(3):150-83.•

Netter FH. Atlas of Human Anatomy, 2nd ed. East Hanover, NJ: Novartis, 1999.•

Parker GD and Williams JAR. Massive intramural duodenal haematoma

following blunt abdominal trauma: case report. Australas

Radiol

1989;33:19204.•

Porter JM and Singh Y. Value of computed tomography in the evaluation of retroperitoneal organ injury in blunt abdominal trauma. Am J Emerg

Med 1998;16(3):225-7.

MK, Weinberger E, Healey P. Intramural duodenal hematoma after blunt abdominal injury. AJR 1998;170:38.

Shanmuganathan

K. Multi-detector row CT imaging of blunt abdominal trauma. Sem

Ultrasound CT MRI 2004;25(2):180-204.•

Shuman WP. CT of blunt abdominal trauma in adults. Radiology 1997;205:297-

Thomsen TW, Brown DFM, Nadel

ES. Blunt renal trauma. J Emerg

Med 2004;26(3):331-7.

http://www.emedicine.com/EMERG/topic1.htm

Blunt Abdominal Trauma: Injury to the Epigastrium

Documents

Case Study 9: Blunt Abdominal T rauma

Pancreatic Injuries in Blunt Abdominal Trauma

Ultrasonographic findings in Blunt Abdominal Trauma among

Conservative management of blunt abdominal trauma in children1

VALIDITAS DIAGNOSTIK SKOR BLUNT ABDOMINAL TRAUMA …

Blunt Abdominal Trauma: Evaluation

Blunt Abdominal Trauma - libreriauniverso.it · 2 Blunt Abdominal Trauma 21 and the traumatologist must maintain a high index of suspi-cion of underlying intra-abdominal and intrathoracic

Blunt Abdominal Injury

Blunt Abdominal Trauma - beck-shop.de file2 Blunt Abdominal Trauma 21 and the traumatologist must maintain a high index of suspi-cion of underlying intra-abdominal and intrathoracic

Blunt Abdominal Trauma - Mosbrook Design

Blunt Abdominal Wall Disruption by Seatbelt Injury; A …applications.emro.who.int/imemrf/Bull_Emerg_Trauma/Bull_Emerg... · Blunt Abdominal Wall Disruption by Seatbelt Injury;

BLUNT INJURY ABDOMEN – AND THEIR IMPACT ON ABDOMINAL …

IMAGING OF BLUNT · 2013. 12. 9. · IMAGING OF BLUNT ABDOMINAL TRAUMA, PART II Ruedi F. Thoeni, M. D. University of California, San Francisco IMAGING OF BLUNT ABDOMINAL TRAUMA, PART

MDCT Blunt Abdominal Trauma

Abdominal Trauma - Blunt · 2018-05-15 · Abdominal Trauma - Blunt Inclusion Criteria: • Blunt Abdominal Trauma • Cooperative patient • Stable Vital Signs (RR>8 or

Blunt Abdominal Trauma in Pregnancy Background - anmc.organmc.org/wp-content/uploads/ClinicalGuidelinesMaster/CG_TraumaInPregnancy.pdf · 8/28/17njm Blunt Abdominal Trauma in Pregnancy

Blunt Abdominal Trauma in The Patient with Left Congenital ...tuanet.org/wp-content/uploads/blunt-abdominal-trauma-in-the... · ประเมินก้อนได้ดีทีสุดคือการทําCT

Penetrating and Blunt Abdominal Trauma

Blunt Abdominal Trauma and Intervention Radiology

CT Imaging of Blunt Abdominal Traumaeradiology.bidmc.harvard.edu/LearningLab/gastro/ledger.pdf · CT Imaging of Blunt Abdominal Trauma Gabriel Ledger, Harvard Medical School Year-