Consultant Radiologist Riyadh Military Hospital

Format of the lectureFormat of the lecture

• Categorization of abdominal trauma patientsCategorization of abdominal trauma patients

• CT techniqueCT technique

• CT findingsCT findings

• Illustrated casesIllustrated cases

Categories of abdominal trauma Categories of abdominal trauma patientspatients

• Category ACategory A - hemodynamically unstable patients- hemodynamically unstable patients• Category BCategory B - hemodynamically stable patients- hemodynamically stable patients• Category CCategory C - patients with hematuria- patients with hematuria

Category ACategory A ““hemodynamicallyhemodynamically unstableunstable””• Need rapid clinical evaluation and immediate Need rapid clinical evaluation and immediate

resuscitation with volume replacementresuscitation with volume replacement

• If not responding, they should go If not responding, they should go immediately to immediately to OROR without imagingwithout imaging

• If they respond ( become hemodynamically If they respond ( become hemodynamically stable )--stable )-- Category BCategory B

• High clinical suspicion of intra-High clinical suspicion of intra-abdominal injury abdominal injury

------------ CT not U/S CT not U/S

• Low clinical suspicion of intra-Low clinical suspicion of intra-abdominal injury abdominal injury

------------ U/S not CT U/S not CT

Category BCategory B ““ hemodynamically hemodynamically stablestable””

High clinical suspicion of High clinical suspicion of intra-abdominal injuryintra-abdominal injury

• don’t ask fordon’t ask for U/SU/S - miss 25% of liver injuries- miss 25% of liver injuries - miss 62 % of splenic injuries- miss 62 % of splenic injuries - most renal injuries- most renal injuries - all pancreatic injuries - all pancreatic injuries - all mesenteric injuries- all mesenteric injuries - all gut injuries- all gut injuries - high proportion of retroperitoneal hematoma- high proportion of retroperitoneal hematoma

Low clinical suspicion of intra-Low clinical suspicion of intra-abdominal injuryabdominal injury

U/SU/S

• If -ve ------- > release the patient If -ve ------- > release the patient fromfrom

observation observation

* If +ve -----* If +ve ----- CTCT

Category CCategory C “ “ patient withpatient with hematuria”hematuria”

• CT cystograhyCT cystograhy

Categories of blunt abdominal Categories of blunt abdominal traumatrauma

• Category ACategory A - - hemodynamically unstable patientshemodynamically unstable patients * no radiological imaging* no radiological imaging• Category BCategory B - - hemodynamically stable patientshemodynamically stable patients * CT – if high suspicion* CT – if high suspicion * US – if low suspicion * US – if low suspicion • Category CCategory C - patients with hematuria- patients with hematuria * CT cystography* CT cystography

CT techniqueCT technique

• CT in blunt abdominal trauma with or CT in blunt abdominal trauma with or without oral contrast ?without oral contrast ?

• Oral contrast is Oral contrast is unnecessaryunnecessary in CT in CT evaluation in patients with acute evaluation in patients with acute blunt abdominal traumablunt abdominal trauma

Why no oral Why no oral contrast ?contrast ?

• Extravasation of oral contrast in bowel Extravasation of oral contrast in bowel perforationperforation

---------------- 0 % - 19 % 0 % - 19 %• Pneumopertoneum Pneumopertoneum ---------------- 50 % 50 % * - small perforations may seal quickly and prevent * - small perforations may seal quickly and prevent

extravasation of contrast and / or air that could then extravasation of contrast and / or air that could then be detected by CTbe detected by CT

• Time delay to diagnosisTime delay to diagnosis• Long transit time Long transit time non opacification non opacification

of distal loops of distal loops • Aspiration of gastric contrast contents Aspiration of gastric contrast contents

with subsequent pulmonary toxic with subsequent pulmonary toxic effectseffects

• Interference with the diagnosis of Interference with the diagnosis of contrast blushcontrast blush

• Oral contrast is Oral contrast is unnecessaryunnecessary in CT in CT evaluation in patients with acute blunt evaluation in patients with acute blunt abdominal traumaabdominal trauma

• 96. Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004; 56(2):314-322.

• Is pneumoperitoneum diagnostic of bowel Is pneumoperitoneum diagnostic of bowel injury?injury?

•No No it is not diagnostic of bowel injury, since it is not diagnostic of bowel injury, since

air transmitted from the chest in air transmitted from the chest in pneumothorax is the pneumothorax is the most commonmost common cause cause of intraperitoneal air in a trauma patientof intraperitoneal air in a trauma patient

• The sensitivity of CT scan with OC for The sensitivity of CT scan with OC for detection of detection of bowel injuriesbowel injuries does not does not significantly differ from CT without OCsignificantly differ from CT without OC

• Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG. Oral contrast is not necessary in Covington DL, Maxwell JG. Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed the evaluation of blunt abdominal trauma by computed

tomography. Am J Surg. 1993;166:680-685tomography. Am J Surg. 1993;166:680-685 • Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of

computed tomography in the diagnosis of blunt small-bowel computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994;168:670-675.perforation. Am J Surg. 1994;168:670-675.

Blunt traumaBlunt trauma

• No oral contrast No oral contrast • Venous phase ----- 70 secVenous phase ----- 70 sec• Delayed scan if injury present --- 3-5 Delayed scan if injury present --- 3-5

minmin

The findings to look forThe findings to look for• HemoperitoneumHemoperitoneum• Contrast blushContrast blush• LacerationLaceration• HematomasHematomas• ContusionContusion• PneumoperitoneumPneumoperitoneum• Devascularization of organsDevascularization of organs• Subcapsular hematomaSubcapsular hematoma

* Laceration* Laceration : : linear shaped linear shaped

hypodense lesionhypodense lesion

* Hematoma* Hematoma : : oval or round oval or round

hypodense areashypodense areas* * Contusion Contusion : : vague ,ill-defined vague ,ill-defined

hpodense area , hpodense area , that is less that is less perfusedperfused

Contrast blushContrast blush

• An area of high density An area of high density compared to the nearby compared to the nearby vessel representing vessel representing active arterial extravasationactive arterial extravasation

Splenic injuriesSplenic injuries

• Splenic lacerationSplenic laceration• hemoperitoneum hemoperitoneum • No contrast blushNo contrast blush

……managed non-managed non-operativelyoperatively

• LacerationsLacerations• HematomaHematoma• HemoperitoneumHemoperitoneum• No contrast blushNo contrast blush

.. Depending on the .. Depending on the clinical condition , clinical condition , the patient will be the patient will be managedmanaged

• HemoperitoneumHemoperitoneum• LacerationLaceration• HematomaHematoma• Contrast blushContrast blush

.. Operative .. Operative managementmanagement

Liver injuriesLiver injuries

• Green arrowGreen arrow: : hematomahematoma

• Blue arrowBlue arrow : contusion : contusion• Yellow arrowYellow arrow: laceration: laceration

• hemoperitoneumhemoperitoneum

• Hematoma Hematoma • hemoperitoneumhemoperitoneum• Contrast blushContrast blush

… … managed operativelymanaged operatively

• Does the presence of contrast blush Does the presence of contrast blush necissetate operative interference ?necissetate operative interference ?

•NoNo It depends on if it is associated with It depends on if it is associated with

hemoperitoneum or nohemoperitoneum or no

• Large subcapsular hematomaLarge subcapsular hematoma• Contrast blushContrast blush• No hemoperitoneumNo hemoperitoneum

… … Managed non-operativelyManaged non-operatively

• Contrast extravasation is of great Contrast extravasation is of great importance especially if it is importance especially if it is associated with hemoperitoneumassociated with hemoperitoneum

Splenic contusion with contrast Splenic contusion with contrast blushblush

• LacerationLaceration• hematoma hematoma

• Lacerations Lacerations • HematomaHematoma• HemoperitoneumHemoperitoneum• Contrast blushContrast blush

• Managed Managed operativelyoperatively

Avulsed Rt hepatic Avulsed Rt hepatic veinvein

Perforated duodenumPerforated duodenum

PancreasPancreas

• Rarely an isolated injury, since the Rarely an isolated injury, since the pancreas is protected by the liver, pancreas is protected by the liver, spleen and the bony thoraxspleen and the bony thorax

• Usually part of a” Usually part of a” package injurypackage injury “ “

Pancreatic injuryPancreatic injury

Isolated injuryIsolated injury

Left sided package Left sided package injuryinjury

Rt sided package injuryRt sided package injury

Bowel injuryBowel injury

• Specific findingsSpecific findings

- Oral CM extravasation- Oral CM extravasation

………………. RARE. RARE…..….. 0 – 19 %0 – 19 %

Diagnostic signs of bowel Diagnostic signs of bowel injuryinjury

• Most common findingsMost common findings

- unexplained intraperitoneal fluid- unexplained intraperitoneal fluid

… … 84 %84 %

- pneumoperitoneum- pneumoperitoneum

… … 50 %50 %

• Other findingsOther findings

- mesenteric stranding- mesenteric stranding

- bowel wall thickening :- bowel wall thickening : * diffuse* diffuse : : hypoperfusionhypoperfusion * focal* focal : : direct traumadirect trauma

HypovolemiaHypovolemia “ shock bowel“ shock bowel syndrome “syndrome “ “ hypoperfusion “ hypoperfusion complex “complex “• Thickened , enhanced small bowel Thickened , enhanced small bowel

mucosamucosa• Enhanced adrenal glandsEnhanced adrenal glands• Enhanced pancreasEnhanced pancreas• Non enhanced spleenNon enhanced spleen• Non enhanced kidneysNon enhanced kidneys• Small IVC Small IVC • Small aorta and mesenteric arteriesSmall aorta and mesenteric arteries

• However, if the CT is negative for gut However, if the CT is negative for gut injury in the face of a high clinical injury in the face of a high clinical suspicion, laparoscopy, surgical suspicion, laparoscopy, surgical exploration, or a period of exploration, or a period of observation plus repeat CT may be observation plus repeat CT may be used to further evaluate the patient used to further evaluate the patient [62-64]. [62-64].

• Thickened Thickened , , enhanced enhanced small small bowel bowel mucosamucosa

• Hypodense spleenHypodense spleen• Hypodense kidneysHypodense kidneys• Enhanced adrenalsEnhanced adrenals

• Hypodense spleenHypodense spleen• Small IVCSmall IVC• Small bowel mucosal enhancementSmall bowel mucosal enhancement

Advantages of CTAdvantages of CT• Decide whether a patient needsDecide whether a patient needs

- - urgent therapeutic surguryurgent therapeutic surgury * active hemorrhage * active hemorrhage * gut perforation* gut perforation

- therapeutic angiography + embolization- therapeutic angiography + embolization * active vascular hemorrhage* active vascular hemorrhage

- non-surgical management- non-surgical management

• Historically liver injury was managed Historically liver injury was managed surgically, but at laparotomy it was found surgically, but at laparotomy it was found that 70% of the bleedings had already that 70% of the bleedings had already stopped by the time the surgeons got stopped by the time the surgeons got therethere

• Patients who went for surgery had more Patients who went for surgery had more transfusions and more complications than transfusions and more complications than patients who were treated non-operativelypatients who were treated non-operatively

Today Today 80% are managed 80% are managed non-operativelynon-operatively

• Nowadays there is a trend towards Nowadays there is a trend towards non-operative managementnon-operative management of of blunt abdominal trauma. blunt abdominal trauma. More than 50% of splenic injury, 80% More than 50% of splenic injury, 80% of liver injury and virtually all renal of liver injury and virtually all renal injuries are injuries are managed non-managed non-operativelyoperatively, because patients proved , because patients proved to have better outcomes on the long to have better outcomes on the long term related to visceral salvage. term related to visceral salvage.

Conclusion Conclusion

Categories of blunt abdominal Categories of blunt abdominal traumatrauma

• Category ACategory A - - hemodynamically unstable patientshemodynamically unstable patients * no radiological imaging* no radiological imaging• Category BCategory B - - hemodynamically stable patientshemodynamically stable patients * CT – if high suspicion* CT – if high suspicion * US – if low suspicion * US – if low suspicion • Category CCategory C - patients with hematuria- patients with hematuria * CT cystography* CT cystography

CT protocolCT protocol

• No oral contrast No oral contrast • Venous phase ----- 70 secVenous phase ----- 70 sec• Delayed scan if injury present --- 3-5 Delayed scan if injury present --- 3-5

minmin

• CT is used to evaluate patients with CT is used to evaluate patients with blunt trauma not only initially, but blunt trauma not only initially, but also for follow up, when patients are also for follow up, when patients are treated non-operatively. treated non-operatively.

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• 2. Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg 1995; 221(6):744-755.

• 3. Garber BG, Yelle JD, Fairfull-Smith R, et al. Management of splenic injuries in a Canadian trauma centre. Can J Surg 1996; 39(6):474-480.

• 4. Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MR 2004; 25(2):180-204.

• 5. Poletti PA, Mirvis SE, Shanmuganathan K et al. CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings. Radiology 2000; 216(2):418-427.

• 6. Maull KI. Current status of nonoperative management of liver injuries. World J Surg 2001; 25(11):1403-1404.

• 7. Delgado Millan MA, Deballon PO. Computed tomography, angiography, and endoscopic retrograde cholangiopancreatography in the nonoperative management of hepatic and splenic trauma. World J Surg 2001; 25(11):1397-1402.

• 8. Toutouzas KG, Karaiskakis M, Kaminski A, Velmahos GC. Nonoperative management of blunt renal trauma: a prospective study. Am Surg 2002; 68(12):1097-1103.

• 9. Smith JK, Kenney PJ. Imaging of renal trauma. Radiol Clin North Am 2003; 41(5):1019-1035.

• 10. Feliciano DV. Diagnostic modalities in abdominal trauma. Peritoneal lavage, ultrasonography, computed tomography scanning, and arteriography. Surg Clin North Am 1991; 71(2):241-

• 11. Gay SB, Sistrom CL. Computed tomographic evaluation of blunt abdominal trauma. Radiol Clin North Am 1992; 30(2):367-388.

• 12. Wherrett LJ, Boulanger BR, McLellan BA, et al. Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. J Trauma 1996; 41(5):815-820.

• 13. McGahan JP, Rose J, Coates TL, et al. Use of ultrasonography in the patient with acute abdominal trauma. J Ultrasound Med 1997; 16(10):653-662.

• 14. Healey MA, Simons RK, Winchell RJ, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful? J Trauma 1996; 40(6):875-885.

• 15. Nordenholz KE, Rubin MA, Gularte GG, Laing HK. Ultrasound in the evaluation and management of blunt abdominal trauma. Ann Emerg Med 1997; 29(3):357-366.

•16. Davis KA, Fabian TC, Croce MA, et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 1998; 44(6):1008-1013.

•17. Hagiwara A, Yukioka T, Ohata S, et al. Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial embolization. AJR 1997; 169(4):1151-1156.

•18. Cox CS Jr, Geiger JD, Liu DC, Garver K. Pediatric blunt abdominal trauma: role of computed tomography vascular blush. J Pediatr Surg 1997; 32(8):1196-1200.

• Published in 2007 in Radiology Published in 2007 in Radiology assistantassistant

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