Imaging in abdominal

trauma

Abdominal trauma

• Trauma causes I0% of deaths

worldwide

• The third commonest cause of death

after malignancy and vascular disease

Blunt abdominal trauma

• Vehicular trauma (75%)

• Blow to the abdomen (15%)

• Fall from height (6-9%)

• Others

– Domestic accidents

– Fights

– Iatrogenic cardiopulmonary resuscitation

Penetrating abdominal injury

• Accidental

• Homicidal

• Iatrogenic

• Stab wounds

• Gun shot wounds

• Shrapnel wounds

• Impalements

• The underappreciation of abdominal

injuries represents

a significant cause of

preventable trauma deaths

ACR Appropriateness Criteria

Category A

• Hemodynamically unstable

• Category B

• Category C

UNSTABLE

INVESTIGATION AVAILABILITY

F A S T D P L

FREE

FLUIDBLOOD

NO YES

CONTINUE

RESUSCITATION LAPAROTOMY

HEMODYNAMIC STABILITY ?

STABLE

CONSCIOUS , RESPONSIVE

YES NO

SUSPICION OF

ABDOMINAL INJURY

YESNO C T

CLINICAL FOLLOW-UP

F A S T

Focused Assessment with Sonography for

Trauma

What is FAST?

• A focused, goal directed, sonographic

examination of the abdomen

• An extension of clinical examination

• Part of the Primary Survey of any

patient with signs of shock or

suspicion of abdominal injury

Focused Assessment with Sonography for Trauma

• a decision-making tool to help

determine the need for transfer to

• the operating room,

• CT scanner

• or angiography suite.

What FAST is NOT

• A definitive diagnostic investigation

• A substitute for CT

• The answer to all our problems

The FAST examination

• FAST examines four areas for free fluid:

Perihepatic & hepato-renal space

Perisplenic

Pelvis

Pericardium

The perihepatic scan

The perihepatic scan

The perihepatic scan

Blood shows as a hypoechoic black stripe between the

capsule liver and the fatty fascia of the kidney

Perihepatic

scan

Perisplenic

Abnormal perisplenic window

The pelvic scan

pericardial

The pericardial scan

• screens for fluid between the fibrous

pericardium and the heart

• The transducer is placed just to the left of

the xiphisternumand angled upwards under

the costal margin.

Subxiphoid view

Normal subcostal view of pericardiumPositive FAST demonstrating

pericardial effusion

Quantification of hemoperitoneum

Huang and associates scoring systems

• Total Score ranging from 0 to 8

• One point was assigned to each anatomic

site in which free fluid was detected during

the FAST scan

• Fluid of more than 2 mm in depth in the

hepatorenal or the splenorenal space was

given 2 points instead of 1

• Floating loops of bowel were given 1 point

• Scores > 3 required exploratory laparotomy

Approximately…

• FAST can detect between 100-250ml

0.5 cm in Morison's Pouch = 500ml

1 cm in Morison's Pouch = 1000ml

CT can detect volumes of free fluid as

low as 100ml

FAST: Strengths and Limitations

Strengths

• Rapid (~2 mins)

• Portable

• Inexpensive

• Technically simple, easy to train

• Can be performed serially

Limitations

• Does not typically identify source of bleeding

• Limited in detecting <250 cc intraperitoneal fluid

• Particularly poor at detecting bowel and mesentery damage

• Difficult to assess retroperitoneum

Extended FAST (eFAST)

• Evaluation of pneumo and

hemothorax in addition to

intraperitoneal injuries.

CT in Abdominal Trauma

• Initial evaluation of

– blunt trauma

– penetrating trauma

• Follow up of non-operative

management

• Rule out Injury

Abdominal Trauma Protocol

• BLUNT INJURY -deceleration, crush,

weapon (e.g. bat)

– venous phase ~70 secs

– Delayed scan if injury present; ~3-5 mins

• PENETRATING INJURY: knives, gun

– Same as blunt

– Additional scan after rectal contrast

material

• The findings to look for in abdominal

trauma are the following:

– Hemoperitoneum

– Pneumoperitoneum

– Contrast blush consistent with active

extravasation

– Subcapsular hematomas

– Laceration

– Contusions

– Devascularization of organs or parts of

organs

HemoperitoneumHyperdense intraperitoneal fluid collection

0–20HU Preexisting ascites

Bile

Urine

Digestive fluid

Diluted or old blood

30–45HU Free Unclotted intraperitoneal

blood

45–70HU Clotted blood/sentinel clot sign

hematoma

>100 HU Extravasation of contrast medium

(vascular or urinary)

Volume

• Detection of fluid in each paracolic

gutter indicates that atleast 200 ml of

blood must be present in each gutter.

• CT visualisation of blood in the

abdomen and pelvis corresponds with

the amounts of more than 500 ml.

Spleen

• The spleen is the most commonly

injured organ in blunt abdominal

trauma

• 40% of all solid organ injuries

Traumatic Splenic Injury

Imaging

– Plain film:

– US: hemoperitoneum

– Contrast-enhanced CT: imaging modality

of choice

– MRI; Confers no additional advantage

in the initial trauma evaluation

– Angiography: therapeutic embolization

Plain film findings for spleen

trauma• left lower rib fracture

• The classic triad indicative of acute splenic rupture

• Left hemidiaphragm elevation

• Left lower lobe atelectasis

• Pleural effusion

CT scan findings that indicate

splenic injury include:

• Hemoperitoneum –

• Localized fluid collections around the

spleen—PERISPLENIC

HAEMATOMA(>60Hounsfield unit

measurement) SENTINEL CLOT SIGN

Clotted blood adjacent to the site of injury is of

higher attenuation value than unclotted blood

which flows away .

• Hypodensity –

Hypodense regions represent areas of

parenchymal disruption,

INTRAPARENCHYMAL HEMATOMA or

SUBCAPSULAR HEMATOMA.

• Hypodense linear parenchymal defect-------

SPLENIC LACERATION

• Laceration traversing two visceral

surfaces—SPLENIC FRACTURE

• Multiple lacerations---SHATTERED

SPLEEN

• Contrast blush or extravasation –

– describes hyperdense areas within the

splenic parenchyma that represent

traumatic disruption or pseudoaneurysm

of the splenic vasculature. Active

extravasation of contrast implies ongoing

bleeding and the need for urgent

intervention

Delayed splenic rupture

• Bleeding due to splenic injury

occurring more than 48 h after blunt

trauma following an apparently normal

CT examination

• Due to ruptures of subcapsular splenic

haematomas.

American Association for the Surgery of Trauma ( AAST)

organ injury severity scale grading system for splenic injury

25

25

the minimal perisplenic

collection.

She was managed

conservatively with uneventful

recovery.

subcapsular haematoma involving

30%–40% of splenic surface area

(arrow).

intraparenchymal

haematoma (arrow) less

than 4 cm in diameter with

no capsular tear.

a 2-cm laceration at the hilum (arrow)

MDCT images demonstrate a sharply

marginated, irregular, linear area of

low attenuation

Subcapsular haematoma (arrow) seen as perisplenic collection that

indents the underlying parenchyma.-----------grade II

multiple intraparenchymal lacerations

with subcapsular haematoma (arrow).

Splenectomy was done with blood loss

of 300 mL.

a laceration at upper pole (arrow).

Intraoperative findings confirmed

a 6-cm laceration with

haemoperitoneum of about 1L.

Splenectomy was performed.

Grade III Subcapsular Hematoma

• Crescent-shaped perisplenic

• Compresses the splenic parenchyma

Splenectomy was

performed for this patient

shattered spleen with large-volume

haemoperitoneum.

focal high attenuation --- due to

active hemorrhage.

Splenectomy was done for this

patient.

non-perfusion of the spleen on

this post contrast image.

Perisplenic hyperdensity --- due

to contrast extravasation.

also a left renal injury (long

arrow).

Splenectomy was done.

Hemoperitoneum of 2L

noted intraoperatively.

laceration at splenic hilum with

massive hemoperitoneum

confirmed Intraoperatively with

blood loss of 1L

Contrast blush

• A contrast blush is defined as an area of high density with density measurements within 10 HU compared to the nearby vessel (or aorta).

• The differential diagnosis is:

– Active arterial extravasation

– Post-traumatic pseudoaneurysm

– Post-traumatic AV fistula

Figure 2a. Splenic arterial embolization for treatment of splenic laceration due to blunt

abdominal trauma in a 26-year-old man.

©2005 by Radiological Society of North America

SEQUELAE of splenic injury

• Healing with scar /fibrosis

• Splenic pseudocyst

• Vascular injury• Pseudoaneuyrsm

• AV fistula

• Splenic infarct

• Delayed splenic rupture

Splenic artery pseudoaneurysms. (A) Arterial phase coronal

reformatted image in a 77-year-old --hyperattenuating foci within the

splenic parenchyma (B) Delayed phase coronal CT -- complete washout

------------consistent with traumatic splenic arterial pseudoaneurysms..

• This patient required endovascular

treatment with coil embolization

(A) Axial MDCT image in the portal venous phase --- large pseudoaneurysm seen as a

well-circumscribed focal area of increased attenuation. Splenic lacerations also.,, a

large quantity of perisplenic hematoma

(B) Excretory phase images -- “wash out” of the pseudoaneurysm, which becomes

isodense to splenic parenchyma. The area of increased density within the perisplenic

hematoma represents an area of active bleeding

SPLENIC PSEUDOANEURYSM

Splenic arteriography confirms

splenic pseudoaneurysms

RUPUTRE OF SPLENIC

PSEUDOANEURYSM

multiple focal areas of increased attenuation in keeping with multiple splenic

vascular lesions , with an adjacent laceration .

Follow-up portal venous phase axial image obtained 6 hours post

admission shows a significant increase in the amount of hemoperitoneum

and active bleeding into the peritoneum, from rupture of the

pseudoaneurysms.

POST TRAUMATIC SPLENIC

INFARCTS

well-demarcated wedge-shaped region of

decreased enhancement , consistent with

the appearance of a posttraumatic splenic

infarct.

Follow-up images

obtained at (B) 3 days,

(C) 1 month, and (D) 4

months show evolution

over time with a

reduction in size of the

infarcted area and loss

of splenic parenchyma .

Splenic abscess as a complication of splenic injury

intraparenchymal haematoma with multiple air pockets within; this was

confirmed intraoperatively.

15 days after embolization,

showing residual enhancing splenic tissue within

the surrounding infarcted spleen.

Post embolisation------

embolization coil at the

splenic hilum

a large splenic infarct

with branching pattern of

intraparenchymal air

Postembolization splenic necrosis

(A) Portal venous and (B) excretory phase axial images distal embolization coils

within the splenic parenchyma.

A well-defined low-attenuation area seen distal to the coil on both images

represents an infarct, which is unchanged in appearance in the excretory phase.

Infarction following embolization.

SPLENIC INJURIES - Management

• Often arterial hemorrhage, therefore nonoperativemanagement less successful.

• Grade IV-V: almost invariably require operative intervention

IMAGING LIVER TRAUMA

Liver

• The liver is the second most

commonly injured organ in abdominal

trauma.

• Between 70 and 90% of hepatic

injuries are minor

• Right lobe most commonly affected(4

times)

• Associated injuries:2/3 have hemoperitoneum

45% have associated splenic injury

33% have rib fractures

Duodenal or pancreatic injury

Biliary injury: hematobilia, biloma, biliary ascites, bile duct disruption

• Ultrasound sensitive for grade 3 or greater

Radiological overview of liver

injury:

• Right lobe> left lobe; 3:1

• Posterior segment most common

(fixed by coronary ligament)

• CT imaging method of choice

Features with impact on the

management and the prognosis

• Number of segments involved by the lacerations (significant if at least three segments are involved)

• Central or subcapsular location of the lacerations and contusions

• Extension of lesions within the portahepatis or the gallbladder fossa

• Importance of the hemoperitoneum

• Vascular lesions with active bleeding or sentinel clot sign

The CT report should

• Precisely mention the lobar or

segmental

• Superficial or central topography of

the contusions

• Along with their extent and location in

relation to the vascular elements.

Classification

(AAST) I-Subcapsular hematoma<1cm,

superficial laceration<1cm deep.

II-Parenchymal laceration 1-3cm deep,

subcapsular hematoma1-3 cm thick.

III-Parenchymal laceration> 3cm deep

and subcapsular hematoma> 3cm

diameter.

IV-Parenchymal/supcapsular

hematoma> 10cm in diameter, lobar

destruction, OR devascularisation

Subcapsular

hematoma greater

than 10 cm .

Contrast blush

No associated

hemoperitoneum

Complete devascularization of the right lobe (i.e. grade 4) .

Contrast blush within the intraparenchymal region, also extention beyond the

lateral margin of the liver.

Hemoperitoneum.

A second contrast blush at a lower level.

after selective right

hepatic arterial

embolization with

gelatin sponge for a

grade 4 hepatic

laceration shows

multiple foci of gas .

Aspiration demonstrated

a sterile hematoma.

Hepatic

artery

embolizatio

n for

trauma.

V- Global destruction or devascularization

of the liver.

VI-Hepatic avulsion

Complications

• Biloma

• Delayed hemorrhage

• Hemobilia

• Hepatic infarcts

• Pseudoaneurysm

• AV fistula

Post-traumatic biloma: evidence of

communication with a biliary ductal

branch.

TRAUMATIC BILE LEAKS

CT image demonstrating a laceration

extending to hepatic dome

the laceration extending down to the left

main hepatic duct

free bilous ascites in the lower abdomen

Cholangiogram image demonstrating

contrast (bile) leaks. The arrow points to

the hepatic dome peripheral bile leak site.

The arrowheads point to the area of the

bile leak from the partially transected left

biliary duct.

Coronal MRCP

(thick slab

HASTE)

performed

several days

after the acute

injury

demonstrates a

large collection

of bile at the site

of the liver

laceration

ERCP

confirms

the

presenc

of a

traumati

bile leak

Inadvertent laceration of an isolated segment. Fluoroscopic image of a percutaneous

transhepatic cholangiogram ---- contrast extravasation into a bile collection.

B, biloma.

The transected bile duct site where it leaks (between arrows) demonstrates

narrowing due to fibrosis as well. Typically, with delayed diagnosis and management

the transected extrahepatic bile ducts show narrowing as seen in this figure.

Traumatic haemobilia

Blood clot in the gallbladder

Traumatic false aneurysm of

the left hepatic artery

Post-embolic occlusion of the left hepatic

artery with microcoils

• Blunt trauma to the liver in a 18-year-

old woman leading to liver laceration

and free bilous ascites.

• Treated with biliary leak site

EMBOSCLEROSIS

(A) PTC demonst contrast (bile) leaks . The upper ( more superficial leak) -- from a

single peripheral bile duct that has a ‘T’ configuration. The lower (more central)--

from a smaller peripheral duct that is separate from the other ‘T’-configured duct.

(B) Image obtained during an N-butyl cyanoacrylate (glue) injection demonstrating

formation of glue globules from the biliary leak sites arising from the ‘T’-configured

bile duct (arrow).

(C) Digitally subtracted cholangiogram demonst truncation (occlusion) of the ‘T’-

configured bile duct (arrowhead), which was the main source of leakage.

(D) Follow-up CECT image demonstrating the the ablated peripheral bile ducts. The

arrow points to a glue globule.

Follow-up image

from a tranhepatic

cholangiogram

demonstrating

hardened glue

globules from the

former side of bile

leaks

(arrowheads).

There are no

longer any bile

leaks.

• Biliary–cutaneous fistula between bile

duct and intrahepatic biloma treated

with alcohol ablation from the

transhepatic biloma side of the fistula

A) Fluoroscopic spot film demonst communication between the intrahepatic biloma and

a right-sided peripheral bile duct . The arrow--- the transhepatic biloma drain, which

essentially converts this refractory biliary–biloma fistula to a biliary–cutaneous fistula. (B)

Image during injection of contrast through a balloon occlusion catheter demonstrating

involved bile duct (arrowheads). A wire is placed coaxially through the balloon occlusion

catheter and its tip is at the duct to cavity ostium (white arrow).

(C) Fluoroscopic image during further access into the bile duct with a 5-French

catheter. The tip of the catheter is just at the ostium of the biloma with the duct .

Contrast injection confirms apposition of the catheter tip into the involved bile duct

(arrowhead). (D) further attempts at obtaining deeper acess into the bile duct with

a 4-French catheter. The tip of the catheter is just beyond the ostium of the biloma

and inside the involved the duct .absolute alcohol was injected from this catheter

position.

After two alcohol ablation sessions, follow-up fluoroscopic caption

of a tube sonogram showed obliteration of the communication

between the biloma and the bile duct

Reference • TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID

SUTTON

• Grainger & Allison's Diagnostic Radiology: A

Textbook of Medical Imaging, 4th ed.

• Imaging of Renal Trauma - RadioGraphics 2001;

21:557–574

• Urethral Injuries after Pelvic Trauma -

RadioGraphics 2008; 28:1631–1643

• http://www.radiologyassistant.nl/en/466181ff6107

3

• American College of Radiology - ACR

Appropriateness Criteria

• CT of the Acute Abdomen - Patrice Taourel

• http://www.sonoguide.com/FAST.html

Thank you

Periportal Edema

• Periportal hypodensities running in

parallel to the portal branches

• Causes

– Diffusion from intraparenchymal bleeding

– Dilatation of periportal lymph vessels

– Vascular or focal bile duct dissection

• Indications for surgical treatment in

liver trauma

– Shock

– Active venous bleeding

– Trauma of the gallbladder

– Choleperitoneum

– Abdominal surgery necessary for other

causes

Imaging of Renal Trauma

• Computed tomography (CT) is the

modality of choice in the evaluation of

blunt renal injury

• Injury to the kidney is seen in

approximately 8%– 10% of patients

with blunt or penetrating abdominal

injuries

Renal criteria for performing

CT in abdominal trauma

• Macroscopic hematuria

• Microscopic hematuria with shock

• Important renal ecchymosis or fracture of

the lumbar transverse process

• Open trauma involving the retroperitoneum

• Mechanism of deceleration (risk of pedicle

injury)

• In children all types of posttraumatic

hematuria

Computed Tomography

• Early and delayed CT scans through the kidneys are necessary

• Excretory-phase contrast (3min)

• The preferred technique – Helical CT performed from the dome of the

diaphragm

• Scanning parameters include – Collimation of 7 mm,

– Pitch of 1.3,

– Image reconstruction intervals of 7 mm.

Subcapsular hematoma

(category I)

Crescent shaped hyperdensity, located

in the periphery of the kidney

Laceration

• Hypodense, irregularly linear areas,

typically distributed along the vessels

and filled with blood.

• They are best analyzed at arterial

phase

– Superficial (<1 cm from the renal cortex)

– Deep (>1 cm from the renal cortex)

– Renal medulla

– Collecting tubule system

Simple renal laceration

(category I)

Major renal laceration without

involvement

of the collecting system (category II)

Major renal laceration involving

the collecting system (category II)

Multiple renal lacerations

(category III)

Shattered kidney (category III)

Segmental Infarct

• Triangular parenchymal area, with a

widest part at the cortex, which is not

enhanced during the different phases,

with clear delineation

Segmental renal infarction

(category II)

Traumatic occlusion of the main

renal artery (category III)

Traumatic renal injury. Coronal reformatted portal venous phase CT image

in a 31-year-old female demonstrates a focal area of devascularization

involving the upper pole of the right kidney.

Traumatic occlusion

of the main renal

artery (category III)

Traumatic renal injury with active contrast extravasation in a 23-year-old male status

post assault. (A) Axial CT image from portal venous phase acquisition demonstrates left

renal laceration with evidence of active extravasation (arrow).

(B) Coronal maximum intensity progection image from portal venous phase acquisition

demonstrates left renal injury with evidence of active extravasation (arrow). This patient

required emergent renorrhaphy.

Active arterial extravasation

(category III)

Vein Pedicle Injury

• Incomplete or absent opacification of

the renal vein

• Persistent nephrogram

• Reduction in excretion

• Nephromegaly

Laceration of the renal vein

(category III)

Urinoma/Urohematoma

• Presence of a more or less significant

breach of the collecting tube system,

with urine escape reflected by

extravasation of contrast medium on

delayed imaging, in an extrarenal

location

Avulsion of the ureteropelvic

junction (category IV)

AAST organ injury severity scale grading system for kidney

injury

Grade 1 Contusion or contained and non -expanding

subcapsular haematoma, without parenchymal

laceration; haematuria

Grade 2 Non -expanding, confined, perirenal haematoma or

cortical laceration less than 1 cm deep; no urinary

extravasation

Grade 3 Parenchymal laceration extending more than 1 cm into

cortex; no collecting system rupture or urinary

extravasation

Grade 4 Parenchymal laceration extending through the renal

cortex, medulla and collecting system

Grade 5 Pedicle injury or avulsion of renal hilum that

devascularizes the kidney; completely shattered

kidney;

thrombosis of the main renal artery

BLADDER INJURY

CT Cystography

• Empty the bladder

• Instill the contrast retrograde through

the foley catheter of avg. 350-400 cc

of contrast

• Image the pelvis

CT classification

TYPES

1. Bladder contusion

2. Intraperitoneal rupture

3. Interstitial bladder injury

4. Extraperitoneal rupture

A. simple

B. complex (bladder neck involved)

5. Combined bladder injury

Intraperitoneal rupture (type 2)

• Cystography

– Contrast in paracolic gutters, around

bowel loops, pouch of Douglas and

intraperitoneal viscera

– ± Pelvic fracture

• CT cystography

– Contrast in paracolic gutters, around

bowel loops, pouch of Douglas and

intraperitoneal viscera

Cystogram of intraperitoneal

bladder rupture

Extraperitoneal rupture (type 4)

• Cystography

– Simple (type 4A): Flame-shaped

extravasation around bladder

– Complex (type 4B): Extravasation

extends beyond the pelvis

– Extravasation best seen on post-

drainage films

• CT cystography

– Perforation by bony spicules

– "Knuckle" of bladder: Trapped bladder by

displaced fracture of anterior pelvic arch

– Simple (type 4A): Extravasation is

confined to perivesical space

– Complex (type 4B): Extravasation extends

beyond perivesical space; thigh, scrotum,

penis, perineum, anterior abdominal wall,

retroperitoneum or hip joint

– "Molar tooth sign": Rounded cephalic

contour (due to vertical perivesicle

components of extraperitoneal fluid)

MOLAR TOOTH SIGN

CT of extraperitoneal bladder

rupture

Type 5

(combined) rupture.

URETHRAL INJURY

• Urethral injury is a

common

complication of

pelvic trauma

• Occurs in as many

as 24% of adults

• With pelvic

fracturesTypically

involve the

proximal (posterior)

portion

CLASSIFICATION OF URETHRAL INJURIES

Colapinto & McCallum Goldman & SandlerGrade I Posterior urethra stretched, but

intact

Posterior urethra stretched but

intact

Grade II Posterior urethral tear above

intact urogenital diaphragm

(UGD)

Partial or complete posterior

urethral tear above intact UGD

Grade III Posterior urethral tear with

extravasation through torn

UGD

Partial or complete tear of

combined anterior and

posterior urethra with torn UGD

Grade IV — Bladder neck injury with

extension to the urethra

Grade IVa — Injury to bladder base with

extravasation simulating type

IV (pseudo grade IV)

Grade V — Isolated anterior urethral injury

Goldman type I injury

Stretching or elongation of the otherwise intact posterior urethra

Intact but stretched urethra

Goldman type II injury

Urethral disruption above the urogenital diaphragm while the

membranous segment remains intact

Contrast agent extravasation above the urogenital diaphragm only

Goldman type III

Disruption of the membranous urethra, extending below the

urogenital diaphragm and involving the anterior urethra

Contrast agent extravasation below the urogenital diaphragm,

possibly extending to the pelvis or perineum; intact bladder neck

Goldman type IV injury

Bladder neck injury extending into the proximal urethra

Extraperitoneal contrast agent extravasation bladder neck disruption

Goldman type IVa injury

Bladder base injury simulating a type IV injury

Periurethral contrast agent extravasation; bladder base disruption

Intestinal and Mesenteric

Traumas

• Bowel or mesentery injury occurs in

5% of patients with abdominal blunt

trauma

• More common following open trauma,

especially in injuries caused by

firearms

• Four CT findings should alert the

radiologist

1. Focal fat infiltration

2. Interloop hematoma (sentinel clot sign)

3. Bowel wall thickening

4. Free intraperitoneal air

Small Bowel Injury

• Diffuse circumferential thickening

– Hypoperfused "shock" bowel

• Focal thickening

– Usually non-transmural injury

• Specific findings, rare

– Bowel content extravasation

– Focal bowel wall discontinuity

• Most common finding

– Unexplained non-physiologic free fluid (84%)

– Mesenteric stranding

– Focal bowel thickening

– Interloop fluid

• If in combination, strongly suggestive

GI Perforation

The direct CT sign

• Transparietal continuity solution, mainly

located on the mesenteric side of the bowel

• The perforation may occur intraperitoneally

or retroperitoneally

Indirect findings of traumatic

bowel perforation

• Peritoneal findings

– Sentinel clot

– Focal mesenteric infiltration

• GI findings

– Pneumoperitoneal air bubbles localized

within the mesentery

– Focal wall thickening

Traumatic duodenal

intramural hematoma

Periduodenal hemorrhage

• Causes of bowel thickening related to

trauma

– Contusion/hematoma

– Perforation

– Distal ischemia due to mesenteric lesion

– Bowel shock

– Secondary to peritonitis

– Bowel spasm

GI Ischemia

• Bowel ischemia

– Segmental (distal branch vessel injury)

– Diffuse thickening of small bowel wall -

hypotensive shock bowel

• Typical CT signs

– Lack of parietal enhancement

– Thickening of bowel wall

– Parietal pneumatosis with presence of air

inside the bowel wall

– Air in the mesentery and portal venous

system

Role of Interventional

Radiology

• Embolization

– Spleen

– Liver

– Pelvis

• Angioplasty + Stent

– Renal artery dissection

Principles of hemostatic

embolization

• Treatment should be derived from the

physiological process of hemostasis

• Resorbable material may be sufficient to

initiate local thrombus

• It should take place at the site of injury

• Minimal tissue loss

• Rebleeding should be avoided by formation

of a stable clot

Agents for embolizations

• Gelfoam– Soaked in an antibiotic solution

– resorable

– Can be cut in variable size

– May result in too distal embolization

– Risks for tissue infarction or late abscess formation

• Coils– Have variable size, length, diameter

– Precise targeted delivery

– Expensive

– Need normal coagulation

• Metal stents– Large-caliber patent artery

Spleen Embolization

Advantages

• Embolization can decrease the amount

of resuscitation fluid to maintain vital

sign.

• Embolization can decrease shock index

• Operation with adjunct embolization can

decrease the mortality rate

• Early embolization may decrease the

mortality rate

• Embolization is a promising way for

stopping bleeding

Reference • TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID

SUTTON

• Grainger & Allison's Diagnostic Radiology: A

Textbook of Medical Imaging, 4th ed.

• Imaging of Renal Trauma - RadioGraphics 2001;

21:557–574

• Urethral Injuries after Pelvic Trauma -

RadioGraphics 2008; 28:1631–1643

• http://www.radiologyassistant.nl/en/466181ff6107

3

• American College of Radiology - ACR

Appropriateness Criteria

• CT of the Acute Abdomen - Patrice Taourel

• http://www.sonoguide.com/FAST.html

Grade III Blunt Pancreatic Injury after 40 feet fall

Blunt abdominal trauma with splenic injury and

hemoperitoneum.

Blunt abdominal trauma with liver laceration.

Blunt abdominal trauma. Right kidney injury with blood in

perirenal space. Injury resulted from high-speed motor vehicle

collision

Ultrasound image of right flank. Clear

hypoechoic stripe exists between right

kidney and liver in Morison pouch.

Traumatic laceration to the liver.

Note extensive free intra-peritoneal blood.

Retroperitoneal Hemorrhage

• Retroperitoneal hemorrhage may

arise from injuries to major vascular

structures, hollow viscera, solid

organs, or musculoskeletal structures

or a combination

Small zone I (central)

retroperitoneal hematoma

Large zone I (central)

retroperitoneal hematoma

with active extravasation

Large zone II (lateral)

retroperitoneal hematoma

Pancreas

• Uncommon injury

• 1.1% incidence in penetrating trauma

and only 0.2% in blunt trauma.

• Rarely an isolated injury.

• Usually part of a 'package injury'

Laceration of the pancreatic

neck without duct injury

Pancreatic transection (neck)

with duct injury

Subtle pancreatic contusion

Indirect Signs

• Edema with global pancreatic enlargement

and loss of lobulation

• Peripancreatic fat infiltration

• Peripancreatic fluid, especially if it is

located around the SMA or the omental

bursa

• Hematic fluid between the dorsal surface of

the pancreas and the splenic vein

• Thickening of the left anterior pararenal

fascia or fluid in the anterior pararenal

space

• Concomitant duodenal injury

AAST GRADING OF PANCREAS INJURY

Grade

Type of

Injury Description of InjuryI Hematoma Minor contusion without duct injury

Laceration Superficial injury without duct injury

II Hematoma Major contusion without duct injury or tissue

loss

Laceration Major laceration without duct injury or tissue

loss

III Laceration Distal transection or parenchymal injury with

duct injury

IV Laceration Proximal transection or parenchymal injury

with probable duct injury (not involving

ampulla)b

V Laceration Massive fragmentation of pancreatic head

Subxiphoid view of cardiac anatomy