Imaging of Abdominal Trauma

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Rathachai Kaewlai, MD Ramathibodi Hospital, Mahidol University, Bangkok Emergency Radiology Minicourse 2013 Slides available at RiTradiology.com or Slideshare.net/rathachai

Introduction

•  Abdominal injuries common in multiply-injured patients (20%-40%)

•  High death rate, similar to head trauma •  Can be blunt or penetrating

– Blunt compressive or deceleration forces – Penetrating: shrapnel, gun shot, blast

Introduction

•  Different forces different types of injuries – Deceleration force vessel injuries – Compression force “package” injuries

•  Each organ reacts differently to forces – Solid organs lacerate, contuse, infarct – Hollow organs perforate

Potential Means to Assess Abdominal Injuries •  Physical examination: poor sensitivity (<50%) •  Diagnostic peritoneal lavage (DPL): now obsolete

owing to limited accuracy and invasiveness •  Imaging has already replaced DPL

–  Ultrasound (FAST): hemoperitoneum –  CT: hemoperitoneum, solid/hollow viscus injuries, active

extravasation/vascular injuries

“Abdomen”

•  Anterior: nipple line to groin crease •  Posterior: tips of scapulae to gluteal

skin crease •  Three basic regions of abdomen

–  Peritoneal cavity + intrathoracic component

–  Retroperitoneum –  Pelvis

Blunt Abdominal Trauma •  Motor vehicle collision (MVC, ~75%),

motorcycle crashes (MCC), pedestrian-automobile impacts, falls and assaults

•  Multiple different organ injuries •  Major complications: peritonitis,

hemorrhagic shock and death •  Two categories:

– Solid organ injuries – Hollow organ injuries

Blunt abdominal trauma evaluation

Hemodynamically stable Hemodynamically unstable

FAST/DPL

Positive Negative

Laparotomy

Positive Negative

Search for other sources

of hemorrhage

Consider discharge Minor injury

Observation

Major, nonoperative

ICU observation

Operative

Laparotomy

Observation

Repeated FAST CT

Penetrating Abdominal Trauma

•  Foreign object pierces skin. Gunshot wounds (GSW), stab wounds

•  External appearance of penetrating wound does NOT determine extent of internal injuries

•  Define trajectory of penetrating wound and consider all possible internal injuries

•  Complications: hemorrhagic shock •  Organs injured: penetrating > blunt trauma = SB, colon/

rectum, stomach, pancreas, diaphragm

Penetrating abdominal trauma evaluation

Hemodynamically stable Hemodynamically unstable

Laparotomy FAST

Positive Negative

Stab Wound GSW

To Back/flank – CT indicated

Anterior – CT considered Thoracoabdominal – CT considered

Shotgun to back/flank – CT indicated

Shotgun to anterior – Laparoscopy/otomy Bullet (higher velocity) – Laparotomy

Focused Assessment with Sonography for Trauma (FAST) •  Been used for over 30 years •  Bedside screening to aid clinicians in identifying

free fluid in thorax or abdomen •  Initially designed to focus primarily on detection

of free fluid – now modified to detect pneumothorax, quantification of fluid

•  Sensitivity 80-90%, specificity 95-100% for free fluid

Anatomical Considerations

•  Site of fluid accumulation depends on position of patient and source of bleeding

•  Free fluid in dependent compartments –  RUQ Morison’s pouch right paracolic gutter

pelvis –  LUQ subphrenic space splenorenal recess

left paracolic gutter pelvis –  Pelvis = rectovesical pouch (M), pouch of Douglas (F)

Scanning Techniques

•  Sequential – Pericardium – Perihepatic – Perisplenic – Pelvis

•  Standard or microconvex probe •  Transthoracic view follows standard

PERICARDIUM •  Global cardiac

function •  Chamber size •  Normal pericardium =

white line surrounding heart

•  Sweeps anterior-posterior

PERIHEPATIC •  Right pleural effusion,

free fluid in Morison’s pouch, free fluid in paracolic gutter

•  Mid-axillary line between 8th-11th ribs with oblique scanning plane

PERISPLENIC •  Left pleural effusion, free

fluid in subphrenic space and splenorenal recess, free fluid in left paracolic gutter

•  Left diaphragm, spleen, left kidney

PELVIC •  Longitudinal and

transverse views •  Free fluid in anterior

pelvis or cul-de-sac •  Ideally should be done

before Foley •  Differentiate partially filled

bladder with free fluid by –  Emptying bladder (Foley)

or –  Retrograde bladder filling

Hemopericardium

•  Anechoic stripe surrounding the heart within parietal and visceral layers of bright hyperechoic pericardial sac

•  Especially helpful in penetrating trauma •  Classic clinical signs found in < 40% of cases with

proven cardiac tamponade •  Bedside cardiac US

–  Reduces time of diagnosis and disposition to OR –  Increases survival

•  Sensitivity 100%, specificity 96.9%, accuracy 97.3%

Free Pleural Fluid •  Anechoic stripe above diaphragm •  US is at least comparable to CXR •  Minimum fluid needed

–  Upright CXR 50-100 mL –  US 20 mL

•  Differentiation of fluid from pleural thickening and lung contusion

•  Complement CXR in diagnosis of hemothorax in supine patient

Hemoperitoneum

•  Anechoic stripe in Morison’s pouch, paracolic gutter, splenorenal recess, left subphrenic space, pelvis

US Features of Organ Injuries •  Not specific goal of FAST to detect organ injury •  Acute laceration

–  Fragmented areas of increased or decreased echo •  Contained intraparenchymal or subcapsular

hemorrhages –  Isoechoic or slightly hyperechoic (difficult to detect)

•  Low sensitivity esp splenic injury

Pitfalls of FAST

•  Contraindication (when emergent Sx needed)

•  Overreliance on FAST: esp negative ones •  Limitations of FAST:

– Morbidly obese – Massive subcutaneous emphysema

•  Pregnancy •  Technical difficulties

How FAST Affects Other Diagnostics •  Reduce number of DPL •  Reduce number of CT •  No change to patient’s risk •  Cost saving

Unboundedmedicine.com

Wired.com

Detection of Pneumothorax •  Pneumothorax occult on CXR in 29-72% •  Extended FAST (EFAST) can identify

pneumothorax before CXR •  Best resolution of pleural interface with high-

resolution probe and small footprint but most practical using same probe as FAST

•  Identify contiguity of visceral and parietal pleura using simple US signs –  Normal = lung sliding (B), seashore sign (M mode) –  Abnormal = loss of lung sliding (B), stratosphere (M),

lung point (B & M)

Detection of Pneumothorax

•  “Air rises, water descends” – Dependent disorders: effusion, consolidation – Nondependent disorders: pneumothorax,

interstitial process

Normal Appearance: Evaluate for Pneumothorax

•  Sagittal view at mid-clavicular line “bat-sign” –  Lung sliding? –  A-line sign? –  Lung point?

Detection of Pneumothorax

•  Normal lung sliding –  Twinkling at level of pleural

line in real time –  Sliding of visceral against

parietal pleura –  Seashore sign on M mode –  Avoid using filters that reduce

Bright pleural line that moves on realtime scanning

seashore

Seashore sign on M mode

Pneumothorax: Loss of Lung Sliding •  Sensitivity 80-100%

(lower in trauma) •  Specificity 83-100% •  Real-time US •  M mode = Barcode or

stratosphere sign •  “Lung point” most specific

sign (alternating areas of barcode and seashore signs)

Barcode or stratosphere sign

Algorithm: Looking for Pneumothorax on US

Lung sliding

Yes Pneumothorax ruled out

No B-lines?

No Lung Point? No Use other

Pneumothorax

Adapted from Lichtenstein D.

Pitfalls of US on Pneumothorax

•  “Loss of lung sliding” alone is not specific for pneumothorax – Pleural adhesion/thickening – Atelectasis – Lobec/pneumonectomy – One-lung intubation

•  Look for “Lung Point” for specificity •  Comparison with contralateral lung

FAST vs. CT FAST CT

Aim for Detection of hemoperitoneum Detection of hemoperitoneum, organ injuries

Accuracy (for hemoperitoneum)

88% Nearly 100%

Accuracy (for organ injuries)

74% Nearly 100%

Missed rate 15% of hemoperitoneum. Up to 25% of liver/spleen, most renal/pancreas/bowel

Benefits Fast, bedside, no patient prep needed, no risk of IV contrast issues

More accurate, guide non-operative management

ACR* Recommendation

Done first and only if hemodynamic unstable before going to OR

Done if hemodynamic stable

*The American College of Radiology

When to do CT

•  Blunt abdominal trauma – Stable patients with positive FAST – Stable patients with negative FAST but

suspicious for injuries (by clinical or labs) •  Penetrating abdominal trauma

– Stable patients with injury to back & flank –  (stable patients with thoracoabdominal &

anterior stab wounds)

At Time of Receiving Consultation •  Must know mechanism of trauma

– Affecting use of contrast •  Review portable CXR and pelvic XR

– Anything obvious been treated? – Signs of aortic injury present? Does patient

also need chest CT? – Pelvic fracture? If yes, is hematuria present?

Does patient need CT cystography?

Review portable trauma CXR… Anything obvious been treated?

Inadvertent arterial line placement Left pneumothorax

Patient Preparation for CT •  Hemodynamic – must be stable •  NPO – should not wait •  IV contrast – a must (if conditions allow) •  Oral contrast – no need for routine cases •  Rectal contrast – no need for routine cases •  Renal function test – risk/benefit ratio •  Pregnancy test - yes

CT Technique •  Do whole abdomen! •  No plain scan •  Phases of scanning

–  With pelvic fractures: late arterial and portovenous whole abdomen

–  Without pelvic fractures: Late arterial upper and portovenous whole abdomen

–  + delays at site of injuries

•  If suspicion of TL spine fx, do small FOV axials and coronal/sagittal reformations

CT Technique •  Helical mode. Thinnest collimation possible and

reformatted to 2-2.5 mm for viewing •  120 kV •  Auto MA based on patient size •  Lower dose for non-standard phases (i.e., late

arterial, delayed) •  Must have coronal and sagittal reformations

Specific Questions •  R/O bowel injuries

–  Oral, IV, rectal contrast •  Penetrating trauma

–  Oral, IV, rectal contrast

•  R/O bladder injuries (gross hematuria + pelvic fractures = a must do) –  CT cystography using 300-400 cc of 2% contrast

instilled through a bladder catheter and image the pelvis

Concerns of CT •  Radiation dose can be reduced by

–  Routine use of automatic tube-current modulation –  Reduce Z-axis (no plain scan or unnecessary delayed

scan) –  Use of Adaptive Statistical Iterative Reconstruction

•  Maximize cost/benefit ratio –  Use of clinical prediction rule, expert recommendation

Important/Urgent Must-Knows

•  Free fluid – Differentiation of blood from other fluid – Differentiation of intra- and extraperitoneal

blood •  Free air •  Active extravasation / vascular injuries •  Hypoperfusion complex

Free Fluid

•  Common findings, seen in 75% of patients with intra-abdominal injuries

•  Determine – Where? (intra- or extraperitoneal) – Type? (blood, urine, bowel content, bile,

ascites) – Volume? (minor, moderate, major)

Free Fluid: Where?

•  Intraperitoneal fluid: Perisplenic, perihepatic, Morison pouch, paracolic gutters, inframesocolic space, lesser sac, between mesenteric leaves

•  Extraperitoneal fluid: pararenal, perirenal, perivesical, pericholecystic spaces

•  Two confusing areas – Morison pouch vs. perihepatic – Pelvis vs. anterior prevesical space

Free Fluid: Where? Intraperitoneal Blood Extraperitoneal Blood Wraps around liver tip No Location of primary organ injury in the peritoneum No Cul-de-sac, mesenteric root Perivesical, anterior paravesical

Free Fluid: Type? •  Always measure HU •  Fluid does not

enhance! Changes in attenuation from pre to post contrast may be seen but should be minimal (<5-10 HU)

Type HU

Blood (acute) 30-45

Blood (clot) 50-60

Contrast (IV, oral, rectal) 100+

Clear fluid (urine, ascites, bile)

Free Fluid: Type

Low-density free fluid in blunt trauma patient proven to be urine leakage from intraperitoneal bladder on CT cystography

Sentinel Clot Sign •  Blood accumulates adjacent

to site of bleeding •  Indirect sign of injury to an

adjacent organ even if the lesion could not be identified

•  Orwig D and Federle MP* –  Sentinel clot seen in

84% of visceral injuries –  Sentinel clot only clue to

bleeding source in 14% •  The rest, CT showed

injury itself (86%)

Orwig D and Federle MP. Am J Roentgenol 1989;153:747

Denser fluid

Free Fluid: Volume

•  You can estimate volume of blood but this is less important than hemodynamic status

•  Each compartment: Morison, perihepatic and perisplenic, paracolic gutters, pelvis

Amount (cc)

# compartment

s with fluid

Minor 100-200 1

Moderate 200-500 2

Large >500 > 2

Becker CD et al. Eur Radiol 1998;8:553.

Intraperitoneal Fluid Quantity

Free Fluid: Volume •  Difficult to quantify

volume in retroperitoneal bleed

Amount CT Character

Minor Fascial thickening

Moderate Confined to retroperitneal space adjacent to its origin (ie, perirenal, anterior/posterior pararenal)

Large Multiple communicating retroperitoneal spaces

Retroperitoneal Hemorrhage Quantity

Active Extravasation •  Jet or focal area of

hyperattenuation (within 10 HU of adjacent major vessel source) within a hematoma on initial images that fades into an enlarged, enhanced hematoma on delayed images

•  Indicates significant bleeding •  Must be quickly communicated

to the clinician (surgical or endovascular Rx may be necessary)

Delayed

Pseudoaneurysm / AVF •  Contained by connective tissue or vessel wall (ie, adventitia). •  Adjacent to a vessel •  Does not enlarge. Same size in all phases •  CECT not reliable to differentiate the two •  >70% of pseudoaneurysms progress to rupture but natural history of AVF is

uncertain

Pseudoaneurysm

Active Extravasation vs. Pseudoaneurysm Characters Active Extravasation Pseudoaneurysm

Edges Ill-defined Defined

Shape Commonly a jet (linear or layering); may be diffuse or focal

Often round or oval; possible neck adjoining artery

Delayed appearance

Increased attenuation or size; possible layering

Less apparent; in isolation, no change in size, similar attenuation with vessels

Management Urgent embolization or surgery if significant injury present*

Urgent or ambulatory embolization or surgery if significant injury present*

*Not all injuries must be treated. Small pseudoaneurysms or those amenable to Rx by direct pressure do not

Hypoperfusion Complex •  Flat IVC, small aorta •  Enhanced: adrenals, kidneys, GB

mucosa, bowel mucosa •  Hypoenhanced: liver, spleen,

pancreas, peripancreatic edema

Flat IVC, small aorta, hyperenhanced kidneys, hyperenhanced GI mucosa, and peripancreatic edema caused by hypoperfusion state from left pelvic ring injury

Flat IVC

Hyperenhanced G

I mucosa

Specific Organ Injuries

•  Solid intraperitoneal organs •  Retroperitoneal organs •  Hollow organs

Liver and Gallbladder

•  Common •  Can be part of RUQ/midline “package injuries”

– Shearing right lobe adjacent to hepatic veins – Compression left lobe

•  Vast majority managed nonoperatively – Surgery if severe injuries with active bleeding and/

or complete destruction of entire hepatic lobe •  Right lobe (75%) > left lobe

•  Periportal tracking common, prob due to.. –  Lymphedema following systemic volume overload,

tension ptx, tamponade or –  Hematoma obstructing hepatic venous outflow

•  Laceration involving hepatic veins (esp. if large > 10 cm focal hypoperfusion) associated with injuries to retrohepatic IVC

laceration

Extraperitoneal blood

•  Liver laceration involving hilum –  Repeated CT or US, cholescintigraphy or direct

cholangiography to detect possible biliary complications

laceration

AAST Organ Injury Scale

Trauma.org

Splenic Injury •  Most frequently affected organ in blunt trauma (?) •  Contusion, parenchymal laceration, subcapsular

hematoma, perisplenic hematoma, fragmentation of parenchyma and disruption of hilar vessels

•  Left lower rib fractures frequently associated •  Perfusion defects due to segmental

devascularization from vascular pedicle injury can be difficult to distinguish from contusions or local reactive hypoperfusion in hypotensive patient

•  Contusion = hypodense area within normally perfused splenic parenchyma

•  Laceration = linear perfusion defect

•  Subcapsular hematoma = lenticular shape with compression of adjacent splenic paenchyma –  Difficult to confidently see splenic capsule –  Sometimes difficult to distinguish btw subcapsular and

perisplenic hematoma

Image from Radiology.cornfield.org

Trauma.org

Nonoperative Management of Splenic Injury •  Now accepted practice: Success rate 95% in

children, 70% in adults •  Well-recognized complication = delayed splenic

rupture –  No reliable CT finding to predict risk of delayed

splenic rupture –  Even a normal CT cannot exclude possibility of

delayed splenic rupture

Pancreas

•  <2% of blunt abdominal trauma •  Up to 90% multiple organ injuries •  Contusion, superficial or partial laceration,

complete transection or disruption •  Can be difficult to diagnose clinically

– Delayed complications: recurrent pancreatitis, fistula, abscess, hemorrhage

– Risk of abscess/fistula high (25-50%) if duct disruption (vs. 10% if duct not disrupted)

Pancreas

•  Predict the presence or absence of ductal disruption by depth of laceration and location – Grade A, pancreatitis or superficial laceration

(<50% pancreatic thickness) – Grade B, deep laceration (>50% thickness) at

tail – Grade C, deep laceration at head

•  Direct CT signs: Pancreatic enlargement, focal linear non-enhancement, comminution, heterogeneous enhancement (subtle initially)

•  Indirect CT signs: Peripancreatic fat stranding, fluid collections, fluid separating splenic vein from parenchyma, hemorrhage, and thickening of left anterior pararenal fascia

Focal linear non-enhancement

Bowel and Mesentery •  3-7% of blunt abdominal trauma •  Jejunum and ileum (near point of fixation—IC

valve and ligament of Treitz) most common •  Colon: transverse, sigmoid and cecum •  Stomach-rare •  Duodenal injury: 2nd/3rd part in close proximity

to spine •  Overall CT sensitivity/specificity 85-95%

•  Direct CT signs: 1) Discontinuity of wall, spillage of contrast or luminal contents into peritoneal or retroperitoneal. 2) Extraluminal air (definite for blunt trauma but not for penetrating trauma)

•  Indirect CT signs: 1) Focal bowel wall thickening, streaky mesenteric fat, unexplained free fluid between mesenteric loops. 2) Generalized bowel wall thickening nonspecific

Colonic contrast leakage

Perforation site at sigmoid colon

Bullet

•  Duodenal perforation vs. hematoma –  Perforation immediate surgery –  Hematoma conservative

•  Helpful if you can give oral contrast immediately before scanning to see leakage

Perforation site

Circumferential wall hematoma

•  Mesenteric injury –  Extravasation of contrast (active bleeding) –  Intramesenteric fluid collections, hemoperitoneum,

thickening bowel loops in bowel ischemia

Initial scan

Delayed scan with progressive increase of

extravasation

Adrenal Glands

•  2% of blunt trauma cases undergone CT •  Usually unilateral, right sided and a/w

ipsilateral intraabominal and thorax injuries •  Majority not clinically significant •  Spontaneous resolution in 2 months •  Specific Rx may be needed if: large

hematoma compressing IVC, bilateral hematomas result in adrenal insufficiency

•  Round or ovoid, stranding of perirenal/periadrenal fat •  Active bleeding due to injuries to suprarenal arteries •  F/U CT in 2-3 months to ensure resolution if unable to differentiate from

pre-existing adrenal mass on trauma CT

Active contrast extravasation in adrenal hematoma

Portovenous Arterial

Kidney and Ureter •  Kidney injury = most common RP injury •  Contusion, laceration, subcapsular hematoma,

shattered kidney, renal artery occlusion •  Major renal hemorrhage with minor trauma

should raise suspicion of underlying pathology (hydronephrosis, cyst, horseshoe kidney, AML, RCC)

•  Macroscopic hematuria + stable urethral injury excluded then CT

•  Renal contusion: focal zones of decreased enhancement, striated nephrogram because of temporarily impaired tubular excretion

Kawashima A, et al. Radiographics 2001

•  Laceration: linear or wedge-shaped hypodense area –  Fracture = involving medial and lateral surface of kidney through hilum –  Shattered kidney = laceration crossing kidney resulting in multiple fragments

Initial Delayed

Laceration Active extravasation

hematoma hematoma

•  Deep laceration results in urine extravasation

•  Delayed scan for confirmation

Initial Delayed

Excreted contrast in left ureter

Urinoma

•  Occlusion of main renal artery (subintimal tear with subsequent thrombosis) or arterial avulsion

•  Cortical enhancement due to patent capsular arteries originating proximal to occlusion should always raise suspicion of injury to main renal artery

No enhancement

Trauma.org

Urinary Bladder •  Most pelvic visceral injuries = bladder and

urethra •  Gynecologic injuries rare after blunt trauma •  Urinary bladder 8% of patients with pelvic fx •  Indicators of bladder injury

– Macroscopic hematuria – Pubic rami fractures – Hemorrhagic shock upon admission

•  Extraperitoneal rupture –  Direct perforation by bony fragment, rupture of pubovesical

ligament near bladder neck after symphysis injury or contusion of distended UB

–  Often involves anterior bladder wall near neck –  Conservative Rx

Bladder contrast in anterior perivesical space

•  Intraperitoneal rupture –  More frequently caused by direct perforation of bone fragment (>

rupture of distended bladder) –  Plugged by omentum or bowel loops making it difficult to detect –  Surgical Rx

Perforation site Low-density free fluid

CT Cystography •  Antegrade bladder filling by excretion of IV

contrast is NOT enough to exclude bladder injuries

•  Absolute indication: pelvic fracture + gross hematuria

•  Technique: 300-500 cc of diluted (2%) contrast instilled through a bladder catheter using gravity drip, scan pelvis, drain bladder

AAST Organ Injury Scaling

Trauma.org

Conclusion •  Trauma to abdomen “torso” often in setting of

multisystem injury •  Choice of imaging depends on hemodynamics

and imaging availability •  CT is the cornerstone in evaluation of stable

patients (impacting management and reduced mortality)

•  Tendency toward non-operative management makes use of CT for monitoring

Conclusion •  Must know: free fluid, active extravasation,

hypoperfusion complex •  IV contrast needed to assess solid visceral

organ and vascular injuries •  Oral and rectal contrast may be needed in

penetrating abdominal trauma •  Antegrade filling of bladder is not enough to

image of suspected bladder injury.

Imaging of Abdominal Trauma

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