Abdominal trauma
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Transcript of 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
UNSTABLE
INVESTIGATION AVAILABILITY
F A S T D P L
FREE
FLUIDBLOOD
NO YES
CONTINUE
RESUSCITATION LAPAROTOMY
HEMODYNAMIC STABILITY ?
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
Blood shows as a hypoechoic black stripe between the
capsule liver and the fatty fascia of the kidney
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
subcapsular haematoma involving
30%–40% of splenic surface area
(arrow).
intraparenchymal
haematoma (arrow) less
than 4 cm in diameter with
no capsular tear.
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.
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..
(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
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
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.
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.
Complications
• Biloma
• Delayed hemorrhage
• Hemobilia
• Hepatic infarcts
• Pseudoaneurysm
• AV fistula
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
• 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
Segmental Infarct
• Triangular parenchymal area, with a
widest part at the cortex, which is not
enhanced during the different phases,
with clear delineation
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 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.
Vein Pedicle Injury
• Incomplete or absent opacification of
the renal vein
• Persistent nephrogram
• Reduction in excretion
• Nephromegaly
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
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
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
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)
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
• 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
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
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.
Retroperitoneal Hemorrhage
• Retroperitoneal hemorrhage may
arise from injuries to major vascular
structures, hollow viscera, solid
organs, or musculoskeletal structures
or a combination
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'
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