ABDOMEN TRAUMA

Penguji:

dr. Marnansjah Daini Rachman, Sp. Rad

Disusun Oleh:

Bima Utomo
0661050138

KEPANITERAAN KLINIK BAGIAN RADIOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN INDONESIA

JANUARI 2011
Introduction

Trauma is the leading cause of death under the age of forty. Of all traumatic deaths, abdominal trauma is
responsible for 10%. 

The findings to look for in abdominal trauma are the following:

 Hemoperitoneum
 Contrast blush consistent with active extravasation
 Laceration: Linear shaped hypodense areas
 Hematomas: oval or round shaped areas
 Contusions: vague ill-defined hypodense areas that are less well perfused
 Pneumoperitoneum
 Devascularization of organs or parts of organs
 Subcapsular hematomas

Nowadays there is a trend towards non-operative management of blunt abdominal trauma. 

More than 50% of splenic injury, 80% of liver injury and virtually all renal injurys are managed non-operatively,
because patients proved to have better outcomes on the long term related to visceral salvage. 
Diagnose with CT ( Computed Tomography )
CT is used to evaluate patients with blunt trauma not only initially, but also for follow up, when patients are treated
non-operatively. 

CT is also used to clear patients before they are dismissed from the ER, because CT has a very high negative predictive
value and can rule out injury in patients who have had a significant mechanism of injury. 
These patients do not have to be admitted for observation.

CT is also increasingly used for penetrating trauma, which traditionally was evaluated operatively.

Trauma Protocol
Blunt injury
A relatively simple protocol can be used for patients with blunt trauma based on scanning the entire abdomen in the
portal venous phase and a subsequent delayed excretory scan 3-5 minutes later if injury is detected on the initial
scan. 
No oral contrast is administered. 

Penetrating injury
Most patients with penetrating trauma are injured in the flank, so there is great risk for bowel perforation. 
If there is no reason for immediate surgery on the initial scan, these patients get an additional scan after the
administration of rectal contrast (50 ml contrast in 1000 ml saline). 
500 ml can be administered if there is isolated leftflank injury, but in all other cases 1000 ml is administered.
1. Spleen Trauma
The spleen is the most commonly injured solid organ (25%). 

Spleen Injury

The standard CT grade of splenic injury of the American Association for the Surgery of Trauma
(AAST) is of limited value since it does not predict the succes rate of a non-operative management. 

The finding of contrast extravasation on the other hand, which is not part of the grading system, has
great impact on the patients management, because when there is active bleeding, there will be failure
of a non-operative management in 80% of the cases. 

In these patients the need for intervention is almost ten times as high compared to patients
without extravasation. In a recent article a new CT grading system is proposed, which is better than the
AAST system (3).

Normal CT-Scan of Spleen

Case 1
This a case of splenic injury. 

Look the images and determine the degree of splenic injury. 

Then continue. 

The findings are the following:

1. There are multiple poorly defined areas of decreased attenuation. They are not linear so they are not
lacerations.
This is the classic presentation of contusions.
2. Ribfracture and subcutaneous emphysema due to pneumothorax.
3. No contrast blush or hemoperitoneum

Because of the absence of hemoperitoneum or active bleeding, this patient has a good prognosis and will be
managed non-operatively.
Case 2

This is another patient with splenic injury. 

The findings are the following:

1. Linear hypodense areas consistent with lacerations.

2. Round and oval hypodense areas consistent with intrasplenic hematoma.
3. Hemoperitoneum.

Depending on the clinical condition this patient will be managed non-operatively, because there is no active
bleeding
 On the left the most commonly used Splenic CT
Injury Grading Scale.

A way to remember this system is:

1. Grade 1 is less than 1 cm.

2. Grade 2 is about 2 cm (1-3 cm).
3. Grade 3 is more than 3 cm.
4. Grade 4 is more than 10 cm.
5. Grade 5 is total devascularization or
American Association for the Surgery of maceration.
Trauma Splenic Injury Scale

The shortecommings of this grading scale are:

 Often underestimates injury extent.

 Significant interobserver variability.
 Does not include:
 Active bleeding
 Contusion
 Post-traumatic infarcts

 Most importantly: no predictive value for non-
operative management (NOM).

Case 3

On the leftimages of a 22-year old male who presented 3 hours after a snowboarding accident with LUQ and left
shoulder pain. 

The findings are the following:

1. Hemoperitoneum around the spleen and the liver.

2. Oval or round shaped areas in the spleen consistent with hematoma.
3. Linear hypodense areas in the anterior part of the spleen consistent with lacerations.
4. Anteriorly aswell as medially of the spleen there are deposits of contrast consistent with extravasation.

So in this case there is a great chance of failure of non-operative management.

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

The differential diagnosis is:

 Active arterial extravasation

 Post-traumatic
pseudoaneurysm
 Post-traumatic AV fistula

How can these entities be

differentiated?

1. A contract blush that is

beyond the borders of the
organ, must be extravasation.
2. In a pseudoaneurysm or AV
fistula the contrast will wash
away with the bloodstream.
3. If there is active arterial
extravasation and we do
delayed imaging, the contrast
will not wash away

Case 4

Up is a different case of splenic injury with lacerations. 

There is also active bleeding with a contrast blush with the density within the range of the
density of the aorta. 
There also is hemoperitoneum, so this patient will probably need surgery.
 2. Liver Tauma

Liver laceration In trauma the liver is the second most commonly involved solid
with active organ in the abdomen after the spleen. 
bleeding However liver injury is the most common cause of death. 
This is due to the fact that there are many major vessels in the
liver, like the IVC, hepatic veins, hepatic artery and portal vein. 

It is important to remember, especially if you are doing

ultrasound, that the posterior segment of the right liver lobe is the
most frequently injured part. 
This part also involves the bare area and this can lead to
retroperitoneal bleeding rather than bleeding into the peritoneal
cavity.

Normally Liver CT-Scan

Case 1

First look at the images on the leftof a patient with liver injury.
Describe the findings.
Then continue.

The findings are:

1. Green arrow: oval shaped hypodense area consistent with hematoma

2. Yellow arrow: linear shaped hypodense area consistent with laceration.
Notice that this laceration crosses the leftportal vein
3. Blue arrow: vague ill defined hypodense area consistent with contusion
4. Fluid around the liver
5. There is almost a transsection of the liver, but both lobes do enhance so there is still normal vascular supply

CT Grading System

CT grading system for liver

injury
On the left the CT grading system
for liver injury, which is almost the
same as the grading system for
splenic injury. 
The only difference with the spleen
is that the liver has two lobes. 
So before you come to grade 5,
which is devascularization or
maceration of both lobes, you
have grade 4, which is
devascularization or maceration of
only one lobe or laceration greater
than 10 cm.
Now regarding the consequences of the CT grading system the following
somewhat conflicting remarks can be made: 

 Shown to be unreliable in predicting need for surgery

 Helpful in guiding management
  Positive correlation between grade of injury and the increased
 likelihood of failed NOM

Case 2

First look at the images on the left of a patient with liver injury. ?

The findings are the following:

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

 Contrast blush within the intraparenchymal region, but also extention beyond the lateral margin of the liver.
 Hemoperitoneum.
 A second contrast blush at a lower level.

So the next question is: does the presence of a contrast blush alter the CT grade of injury? 
The answer is: it does not, because active bleeding is not part of the grading system.
However there is increased likelihood of failure of non-operative management.
Whenever there is a contrast blush, it is important to note if the contrast blush is associated with a hemoperitoneum and if it
extends beyond the parenchyma, as in this case

Case 3

First look at the images on the left of a patient with liver injury. 

The findings are the following:

 Subcapsular hematoma greater than 10 cm (i.e. grade 4 injury)

 Contrast blush
 No associated hemoperitoneum
 So despite the fact that there is a grade 4 injury and contrast extravasation, this patient will be treated non-operatively and
probably will do fine, because there is no bleeding into the peritoneal cavity.
So the important thing to remember it that, the grading system is of limited help in the management of the patient.
Contrast extravasation on the other hand is of great importance especially if it is associated with hemoperitoneum.

Case 4

On the lefttwo more examples of laceration.

Lacerations can be stellate, like the example on the leftor branching like the one on the right.

Case 5

First look at the images on the up of a patient with liver injury. 

Ask yourself the following questions:

1. What contrast materials are on board?

2. What is the phase of imaging?
3. Where does the contrast surrounding the liver come from?

There is i.v. contrast and images were taken in the portal phase.
There is also oral contrast filling of the stomach.
The contrast surrounding the liver could be a result of stomach or bowel perforation, but since there was no
pneumoperitoneum, this was thought to be unlikely.
So the extravasation was thought to be a result of active bleeding and since there is a great amount of contrast
surrounding the liver, this was thought to be a huge leak.

At the OR an avulsed right hepatic vein was found.

This diagnosis has a 90-100% mortality and this patient died in the OR.
 Some final remarks conceirning liver injury:

 Historically liver injury was managed surgically, but at laparotomy it was found that
70% of the bleedings had already stopped by the time the surgeons got there.
 Importantly, patients who went for surgery had more transfusions and more
complicaties than patients who were treated non-operatively.
 Today about 80% is managed non-operatively.
 Delayed complications occur in 10-25% of all patients and include:
o hemorrhage (2-6%)
o hepatic abscess (1-4%)
o biloma (<1%)
 References
1. Imaging of Renal Trauma: A Comprehensive Review 
by Akira Kawashima, MD, Carl M. Sandler, MD, Frank M. Corl, MS, O. Clark West, MD, Eric P. Tamm, MD, Elliot K.
Fishman, MD and Stanford M. Goldman, MD
Radiographics. 2001;21:557-574

2. PDF format: American College of Radiology, ACR Appropriateness Criteria® for Blunt Abdominal Trauma 
This review considers the issue of blunt abdominal trauma in adults. A continued trend is noted for detection of specific
findings that do predict the need for therapeutic surgery or for angiographic embolization or that predict a period of close
observation is needed for an injured patient. This trend in imaging parallels a strong trend in trauma therapy toward
nonoperative management of injuries of the spleen, liver, and kidney even when hemoperitoneum is present.

3. Optimization of Selection for Nonoperative Management of Blunt Splenic Injury: Comparison of MDCT Grading
Systems 
by Helen Marmery et al.
AJR 2007; 189:1421-1427