Imaging in abdominal trauma

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Imaging in abdominal trauma

  1. 1. Imaging in abdominal trauma S THIYAGARAJA N
  2. 2. Abdominal trauma• Trauma causes I0% of deaths worldwide• The third commonest cause of death after malignancy and vascular disease
  3. 3. Blunt abdominal trauma• Vehicular trauma (75%)• Blow to the abdomen (15%)• Fall from height (6-9%)• Others – Domestic accidents – Fights – Iatrogenic cardiopulmonary resuscitation
  4. 4. Mechanism of injury• Direct impact or movement of organs• Compressive, stretching or shearing forces• Solid Organs > Blood Loss• Hollow Organs > Blood Loss and Peritoneal Contamination• Retroperitoneal > Often asymptomatic initially
  5. 5. Penetrating abdominal injury • Accidental • Homicidal • Iatrogenic • Stab wounds • Gun shot wounds • Shrapnel wounds • Impalements
  6. 6. Vectors of Force - Trauma "Packages"Right-sided Midline Left-sidedR hepatic lobe Left hepatic SpleenR kidney lobe L kidneyDiaphragm Pancreatic Diaphragmpancreatic body Pancreatic tailhead Aortaduodenum TransverseIVC colon Duodenum Small bowel
  7. 7. Right-sided Trauma "Package
  8. 8. ACR Appropriateness CriteriaCategory A• Hemodynamically unstable• Clinically obvious major abdominal trauma• Unresponsive profound hypotension• Resuscitation with volume replacement.• Not respond to resuscitation• Operating room without imaging
  9. 9. HEMODYNAMIC STABILITY ? UNSTABLE INVESTIGATION AVAILABILITYFAST DPL FREE BLOOD FLUID NO YES CONTINUERESUSCITATION LAPAROTOMY
  10. 10. Category B• Hemodynamically stable• Mild to moderate responsive hypotension• Significant trauma and have at least moderate suspicion of intra-abdominal injury based on clinical signs and symptoms• These patients should be evaluated by imaging
  11. 11. Category C• Hemodynamically stable• Patients with hematuria after blunt abdominal trauma• All patients with gross hematuria and pelvic fracture require additional imaging of the bladder to exclude bladder rupture
  12. 12. STABLE CONSCIOUS , RESPONSIVE YES NO SUSPICION OFABDOMINAL INJURYNO YES CTCLINICAL FOLLOW-UP
  13. 13. What is FAST? Focused Assessment with Sonography for Trauma• A focused, goal directed, sonographic examination of the abdomen• Goal is presence of haemoperitoneum or haemopericardium• An extension of clinical examination• Part of the Primary Survey of any patient with signs of shock or suspicion of abdominal injury
  14. 14. What FAST is NOT• A definitive diagnostic investigation• A substitute for CT• The answer to all our problems
  15. 15. The ABCDE of Trauma• A - Airway• B - Breathing• C - Circulation (FAST)• D - Disability• E - Environment and Exposure
  16. 16. The FAST examination• FAST examines four areas for free fluid:  Perihepatic & hepato-renal space  Perisplenic  Pelvis  Pericardium
  17. 17. The perihepatic scan• The hepatorenal space (pouch of Morison)• most dependent part of the upper peritoneal cavity• The probe is placed in the right mid- to posterior axillary line at the level of the 12th ribs.
  18. 18. The perihepatic scan
  19. 19. The perihepatic scanBlood shows as a hypoechoic black stripe between the capsule liver and the fatty fascia of the kidney
  20. 20. Perihepaticscan
  21. 21. Perisplenic window• Transducer positioned in left posterior axillary line between 10th and 11th ribs with beam in coronal plane.• Demonstrates spleen, kidney and diaphragm• May be marred by acoustic shadows from ribs• May be improved by imaging patient whilst
  22. 22. Abnormal perisplenic window
  23. 23. The pelvic scan• The pelvic examination visualises the cul-de- sac: the Pouch of Douglas in females and the rectovesical pouch in the male• Most dependent portion of the lower abdomen and pelvis, where fluid will collect• The transducer is placed midline just superior to the symphysis pubis
  24. 24. The pericardial scan• The pericardial examination 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.
  25. 25. Subxiphoid view of cardiac anatomy
  26. 26. Subxiphoid viewNormal subcostal view of pericardium Positive FAST demonstrating pericardial effusion
  27. 27. Quantification of hemoperitoneumHuang 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
  28. 28. Approximately…• FAST can detect between 100-250ml 0.5 cm in Morisons Pouch = 500ml 1 cm in Morisons Pouch = 1000mlCT can detect volumes of free fluid as low as 100ml
  29. 29. FAST: Strengths and LimitationsStrengths Limitations• Rapid (~2 mins) • Does not typically• Portable identify source of• Inexpensive bleeding• Technically simple, • Requires extensive easy to train training to assess parenchyma reliably• Can be performed • Limited in detecting serially <250 cc intraperitoneal• Useful for guiding fluid triage decisions in • Particularly poor at trauma patients detecting bowel and mesentery damage • Difficult to assess retroperitoneum • Limited by habitus in obese patients
  30. 30. Extended FAST (eFAST)• Evaluation of pneumo and hemothorax in addition to intraperitoneal injuries.• Hemothorax – Ultrasound is much more sensitive for detecting pleural fluid and can identify as little as 20mL in the pleural space• Pneumothorax – Using ultrasound to evaluate for a pneumothorax is a relatively new concept but it is easy to learn
  31. 31. eFAST Anterior Thoracic Views• Probe is usually placed on the anterior chest in the 3-4th intercostal space and midclavicular line• When ―Sliding sign‖(seashore sign) is not present, a pneumothorax is suspected.• Comparing one side of the chest to the other may be helpful.
  32. 32. DPL Procedure• To identify hollow viscus injury (stomach, small bowel, colon) or diaphragmatic injury• Introduce catheter infraumbilically and infuse fluid
  33. 33. DPL• Highly sensitive to intraperitoneal blood, but low specificity nontherapeutic explorations.• Significant injuries may be missed – Diaphragm – Retroperitoneal hematomas – Renal, pancreatic, duodenal – Minor intestinal – Extraperitoneal bladder injuries
  34. 34. CT in Abdominal Trauma• Initial evaluation of – blunt trauma – penetrating trauma• Follow up of non-operative management• Rule out Injury
  35. 35. 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
  36. 36. • 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
  37. 37. CT findings of shock• Collapse of inferior vena cava• Small aorta• Persistent nephrogram without excretion• Hypodense spleen, without enhancement and normal vascular pedicle• Increased enhancement of the small bowel wall• Increased enhancement of the adrenal glands• Sometimes findings of right cardiac insufficiency with reflux into the hepatic veins
  38. 38. Hemoperitoneum Hyperdense intraperitoneal fluid collection0–20HU Preexisting ascites Bile Urine Digestive fluid Diluted or old blood30–45HU Free Unclotted intraperitoneal blood45–70HU Clotted blood/sentinel clot sign hematoma>100 HU Extravasation of contrast medium (vascular or urinary)
  39. 39. 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.
  40. 40. SENTINEL CLOT SIGN• Clotted blood adjacent to the site of injury is of higher attenuation value than unclotted blood which flows away .• When the source of intraperitoneal bleed not evident, the location of highest attenuating blood clot is a clue
  41. 41. Ascites – Radiographic findings• Obliteration of inferior edge of liver• Widening of distance b/n flank stripe &asding colon• AF b/n liver & lateral abd wall may result in visualization of a lucent band –Hellmer‘s sign• Dog ear sign or ‗Mickey mouse ears‘ sign(100- 150ml)- fluid density lateral to rectal gas shadows.• Separation and floating of bowel loops• Bulging properitoneal flank stripe• Poor definition of major abd. organs and psoas• Overall abdominal haziness
  42. 42. PNEUMOPERITONEUM• FREE AIR SENSITIVITY OF IMAGING STUDIES – COMPUTED TOMOGRAPHY- 99% – AP UPRIGHT CHEST RADIOGRAPH - 76% – LEFT DECUBITUS ABDOMEN RADIOGRAPH 80 - 90% – SUPINE ABDOMEN RADIOGRAPH - 56%
  43. 43. Signs of a pneumoperitoneum on the supine radiographRight upper quadrant gas Perihepatic Subhepatic Morrison‘s pouch Fissure for the ligamentum teresRigler‘s (double wall) signLigament visualization Falciform (ligamentum teres) Umbilical (inverted V sign) medial and lateralUrachusTriangular airThe cupola signFootball or air dome
  44. 44. Spleen• The spleen is the most commonly injured organ in blunt abdominal trauma• 40% of all solid organ injuries
  45. 45. 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
  46. 46. Parenchymal ContusionHypodense intraparenchymalarea with irregular contours
  47. 47. Parenchymal Laceration• Superficial, linear hypodensity, usually less than 3 cm in length• Fracture - involves two visceral surfaces, or if its length is more than 3 cm• Multiple fractures - Scattered spleen
  48. 48. Subcapsular Hematoma• Crescent-shaped perisplenic• Compresses the splenic parenchyma
  49. 49. Vascular Trauma• The most dangerous vascular traumatic lesions are arterial lesions• Irregular area of increased density relative to background spleen• Typically the attenuation value is within 10 HU of the adjacent artery
  50. 50. 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.
  51. 51. Splenic CT Injury Grading ScaleGrade I Laceration(s) < 1 cm deep Subcapsular hematoma < 1cm diameterGrade II Laceration(s) 1-3 cm deep Subcapsular or central hematoma l-3cm diameterGrade III Laceration(s) 3-10 cm deep Subcapsular or central hematoma 3-10 cm diameterGrade Laceration(s) > 10 cm deepIV Subcapsular or central hematoma > 10cm diameterGrade V Splenic tissue maceration or devascularization
  52. 52. A way to remember this system is:• Grade 1 is less than 1 cm.• Grade 2 is about 2 cm (1-3 cm).• Grade 3 is more than 3 cm.• Grade 4 is more than 10 cm.• Grade 5 is total devascularization or maceration.
  53. 53. The shortecommings of this gradingscale are:• Often underestimates injury extent.• Significant inter observer variability.• Does not include: – Active bleeding – Contusion – Post-traumatic infarcts• Most importantly: no predictive value for non-operative management
  54. 54. 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
  55. 55. Splenic CT Injury Grading ScaleGrade I Laceration(s) < 1 cm deep Subcapsular hematoma < 1cm diameterGrade II Laceration(s) 1-3 cm deep Subcapsular or central hematoma l-3cm diameterGrade III Laceration(s) 3-10 cm deep Subcapsular or central hematoma 3-10 cm diameterGrade Laceration(s) > 10 cm deepIV Subcapsular or central hematoma > 10cm diameterGrade V Splenic tissue maceration or devascularization
  56. 56. American Association for the Surgery of Trauma ( AAST) organ injury severity scale grading system for splenic injuryGrade 1 Small subcapsular haematoma, less than 10% of surface areaGrade 2 Moderate subcapsular haematoma on 10 –50% of surface area; intraparenchymal haematoma less than 5 cm in diameter; capsular laceration less than 1 cm deepGrade 3 Large or expanding subcapsular haematoma on greater than 50% of surface area; intraparenchymal haematoma greater than 5 cm diameter; capsular laceration 1 –3cm deepGrade 4 Laceration greater than 3 cm deep; laceration involving segmental or hilar vessels producing major devascularization ( >25%)Grade 5 Shattered spleen; hilar injury that devascularizes the spleen
  57. 57. SPLENIC INJURIES - Management• Often arterial hemorrhage, therefore nonoperative management less successful.• Predictive factors for nonop success: – Localized trauma to flank/abdomen – Age<60 – No associated trauma precluding obs – Transfusion <4u rbcs – Grade I-III• Grade IV-V: almost invariably require operative intervention• Delayed hemorrhage (hours to weeks post-injury): 8-21%
  58. 58. 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
  59. 59. • 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
  60. 60. Radiological overview of liver injury:• Right lobe> left lobe; 3:1• Posterior segment most common (fixed by coronary ligament)• CT imaging method of choice
  61. 61. Features with impact on themanagement 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 porta hepatis or the gallbladder fossa• Importance of the hemoperitoneum• Vascular lesions with active bleeding or sentinel clot sign
  62. 62. 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.
  63. 63. Classification (AAST)I-Subcapsular hematoma<1cm,superficial laceration<1cm deep.
  64. 64. II-Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick.
  65. 65. III-Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm diameter.
  66. 66. IV-Parenchymal/supcapsularhematoma> 10cm in diameter, lobar destruction,
  67. 67. V- Global destruction or devascularization of the liver.
  68. 68. VI-Hepatic avulsion
  69. 69. 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
  70. 70. Complications• Biloma• Delayed hemorrhage• Hemobilia• Hepatic infarcts• Pseudoaneurysm• AV fistula
  71. 71. • Indications for surgical treatment in liver trauma – Shock – Active venous bleeding – Trauma of the gallbladder – Choleperitoneum – Abdominal surgery necessary for other causes
  72. 72. Retroperitoneal Hemorrhage• Retroperitoneal hemorrhage may arise from injuries to major vascular structures, hollow viscera, solid organs, or musculoskeletal structures or a combination
  73. 73. Small zone I (central)retroperitoneal hematoma
  74. 74. Large zone I (central)retroperitoneal hematoma with active extravasation
  75. 75. Large zone II (lateral)retroperitoneal hematoma
  76. 76. 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
  77. 77. Laceration of the pancreatic neck without duct injury
  78. 78. Pancreatic transection (neck) with duct injury
  79. 79. Subtle pancreatic contusion
  80. 80. 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
  81. 81. AAST GRADING OF PANCREAS INJURY Type ofGrade Injury Description of Injury I 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
  82. 82. 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
  83. 83. 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
  84. 84. 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.
  85. 85. Subcapsular hematoma (category I) Crescent shaped hyperdensity, located in the periphery of the kidney
  86. 86. 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
  87. 87. Simple renal laceration (category I)
  88. 88. Major renal laceration without involvementof the collecting system (category II)
  89. 89. Major renal laceration involvingthe collecting system (category II)
  90. 90. Multiple renal lacerations (category III)
  91. 91. Shattered kidney (category III)
  92. 92. Segmental Infarct• Triangular parenchymal area, with a widest part at the cortex, which is not enhanced during the different phases, with clear delineation
  93. 93. Segmental renal infarction (category II)
  94. 94. Traumatic occlusion of the main renal artery (category III)
  95. 95. Traumatic occlusion of the main renal artery (category III)
  96. 96. Active arterial extravasation (category III)
  97. 97. Vein Pedicle Injury• Incomplete or absent opacification of the renal vein• Persistent nephrogram• Reduction in excretion• Nephromegaly
  98. 98. Laceration of the renal vein (category III)
  99. 99. 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
  100. 100. Avulsion of the ureteropelvic junction (category IV)
  101. 101. AAST organ injury severity scale grading system for kidney injuryGrade 1 Contusion or contained and non -expanding subcapsular haematoma, without parenchymal laceration; haematuriaGrade 2 Non -expanding, confined, perirenal haematoma or cortical laceration less than 1 cm deep; no urinary extravasationGrade 3 Parenchymal laceration extending more than 1 cm into cortex; no collecting system rupture or urinary extravasationGrade 4 Parenchymal laceration extending through the renal cortex, medulla and collecting systemGrade 5 Pedicle injury or avulsion of renal hilum that devascularizes the kidney; completely shattered kidney;
  102. 102. BLADDER INJURY
  103. 103. CT Cystography• Empty the bladder• Instill the contrast retrograde through the foley catheter of avg. 350-400 cc of contrast• Image the pelvis
  104. 104. CT classificationTYPES1. Bladder contusion2. Intraperitoneal rupture3. Interstitial bladder injury4. Extraperitoneal rupture A. simple B. complex (bladder neck involved)5. Combined bladder injury
  105. 105. 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
  106. 106. Cystogram of intraperitoneal bladder rupture
  107. 107. 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
  108. 108. • 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)
  109. 109. CT of extraperitoneal bladder rupture MOLAR TOOTH SIGN
  110. 110. Type 5(combined) rupture.
  111. 111. 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
  112. 112. CLASSIFICATION OF URETHRAL INJURIES Colapinto & McCallum Goldman & SandlerGrade I Posterior urethra stretched, but Posterior urethra stretched but intact intactGrade II Posterior urethral tear above intact urogenital diaphragm (UGD) Partial or complete posterior urethral tear above intact UGDGrade III Posterior urethral tear with Partial or complete tear of extravasation through torn combined anterior and UGD posterior urethra with torn UGDGrade IV — Bladder neck injury with extension to the urethraGrade IVa — Injury to bladder base with extravasation simulating type IV (pseudo grade IV)Grade V — Isolated anterior urethral injury
  113. 113. Goldman type I injuryStretching or elongation of the otherwise intact posterior urethra Intact but stretched urethra
  114. 114. Goldman type II injuryUrethral disruption above the urogenital diaphragm while the membranous segment remains intactContrast agent extravasation above the urogenital diaphragm only
  115. 115. Goldman type IIIDisruption 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
  116. 116. Goldman type IV injury Bladder neck injury extending into the proximal urethraExtraperitoneal contrast agent extravasation bladder neck disruption
  117. 117. Goldman type IVa injury Bladder base injury simulating a type IV injuryPeriurethral contrast agent extravasation; bladder base disruption
  118. 118. 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
  119. 119. • 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
  120. 120. 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
  121. 121. GI PerforationThe direct CT sign• Transparietal continuity solution, mainly located on the mesenteric side of the bowel• The perforation may occur intraperitoneally or retroperitoneally
  122. 122. 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
  123. 123. Traumatic duodenalintramural hematoma
  124. 124. Periduodenal hemorrhage
  125. 125. • Causes of bowel thickening related to trauma – Contusion/hematoma – Perforation – Distal ischemia due to mesenteric lesion – Bowel shock – Secondary to peritonitis – Bowel spasm
  126. 126. 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
  127. 127. Role of Interventional Radiology• Embolization – Spleen – Liver – Pelvis• Angioplasty + Stent – Renal artery dissection
  128. 128. 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
  129. 129. 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
  130. 130. Spleen Embolization
  131. 131. 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
  132. 132. Reference• TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID SUTTON• Grainger & Allisons 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
  133. 133. Reference• TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID SUTTON• Grainger & Allisons Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed.• Imaging of Renal Trauma - RadioGraphics 2001; 21:557–574• Urethral Injuries after Pelvic Trauma -• Thank you 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

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