powerpoint on abdominal trauma imaging

1. INTRODUCTION
• Accounts for 5% of trauma mortality, 15% polytrauma
mortality
• Excessive bleeding is the cause of 80-90% death
• Advances in cross sectional imaging and image guided
interventional therapies help in conservative management
• Radiologist must have detailed knowledge of-
Patterns of injury
Imaging appearance of traumatic injuries
Assessment of hemodynamic status
Common image artifacts

2. • Blunt trauma: accounts for two-thirds – majorly RTA(80%),
falls, assault, industrial accidents
• Penetrating: results due to Gunshot injuries, stab wounds

3. BLUNT ABDOMINAL TRAUMA
Mechanism of injury
• Rapid deceleration forces
• Crushing injuries
• Extreme external compression
Factors determining the organs injured
• Energy delivered at impact
• The part of the body struck first
• Direction of blow

4. BLUNT ABDOMINAL TRAUMA
ACR guideline appropriateness criteria,
Category A
• Hemodynamically unstable patients with clinically obvious major
trauma with unresponsive profound hypotension

5. CATEGORY B-HEMODYNAMICALLY STABLE AT
PRESENTATION OR STABILISED AFTER RESUSCITATION

6. Category C:
Suspected lower urinary tract injury

7. IMAGING MODALITIES
• Radiograph
• Ultrasound
• Computed tomography
• Angiography
• Magnetic resonance imaging

8. RADIOGRAPH
• Not routinely recommended.
• Pneumoperitoneum.
• Associated fractures, pneumothorax, pleural
effusion
• Hemoperitoneum: insensitive, only >800cc
intraperitoneal volume shows sign e.g.-“dog
ear “or “bladder ear” sign
Less sensitivity and specificity, limited role

11. Linear hypodense areas in liver
s/o laceration along with
assosciated rib fracture

12. ULTRASOUND
• Commonly used for Initial assessment of abdominal trauma.
• FAST (Focused Assessment with Sonography in Trauma)
• Fast overview of abdomen to detect free fluid, indicating
hemoperitoneum and visceral organ injury in trauma setting
within few minutes.
• Parenchymal organ injuries may be detected. However
search should not delay the examination.

13. ULTRASOUND
Technique
1. Transverse epigastric-pericardial fluid and injury to left
lobe of liver
2. Longitudinal rt upper quadrant-right lobe, right
kidney,morrison’s pouch and perihepatic
3. Longitudinal lt upper quadrant-spleen, left kidney and
perisplenic
4. Transverse and longitudinal suprapubic-UB , freefluid in
POD and pelvis
• Bilateral longitudinal thoracic – for pleural effusion
• Bilateral longitudinal flanks-paracolic gutters

15. ULTRASOUND
• Pericardial effusion
• Visceral organ injury
• Pleural effusion
• Pneumothorax

16. ULTRASOUND
Interpretation
• For free fluid, Sensitivity 64-98%
Specificity 86-100%
• Negative FAST should be viewed with suspicion if
findings do not commensurate with clinical condition
• Positive FAST in hemodynamically stable patient –
CECT for detailed evaluation

17. ULTRASOUND
Advantages
• Easily available, mobile equipment
• Provide quick overview of abdomen for free fluid
• Consolidate operative decision in unstable patients
• High sensitivity for pericardial effusion (97-100%)
Limitations
• Operator dependent
• Excessive bowel gases, open wounds, bandages, cutaneous
emphysema
• Limited sensitivity for detection of visceral organ injury
• Unreliable for retroperitoneal trauma

18. ULTRASOUND
Recommendations……
• Scan for free fluid and pericardial effusion
• If time permits, look for injuries of solid organs
• If chest trauma with respiratory distress, look for pneumothorax
• Use FAST for overview, not for definitive diagnosis
• Too much time should not be wasted

19. COMPUTED TOMOGRAPHY (CT)
• Gold standard
• Associated injuries to head, chest, spine,
pelvis
• High sensitivity and specificity for detection
of various organ injuries and
hemoperitoneum
• Following negative CECT, patient could be
safely discharged without even period of
observation

20. COMPUTED TOMOGRAPHY (CT)
Technique
• Contrast enhanced thin section scans from lower chest
to inferior margin of pubic symphisis
• 60-70 sec after injecting 100-120 ml of contrast at rate
of 2.5-3 ml/sec
• Use of oral contrast-not commonly used
• Delayed scanning to detect renal collecting system
injury
• Bone window- for subtle fractures
• Lung window

21. COMPUTED TOMOGRAPHY (CT)
Technical limitations
• Motion artifacts
• Successful breath holding is often not
possible
• Streak artifacts

22. CT SIGNS IN ABDOMINAL TRAUMA
Approximation of volume
• Fluid in Paracolic gutter – 200 ml in each
• Fluid in abdomen and pelvis – 500 ml

23. CT SIGNS IN ABDOMINAL TRAUMA
Hemoperitoneum
• Acute extravasated non clotted blood 30-45
HU
• Clotted blood at the site of bleeding 45-70
HU
• Detection of fluid in a patient of abdominal
trauma is considered hemoperitoneum unless
proven otherwise.

24. Sentinel clot sign :
Clotted blood adjacent to site of injury
has higher attenuation than unclotted
blood which flows away

25. CT SIGNS IN ABDOMINAL TRAUMA
• Active arterial contrast extravasation
HU similar to adjacent artery or 95-350 HU
• Hemodynamic status -hypoperfusion complex signify
clinical shock

27. CT SIGNS IN ABDOMINAL TRAUMA
Pneumoperitoneum
• Perforation of hollow viscus
• Pneumothorax
• Mechanical ventilation
Lung window setting

28. SPLENIC TRAUMA
• MC injured organ after blunt trauma (25 %)
• Most vascular organ (contains 500-600 ml blood)
• CECT
Portal venous phase: to avoid heterogenous
enhancement in arterial phase

29. SPLENIC TRAUMA
Subcapsular hematoma
• Lenticular collection,
flattening the adjacent
parenchyma
• Uncomplicated resolves in
4-6 weeks

31. SPLENIC TRAUMA
Laceration
• Nonenhancing linear or branching areas
• Decrease in number and size with time
• Delayed phase: appear to ‘fill-in’ from
periphery
• Splenic cleft: unchanged on delayed with
smooth or rounded margins
• Multiple lacerations: shattered spleen

33. SPLENIC TRAUMA
Active extravasation of contrast
• Linear or irregular hyperdensity
• 95-350 HU
• Surrounded by hematoma
• Delayed phase: fades away in
surrounding hematoma or
increase in density
• Surgical/angiographic
intervention

34. SPLENIC TRAUMA
Vascular injuries
• Pseudoaneurysms and AV fistula
• Well circumscribed focal hyperdense area
• Smooth margins, no adjacent hematoma
• Follow attenuation of adjacent artery
• Surgical/angiographic intervention

35. AAST GRADING OF SPLENIC TRAUMA
• Grade I: Subcapsular haematoma <10% of surface area
Capsular laceration <1 cm depth
• Grade II: Subcapsular haematoma 10-50% of surface area
Intraparenchymal haematoma <5 cm in diameter
Laceration 1-3 cm depth not involving trabecular vessel
• Grade III: Subcapsular haematoma >50% of surface area or expanding
Intraparenchymal haematoma >5 cm or expanding
Laceration >3 cm depth or involving trabecular vessel
Ruptured subcapsular or parenchymal haematoma
• Grade IV: Laceration involving segmental or hilar vessels with
Major devascularization (>25% of spleen)
• Grade V: Shattered spleen
Hilar vascular injury with devascularised spleen

37. Laceration <1 cm
Subcapsular hematoma <10% of
surface area

38. Laceration 1-3 cm
Subcapsular hematoma 10%-50%
of surface area

39. Laceration <3cm
Subcapsular hematoma <50% of
surface area

40. >25%-75%
devascularisation

42. SPLENIC TRAUMA
Pitfalls
• Premature scanning before portal venous
phase resulting in heterogenous
enhancement
• Splenic cleft mistaken as laceration
• Perisplenic fluid of ascites mistaken as
hemoperitoneum

43. SPLENIC TRAUMA
Management
• Hemodynamic status, associated other injuries, imaging
findings
• Non-operative management
Active haemorrhage or vascular injuries
• Angiography and splenic artery embolisation
• Non-operative management possible in upto 90% patients
• Effect of SA embolisation on immune function is not
established

44. LIVER & BILIARY TRACT
• Liver is 2nd most common injured solid organ
• Right lobe injured more frequently and severely
• Posterior segments injured more frequently
• Majority(80%) cause hemoperitoneum which correlates with the
integrity of liver capsule
• Nonsurgical management is preferred for stable patients
• CT is the modality of choice for stable patients

45. LIVER & BILIARY TRACT
Laceration
• MC type of liver injury
• Travel along vascular planes and
fissures
• Superficial (<3cm) or deep
(>3cm)

46. LIVER & BILIARY TRACT
Subcapsular hematoma
• MC located at antero-
lateral aspect of right
lobe of liver

47. LIVER & BILIARY TRACT
Parenchymal contusions
• Focal, intraparenchymal
irregular area of low or
mixed attenuation

48. LIVER & BILIARY TRACT
• When laceration or contusion in postero-superior segment
adjacent to bare area, high chances of associated retroperitoneal
hematoma or adrenal hematoma

49. LIVER & BILIARY TRACT
Periportal tracking
• Hypodense areas along
PV branches due to -
Blood tracking along
periportal connective
tissue
Distension of periportal
lymphatics

50. LIVER & BILIARY TRACT
Active haemorrhage
• Indicates ongoing, potential, life-
threatening bleeding
• Focal hyperdense area
• Differentiated from clotted blood by CT
attenuation

51. LIVER & BILIARY TRACT
Major hepatic venous injury
• Laceration or hematoma
extending into hepatic veins or
IVC
• Surgical management

52. AAST GRADING OF LIVER TRAUMA
• Grade I: Haematoma: sub capsular, < 10% surface area
Laceration: capsular tear, < 1cm depth
• Grade II: Haematoma: sub capsular, 10 - 50% surface area
Haematoma: intraparenchymal < 10cm diameter
Laceration: capsular tear, 1 - 3cm depth
• Grade III: Haematoma: sub capsular, > 50% surface area,
Haematoma: intraparenchymal > 10 cm diameter
Laceration: capsular tear, > 3 cm depth
• Grade IV: Haematoma: ruptured intraparenchymal with active bleeding
Laceration: parenchymal distruption involving 25 - 75% hepatic lobes or
Involves 1-3 Couinaud segments (within one lobe)
• Grade V: Laceration: parenchymal distruption involving >75% helpatic lobe or
Involves > 3 Couinaud segments (within one lobe)
Vascular: juxtahepatic venous injuries (IVC, major hepatic vein)

54. 1- 3 segments are involved

55. Involves > 3 Couinaud segments (within
one lobe)

56. LIVER & BILIARY TRACT
Follow up CT
• Not required in asymptomatic low grade
injuries (grade I-III)
• Required in,
Symptomatic patients
High grade injuries (IV-VI)
• At 1-4 weeks duration

57. LIVER & BILIARY TRACT
Delayed complications
• Delayed haemorrhage- due to rupture of
pseudoaneurysm
• Abscess
• Hepatic artery pseudoaneurysm
• Biliary complications
Biloma- due to bile leak into hematoma
Bile peritonitis
More in high grade injuries: follow up CT at 7-28 days

58. LIVER & BILIARY TRACT
Abscess
• Well defined fluid
collection with gas
bubbles or air-fluid level
• Pain, tenderness, fever,
leukocytosis
• Percutaneous catheter
drainage

59. LIVER & BILIARY TRACT
Biloma
• Leakage of bile in hematoma,
increases pressure leading to
necrosis and biloma formation
• Well encapsulated, hypodense
intraparenchymal or perihepatic
collection
• Image guided percutaneous
aspiration for confirmation
• ERCP to confirm and treat

60. LIVER & BILIARY TRACT
Bile peritonitis
• Due to leakage of bile into peritoneal caity
• Fever, persistent pain and tenderness, distension,
leukocytosis, peritonitis
• Persistent or increased free fluid with thickening
and enhancement of peritoneum

61. LIVER & BILIARY TRACT
Pitfalls
• Fatty liver
• Streak or beam
hardening artifacts
• Motion artifacts

62. LIVER & BILIARY TRACT
Management
• Non surgical management is preferred in stable pt
• Hemodynamic unstable, major venous injury,
peritonitis: surgical management
• Active bleeding, pseudoaneurysm: angiography and
embolisation
• Follow up CT in high grade injuries for delayed
complications

63. LIVER & BILIARY TRACT
Prognosis
• Upto 90% of patients can be managed non surgically
with success rate upto 95%
• Hemoperitoneum 1 week
• Laceration 3 4 weeks
• Hematoma 6 8 weeks
• Biloma may persist for years
• Hepatic parenchymal homogeneity is restored in 2 3
months

64. EXTRAHEPATIC BILE DUCT &
GALL BLADDER
Rare injuries, usually associated with other major organ
trauma
Mechanism of injuries
• Torsion, shearing or compression forces
• Distended GB in pre-prandial state
• Extrahepatic bile duct injuries occur at sites of fixation during
acute deceleration or impact
• Superior displacement of liver during impact

65. EXTRAHEPATIC BILE DUCT &
GALL BLADDER
Three types of GB injury
• Contusion
• Laceration or perforation
• Complete avulsion

66. EXTRAHEPATIC BILE DUCT &
GALL BLADDER
Gall bladder injuries
• Collapsed GB in fasting patient
• Wall thickening or irregularity
• Discontinuity in wall
• Hyperdense fluid layering in lumen
• Pericholecystic fluid
Bile duct injury: Non specific findings

67. PANCREATIC TRAUMA
Introduction
• Uncommon, amounting to 3-12% of all abdominal
injuries.
• Often occurs during traffic accidents as a result of the
sudden direct impact on the upper abdomen.
• Isolated injuries uncommon, mostly associated with
adjacent organ injuries

68. PANCREATIC TRAUMA
• Identification of a blunt injury of pancreas may be
difficult because imaging findings are often subtle.
• Computed tomography (CT) provides the safest and
most comprehensive means of diagnosis of pancreatic
injury in hemodynamically stable patients

69. PANCREATIC TRAUMA
Mechanism of injury
• Usually results from severe anteroposterior
compression trauma against the spinal column, mostly
in connection with seat belt injuries, deceleration
trauma, bicycle injuries
• Most common in the pancreatic body (approx. 65%).
Those to the pancreatic tail and head are less
common.
• More common among children

70. PANCREATIC TRAUMA
CT findings
• 20-40% are normal upto 12-24 hours
• The sensitivity and specificity of CT in detecting
pancreatic trauma of all grades are reported to be around
80%, and grades of injury tend to be underestimated with
CT.
• Integrity of the pancreatic duct is the most important
factor
• CT is limited in detection of pancreatic injuries when only
little peripancreatic fat tissue is present and in detection
of pancreatic duct injuries.

71. PANCREATIC TRAUMA
CT findings
Direct signs
• Laceration or fracture
• Contusion
• Active bleeding

72. RELEVANT FACTORS
• Laceration involving the pancreatic duct is suspected
when 50% of anteroposterior or craniocaudal width
involved
• Location of laceration-m/c at neck.position determined
with respect to superior mesenteric artery.if right-
Whipple’s surgery done.If left-distal pancreatectomy
done.

73. PANCREATIC TRAUMA
Indirect signs
• Focal or diffuse enlargement of the gland
• Peripancreatic fluid collection
• Fluid separating pancreas from splenic vein
• Thickening of anterior renal fascia

74. AAST GRADING OF PANCREATIC
TRAUMA
• Grade I : Minor contusion/laceration but without duct
injury
• Grade II : Major contusion / laceration but
without duct injury
• Grade III : Distal laceration or parenchymal injury
with duct injury
• Grade IV : Proximal laceration or parechymal
injury with injury to bile duct / ampulla
• Grade V : Massive disruption to pancreatic head

80. PANCREATIC TRAUMA
Management
• If associated with pancreatic ductal injury:
ERCP guided stent placement or surgical
management
• No pancreatic ductal injury: conservative Mx
• Active bleeding: angiography and
embolisation

81. PANCREATIC TRAUMA
Prognosis
• Delays in diagnosis, incorrect classification of the injury, or
delays in treatment can increase the morbidity and mortality
considerably.
• Mortality ranges from 9 - 34%
• Morbidity 11 - 62 %

82. DUODENAL INJURY
Coexisting injuries with the pancreatic injury are common(50-98%)
It is important to differentiate between duodenal hematoma, laceration and perforation
Doudenal injury scale
Grade1- Hematoma involving a single portion of duodenum or partial thickness
laceration without perforation
Grade II- Hematoma involving more than one portion of or disruption of <50%
circumference or major laceration without duct injury or tissue loss
Grade III-Laceration with disruption of 50-75% circumference of second portion or
disruption f 50-100% circumference of 1st,2nd and 3rd part of duodenum
Grade IV-Laceration with disruption of >75% circumference of 2nd portion or involving
ampulla or distal common bile duct
Grade V-Massive laceration with disruption of duodenopancreatic groove

83. Grade 1 and II are managed conservatively with follow up
imaging after 7 to 10 days.Grade III and above require
surgical management

84. ADRENAL INJURY
•Most common retroperitoneal injury- unilateral(80%), m/c on right
side
•Adrenal hematoma- round, oval homogenous density mass(40-
75HU), periadrenal stranding, apparent thickening of ipsilateral crus
of diaphragm
•Bilateral-adrenal insufficiency
•If bilateral haemorrhage – leads to adrenal insufficiency

85. BOWEL INJURY
• DIRECT SIGNS-
• Bowel wall disruption
• oral contrast extravasation

86. INDIRECT SIGNS
• Free intra/retroperitoneal air
• Free intra/retroperitoneal fluid
• Focal area of bowel wall
thickening
• Abnormal bowel wall
enhancement-increased,patchy
or reduced enhancement

88. DIRECT SIGNS-
Active contrast extravasation within
mesentery
Beaded appearance and abrupt termination of
mesenteric vessels.
INDIRECT SIGNS-
Mesenteric hematoma, mesenteric infiltration,
bowel wall thickening , pneumatosis
intestinalis
MESENTERIC INJURY

92. DIAPHRAGMATIC INJURY
• Incidence-1-6% in blunt trauma
• Penetrating>blunt, Left>right
(protective effect of liver)
• Bilateral-1-5%,most common at
posterolateral aspect
• Frequently associated with other
injuries

93. SPECIFIC SIGNS ON CHEST
RADIOGRAPH-
• Visualisation of bowel loops above the diaphragmLoss of normal
diaphragmatic contour
• Detection of NG tube above the left hemidiaphragm

94. NON SPECIFIC SIGNS ON CHEST
RADIOGRAPH
• Elevated dome of diaphragm
• Pleural effusion
• Atelectasis with contralateral mediastinal shift
• Hemothorax
• Pneumothorax
• Lower rib fractures

95. CT SIGNS
• Focal diaphragmatic discontinuity or elevation
• Focal diaphragmatic thickening or retraction
• Herniated abdominal contents into thorax
• Collar sign- narrowed waist of herniated
intrabdominal organ due to compression at
neck
• Dependent viscera sign- herniated
intrabdominal content abutting the posterior
thoracic wall.

97. Dependent viscera sign- herniated
intrabdominal content abutting the
posterior thoracic wall.

98. PENETRATING ABDOMINAL
TRAUMA
Mechanism of injury
• Complex interaction of multiple factors
• Permanent cavity, temporary cavity
Mass, material, size and velocity of bullet
Amount of kinetic energy lost along the path of bullet
How rapidly that energy is dissipated
Specific density, elasticity and cohesiveness of tissue
• If strikes bone: bone or bullet fragment create secondary missiles

99. RENAL TRAUMA
• Basic renal injuries include-contusions,lacerations and
infarcts
• Complicated by intrarenal/extrarenal hematoma or
urinary extravasation

102. GRADE I
Subcapsular hematoma of right kidney
without any laceration

103. GRADE II

104. GRADE III

105. GRADE IV

108. GRADE V

110. FOLLOW UP IMAGING IN RENAL
TRAUMA
• Usually not indicated in grade I to Grade III injuries and,Grade IV injuries
without urinary extravasation
• Done in grade IV injures with urinary leak and grade V injuries who are
managed conservatively
• Patient with signs of complications(fever, falling hematocrit)

111. VASCULAR INJURIES
• Compression and deceleration injuries are most common
• DIRECT SIGNS-irregular,extravascular active extravasation, traumatic
occlusion-sudden cutoff
• INDIRECT SIGNS-end organ abnormality-hypoenhancement

112. PENETRATING ABDOMINAL
TRAUMA
• Computed tomography is the imaging
modality of choice in hemodynamically
stable patients, with no clinical evidence for
exploratory laparotomy
• Triple contrast CT should be done ideally
whenever conservative management is
decided

113. PENETRATING ABDOMINAL
TRAUMA
Protocol for triple contrast CT
• Intravenous administration 100–120 mL of iodinated contrast
material at a rate of 2.5- 4 mL/sec
• A total volume of 800 mL (divided into two doses of 400 mL) of
water-soluble oral contrast material is administered 30 minutes
and immediately before scanning
• 1 L of diluted water-soluble contrast material is administered
per rectally while the patient is on the CT table
• Portal venous phase images are obtained 60–70 seconds after
administration of contrast
• Delayed images are helpful in evaluating the renal and urinary
systems and characterizing extravascular collections of contrast-
enhanced blood.

114. PENETRATING ABDOMINAL
TRAUMA
CT findings requiring exploratory laparotomy
• Solid-organ injury with active arterial extravasation
• Diaphragmatic injury
• Bowel and mesenteric injuries
• Major vascular injury
• Intraperitoneal bladder rupture

115. PENETRATING ABDOMINAL
TRAUMA
Management
• Hemodynamically unstable and have a clinical indication for
exploratory laparotomy, such as evisceration or gastrointestinal
bleeding - laparotomy
• Triple-contrast CT
Patients with no signs of peritoneal violation - close observation and
early discharge.
If peritoneal violation present - laparotomy
Only solid organ injury - clinical judgment may be used to determine
the next step: close observation, angiography, or laparotomy

116. ROLE OF INTERVENTION RADIOLOGY IN
TRAUMA
• Abdominal trauma (unstable patient)- Surgery.
• Pelvic trauma (unstable patient)- Angiography and embolisation.
• Balloon occlusion-Inflation of an angioplasty balloon proximal to or
at a major arterial injury may temporarily stop or reduce life
threatening haemorrhage
• Transarterial embolization(TAE)- TAE can stop arterial haemorrhage,
thus avoiding the need for surgery.Gelform particles like polyvinyl
alcohol and coils are commonly used
• Stent grafts-Stent grafts are used for the treatment of large vessel
injuries t avoid complex surgical repairs particularly in areas with
trauma related anatomic distortion