Ct cach doc phim o bung

CÁCH ĐỌCCÁCH ĐỌC
CHỤP CLVTCHỤP CLVT
BỤNGBỤNG
Bùi Văn GiangBùi Văn Giang
Saint Paul, 8-2008Saint Paul, 8-2008

Một số khái niệmMột số khái niệm
 Cửa sổCửa sổ
 Đơn vị tỷ trọngĐơn vị tỷ trọng
 Giải phẫuGiải phẫu
 Một số dấu hiệu cơ bảnMột số dấu hiệu cơ bản

 Nhu mô: tổn thương tạng: u, vỡ,Nhu mô: tổn thương tạng: u, vỡ,
nang, chảy máunang, chảy máu
 Mỡ: thâm nhiễm mỡ (viêm), khíMỡ: thâm nhiễm mỡ (viêm), khí
(thủng tạng rỗng).(thủng tạng rỗng).

 Đơn vị tỷ trọngĐơn vị tỷ trọng
 Khí: -1000HUKhí: -1000HU
 HH22O: 0 HUO: 0 HU
 Mỡ: <0 HUMỡ: <0 HU
 Dịch 20HUDịch 20HU
 Nhu mô: 30-40Nhu mô: 30-40
 Máu 70-80HUMáu 70-80HU
 Xương >100 HUXương >100 HU

 Cửa sổ
 Đơn vị tỷ trọng
 Giải phẫu lớp cắtGiải phẫu lớp cắt

 Cửa sổ
 Đơn vị tỷ trọng
 Giải phẫu

Pancréatite aiguë +
thrombose splénique

Viêm t y c p + gi phìnhụ ấ ả

Chấn thương thận kínChấn thương thận kín
Đ 1ộĐ 1ộ

Đ 1ộĐ 1ộ
•• Đ 1: 75-85 % ch n th ng th n kínộ ấ ươ ậĐ 1: 75-85 % ch n th ng th n kínộ ấ ươ ậ
•• T n th ng nh :ổ ươ ỏT n th ng nh :ổ ươ ỏ
- Đ ng gi p nh nhu mô, không l n t i t y th nụ ậ ỏ ấ ớ ủ ậ- Đ ng gi p nh nhu mô, không l n t i t y th nụ ậ ỏ ấ ớ ủ ậ
- T máu d i baoụ ướ- T máu d i baoụ ướ
•• Đi u tr b o t nề ị ả ồĐi u tr b o t nề ị ả ồ
[5]:Kawashima RadioGraphics 2001

Đ 2ộĐ 2ộ

•• Đ 2: 10%ộĐ 2: 10%ộ
•• T n th ng nhu mô nhi u:ổ ươ ềT n th ng nhu mô nhi u:ổ ươ ề
- Rách nhu mô vào t i t y th n.ớ ủ ậ- Rách nhu mô vào t i t y th n.ớ ủ ậ
- Thi u máu thùy th n.ế ậ- Thi u máu thùy th n.ế ậ
Đ 2ộĐ 2ộ

•• Đ 3 : T n th ng nhu mô n ngộ ổ ươ ặĐ 3 : T n th ng nhu mô n ngộ ổ ươ ặ
- 5%- 5%
- Rách nhu mô th n ph c t p vào t i xoangậ ứ ạ ớ- Rách nhu mô th n ph c t p vào t i xoangậ ứ ạ ớ
th n kèm t n th ng m ch ngo i vi gây t máu,ậ ổ ươ ạ ạ ụth n kèm t n th ng m ch ngo i vi gây t máu,ậ ổ ươ ạ ạ ụ
đái máu, thi u máu nhu môếđái máu, thi u máu nhu môế
- Đ 4 : T n th ng sâu vào t i đ ngộ ổ ươ ớ ườ- Đ 4 : T n th ng sâu vào t i đ ngộ ổ ươ ớ ườ
bài xu t, m ch máuấ ạbài xu t, m ch máuấ ạ
Đ 3ộĐ 3ộ

Đ 3ộĐ 3ộ

Đ 4ộĐ 4ộ

DIVERTICULITEDIVERTICULITE
COECALECOECALE

Trauma to the Solid VisceraTrauma to the Solid Viscera
Trauma to the Solid VisceraTrauma to the Solid Viscera
• LiverLiver
• SpleenSpleen
• KidneyKidney
• PancreasPancreas
• AdrenalAdrenal
Other Traumatic InjuriesOther Traumatic Injuries
• DiaphragmDiaphragm
• MesenteryMesentery
• SpineSpine
• AortaAorta
• Abdominal WallAbdominal Wall

Hepatic Injury ClassificationHepatic Injury Classification
GradeGrade CriteriaCriteria
11 Capsular avulsionCapsular avulsion
Superficial laceration(s) < 1 cm. deepSuperficial laceration(s) < 1 cm. deep
Subcapsular hematoma < 1 cm. thickSubcapsular hematoma < 1 cm. thick
Periportal blood trackingPeriportal blood tracking
22 Lacerations(s) 1-3 cm. deepLacerations(s) 1-3 cm. deep
Central/subcapsular hematoma(s) 1-3 cm. thickCentral/subcapsular hematoma(s) 1-3 cm. thick
33 Laceration(s) > 3 cm. deepLaceration(s) > 3 cm. deep
Central/subcapsular hematoma(s) > 3 cm. thickCentral/subcapsular hematoma(s) > 3 cm. thick
44 Central/subcapsular hematoma(s) > 10 cm. thickCentral/subcapsular hematoma(s) > 10 cm. thick
55 Bilobar maceration or devascularizationBilobar maceration or devascularization

hemangiomahemangioma
 Globular peripheralGlobular peripheral
enhancementenhancement
 Lesion fills inLesion fills in
from peripheryfrom periphery

 Gunshot to liver with active bleedGunshot to liver with active bleed

Liver InjuryLiver Injury
 Grade 1 lacerationGrade 1 laceration  Liver laceration thought toLiver laceration thought to
be fissurebe fissure

 Grade 2 liver lacerationGrade 2 liver laceration

 Grade 3Grade 3
SubcapsularSubcapsular
hematomahematoma
 Grade 3Grade 3
IntraparenchymalIntraparenchymal
hematomahematoma

Liver LacerationLiver Laceration
 Grade 4 lacerationGrade 4 laceration  Delayed bilomaDelayed biloma
formationformation

Liver LacerationLiver Laceration
 Laceration extends to inferior vena cavaLaceration extends to inferior vena cava

 Devascularized leftDevascularized left
lobelobe
 Gallbladder hematomaGallbladder hematoma

Splenic Injury ClassificationSplenic Injury Classification
GradeGrade CriteriaCriteria
11 Localized capsular disruptionLocalized capsular disruption
Small subcapsular hematomaSmall subcapsular hematoma
22 Small peripheral lacerationsSmall peripheral lacerations
Parenchymal hematoma < 3 cm.Parenchymal hematoma < 3 cm.
33 Fracture extending to hilumFracture extending to hilum
Parenchymal hematoma > 3 cm.Parenchymal hematoma > 3 cm.
44 Shattered spleenShattered spleen
Vascular disruptionVascular disruption

Splenic InjurySplenic Injury
 Congenital cleftCongenital cleft

 Grade 1 injuryGrade 1 injury  Grade 2 injuryGrade 2 injury

 Grade 3 injuryGrade 3 injury  Grade 4 injuryGrade 4 injury

 Infarcted spleenInfarcted spleen

 Sentinel clot signSentinel clot sign

 Active arterial bleedActive arterial bleed  Delayed hematomaDelayed hematoma

 Active arterial extravasation from splenicActive arterial extravasation from splenic
lacerationlaceration
 Subcapsular and perisplenic hematomasSubcapsular and perisplenic hematomas

Splenic injurySplenic injury
 AngiographicAngiographic
embolizationembolizationActive bleedActive bleed

Pancreas injuryPancreas injury
 Pancreatic laceration with pseudocystPancreatic laceration with pseudocyst

Pancreas injuryPancreas injury
 Pancreas tail lacerationPancreas tail laceration
with blood in left anteriorwith blood in left anterior
pararenal spacepararenal space
 Pancreatic bodyPancreatic body

Pancreas InjuryPancreas Injury
 Pancreatic neckPancreatic neck
laceration - bloodlaceration - blood
between pancreasbetween pancreas
and splenic veinand splenic vein
 Pancreatic headPancreatic head
contusioncontusion

Renal Injury ClassificationRenal Injury Classification
CategoryCategory CriteriaCriteria
MinorMinor Renal contusionRenal contusion
(85%)(85%) Small corticomedullarySmall corticomedullary
Intrarenal hematomaIntrarenal hematoma
Segmental infarctionSegmental infarction
Small subcapsularSmall subcapsular
hematomahematoma

Renal Injury ClassificationRenal Injury Classification
MajorMajor Parenchymal lacerations that communicateParenchymal lacerations that communicate
(10%)(10%) with the collecting systemwith the collecting system
Large subcapsular hematomaLarge subcapsular hematoma
Complete lacerationComplete laceration
Renal fractureRenal fracture
Renal vein injuriesRenal vein injuries
CatastrophicCatastrophic Shattered kidneyShattered kidney
(5%)(5%) Renal artery avulsion or occlusionRenal artery avulsion or occlusion

Renal InjuryRenal Injury
 Ruptured congenitalRuptured congenital
UPJ obstructed kidneyUPJ obstructed kidney
 Ruptured calycealRuptured calyceal
diverticulumdiverticulum

 Renal contusionRenal contusion  Renal laceration withRenal laceration with
perirenal hematomaperirenal hematoma

 Small lacerationSmall laceration  Delayed scan-Delayed scan-
extravasation ofextravasation of
contrastcontrast

 Extravasated contrastExtravasated contrast
on 10 min delay scanon 10 min delay scan
 Ureter intact-surgeryUreter intact-surgery
not necessarynot necessary

 Bilateral renal extravasation of contrastBilateral renal extravasation of contrast

 Fractured kidneyFractured kidney  DevascularizedDevascularized
segment,largesegment,large
hematomahematoma

 UPJ lacerationUPJ laceration  Renal artery occlusionRenal artery occlusion

Arterial occlusion causingArterial occlusion causing
renal infarctionrenal infarction
 Arterial OcclusionArterial Occlusion

Renal injuryRenal injury
 Renal artery pseudoaneurysmRenal artery pseudoaneurysm

Renal injuryRenal injury
 Renal artery pseudoaneurysmRenal artery pseudoaneurysm
embolizedembolized

Adrenal HematomaAdrenal Hematoma
 Adrenal hematoma and grade II liver lacerationAdrenal hematoma and grade II liver laceration
 Patient struck on right sidePatient struck on right side

Bladder TraumaBladder Trauma
 CT Cystography in the Evaluation ofCT Cystography in the Evaluation of
Bladder TraumaBladder Trauma
 Lis,L.E., Cohen,A.J.Lis,L.E., Cohen,A.J.
 J Comput Assist Tomogr 1990;14:386-389J Comput Assist Tomogr 1990;14:386-389

Bladder Rupture(intraperitoneal)Bladder Rupture(intraperitoneal)
 CT cystogram-350 cc of contrast (4%) infusedCT cystogram-350 cc of contrast (4%) infused
through Foley catheter.through Foley catheter.
 free contrast in peritoneal cavityfree contrast in peritoneal cavity

Bladder Rupture(intraperitoneal)Bladder Rupture(intraperitoneal)
 Free contrast aroundFree contrast around
liverliver
 Contrast in cul-de-sacContrast in cul-de-sac

Bladder Rupture(extraperitoneal)Bladder Rupture(extraperitoneal)
 Extravasated contrastExtravasated contrast
prevesicle spaceprevesicle space
 Contrast tracks intoContrast tracks into
scrotumscrotum

Mimic of bladder ruptureMimic of bladder rupture
 Paravesicle hematoma with active arterial bleedParavesicle hematoma with active arterial bleed

ChestChest
 Pericardial and pleural effusionPericardial and pleural effusion

Chest TraumaChest Trauma
 Severe Lung contusionSevere Lung contusion

 Lung contusionLung contusion  Pneumothorax, lacerationsPneumothorax, lacerations

 ParavertebralParavertebral
hematomahematoma
 T6 vertebralT6 vertebral
body fracturebody fracture

Chest traumaChest trauma
Traumatic rupture of inferior vena cava into pericardiumTraumatic rupture of inferior vena cava into pericardium

DiaphragmDiaphragm
 Huge diaphragmatic hernia-patient fell fromHuge diaphragmatic hernia-patient fell from
ladderladder

Diaphragmatic HerniaDiaphragmatic Hernia
 Subtle traumaticSubtle traumatic
diaphragmatic herniadiaphragmatic hernia
 Two days later,Two days later,
stomach up in cheststomach up in chest

Diaphragmatic HerniaDiaphragmatic Hernia
 Stomach in chestStomach in chest
 Stomach constricted passing through diaphragmStomach constricted passing through diaphragm

Abdominal WallAbdominal Wall
 Actively bleeding rectus muscle hematomaActively bleeding rectus muscle hematoma

Soft tissue injurySoft tissue injury
 Back hematomaBack hematoma

SpineSpine
COMBINATIONCOMBINATION
INJURIESINJURIES

Spine TraumaSpine Trauma
 Originally missed burst fractureOriginally missed burst fracture

Spine TraumaSpine Trauma
 Posterior element spinousPosterior element spinous
fracturefracture
 patient withpatient with
AnkylosingAnkylosing
SpondylitisSpondylitis

Combination InjuriesCombination Injuries
 Devascularized leftDevascularized left
lobe of liverlobe of liver  Pancreatic laceration andPancreatic laceration and
left renal infarctleft renal infarct

 Wide mediastinumWide mediastinum  Periaortic hematoma-Periaortic hematoma-
sign of aortic injurysign of aortic injury

 Aortic tearAortic tear  Jejunal perforationJejunal perforation

 Aortic tearAortic tear  Pancreatic lacerationPancreatic laceration

 Aortic tearAortic tear  Bladder hematoma andBladder hematoma and
rupturerupture

 Jejunal perforationJejunal perforation
 Intraperitoneal bladder perforationIntraperitoneal bladder perforation

 Pattern of Impact determines combinationPattern of Impact determines combination
injuriesinjuries
 Avoid Satisfaction of Search ErrorAvoid Satisfaction of Search Error

Trauma to the Hollow VisceraTrauma to the Hollow Viscera
 DuodenumDuodenum
 JejunumJejunum
 IleumIleum
 ColonColon
 StomachStomach

Bowel and Mesenteric InjuriesBowel and Mesenteric Injuries
- 5% of patients after blunt abdominal trauma who undergo5% of patients after blunt abdominal trauma who undergo
surgical explorationsurgical exploration
- Mortality of duodenal perforationMortality of duodenal perforation
= 65% if surgery delayed > 24 hours= 65% if surgery delayed > 24 hours
= 5% if surgery done in 1= 5% if surgery done in 1stst
24 hours24 hours
CT FindingsCT Findings
Bowel Wall InjuriesBowel Wall Injuries
- thickeningthickening
-- intense wall enhancementintense wall enhancement

PneumoperitoneumPneumoperitoneum
-anterior peritoneal surface-anterior peritoneal surface
-perihepatic/splenic areas-perihepatic/splenic areas
-mesentery/omentum-mesentery/omentum
-ligaments (falciform, etc)-ligaments (falciform, etc)
Free FluidFree Fluid
-small bowel, low density & no air-small bowel, low density & no air
-blood, intermediate density (high density if arterial)-blood, intermediate density (high density if arterial)
-oral contrast, very high density, > 150 HU-oral contrast, very high density, > 150 HU

Duodenal TraumaDuodenal Trauma
 Duodenal hematomaDuodenal hematoma
Duodenal InjuriesDuodenal Injuries
-descending/horizontal-descending/horizontal
segmentssegments
-Retro/intraperitoneal-Retro/intraperitoneal

Duodenal InjuryDuodenal Injury
 Duodenal perforation-Duodenal perforation-
missed originallymissed originally
 Perforation seen on UGIPerforation seen on UGI
examexam

Duodenal PerforationDuodenal Perforation
 Periduodenal hematomaPeriduodenal hematoma  One day later,One day later,
duodenal perforationduodenal perforation

Jejunal/Ileal InjuryJejunal/Ileal Injury
 CT FindingsCT Findings
 fixation pointsfixation points
 ligament of Treitzligament of Treitz
 ileocecal valveileocecal valve

Jejunal InjuryJejunal Injury
 Triangles imply extraluminal fluidTriangles imply extraluminal fluid
 Jejunal perforationJejunal perforation

 Mesenteric hematomaMesenteric hematoma Jejunal perforationJejunal perforation

 Jejunal hematoma which perforatedJejunal hematoma which perforated

Jejunal PerforationJejunal Perforation
 Wall thickeningWall thickening  Seat belt signSeat belt sign

Bowel wall thickeningBowel wall thickening  Blood in pelvisBlood in pelvis

 Extravasated oralExtravasated oral
contrastcontrast
 Burst fracture of L2Burst fracture of L2

Free Intraperitoneal AirFree Intraperitoneal Air
 ““Little bubbles, big troubles”Little bubbles, big troubles”
 DistributionDistribution
- around liver- around liver
- in mesentery- in mesentery
- posterior to the rectus abdominis muscles- posterior to the rectus abdominis muscles
midrectus recessmidrectus recess
pararectus recessespararectus recesses
Delayed Scans May Be HelpfulDelayed Scans May Be Helpful

 Occult jejunal injuryOccult jejunal injury
 Subtle bowel wallSubtle bowel wall
thickeningthickening
 Free fluid in pelvisFree fluid in pelvis

 Extraluminal airExtraluminal air
at porta hepatis,at porta hepatis,
over liverover liver
 Same patient one day laterSame patient one day later
 Extravasation of oralExtravasation of oral
contrastcontrast

 Paracolic gutter fluid and mesenteric fluid mayParacolic gutter fluid and mesenteric fluid may
have different originshave different origins

 Extraluminal gas bubblesExtraluminal gas bubbles
LITTLE BUBBLESLITTLE BUBBLES
BIG TROUBLESBIG TROUBLES

Ileal, Cecal, Gastric TraumaIleal, Cecal, Gastric Trauma
Intense Bowel Wall EnhancementIntense Bowel Wall Enhancement
 Low flow stateLow flow state
 Intravasation of contrastIntravasation of contrast

Jejunal, Ileal InjuriesJejunal, Ileal Injuries
 Bowel wallBowel wall
enhancement-jejunalenhancement-jejunal
and ileal perforationsand ileal perforations
 pneumoperitoneumpneumoperitoneum

Ileal InjuryIleal Injury
 Ileal wallIleal wall
enhancementenhancement
 At operation, ileal perforationAt operation, ileal perforation
 Bubble ofBubble of
extraluminal air inextraluminal air in
pararectus recesspararectus recess

Ileal InjuryIleal Injury
 Ileal injury – wallIleal injury – wall
thickeningthickening
 Delayed perforationDelayed perforation

Ileal PerforationIleal Perforation
 SubtleSubtle
pneumoperitoneumpneumoperitoneum  Ileal perforationIleal perforation

Colonic InjuryColonic Injury
Pneumatosis of cecal wall-degloving injury ofPneumatosis of cecal wall-degloving injury of
serosaserosa

 Cecal perforationCecal perforation  Traumatic herniaTraumatic hernia

 Colonic infarctColonic infarct  Traumatic herniaTraumatic hernia

 Stab wound to colonStab wound to colon
 extravasated contrastextravasated contrast
Rectal Contrast usedRectal Contrast used
alsoalso

Stomach InjuryStomach Injury
 Greater curvature hematoma and perforationGreater curvature hematoma and perforation
Stomach RuptureStomach Rupture
-children > adults-children > adults
-anterior wall > greater curve >-anterior wall > greater curve >
lesser curvelesser curve
-associated with splenic trauma-associated with splenic trauma

Stomach RuptureStomach Rupture
 Pneumoperitoneum-falciform ligament seenPneumoperitoneum-falciform ligament seen
 CT-pneumoperitoneumCT-pneumoperitoneum

Stomach PerforationStomach Perforation
 Extravasated oral contrast from stomachExtravasated oral contrast from stomach

Mesenteric InjuriesMesenteric Injuries
 mesenteric fat streakingmesenteric fat streaking
 mass effect on bowelmass effect on bowel

Mesenteric InjuryMesenteric Injury
 Mesenteric hematomasMesenteric hematomas

 Superior mesenteric vein bleedSuperior mesenteric vein bleed

 Missed mesenteric bleedMissed mesenteric bleed
mimicking bowel loopmimicking bowel loop
 Delayed HematomaDelayed Hematoma

PneumoperitoneumPneumoperitoneum
 Plain filmPlain film  CT with lung windowsCT with lung windows

PneumoretroperitoneumPneumoretroperitoneum
 Plain filmPlain film  CTCT

Shock BowelShock Bowel
 Small aorta and IVCSmall aorta and IVC
 Nonexcreting kidneysNonexcreting kidneys
 Diffuse bowel wall edemaDiffuse bowel wall edema

 Diffuse bowel wall edemaDiffuse bowel wall edema

OverhydrationOverhydration
 Periportal edemaPeriportal edema
Bowel wall thickeningBowel wall thickening
Distended IVC andDistended IVC and
aortaaorta
Periportal edemaPeriportal edema
RetroperitonealRetroperitoneal
effusionseffusions

OverhydrationOverhydration
 Retroperitoneal effusionRetroperitoneal effusion  Diffuse bowel wall edemaDiffuse bowel wall edema

 Jejunal perforationJejunal perforation Shock bowelShock bowel

CT signs suggestive of small bowelCT signs suggestive of small bowel
injuryinjury
NO. (%)NO. (%)
Small bowel wall thickeningSmall bowel wall thickening 18/19 (95)18/19 (95)
Free Fluid or blood withoutFree Fluid or blood without
associated solid visceral injuryassociated solid visceral injury 9/19 (47)9/19 (47)
Casey L, Vu D, Cohen AJ. Small Bowel RuptureCasey L, Vu D, Cohen AJ. Small Bowel Rupture
after Blunt Trauma: CT signs and Their Sensitivityafter Blunt Trauma: CT signs and Their Sensitivity

CT signs pathognomic of bowelCT signs pathognomic of bowel
rupturerupture
NO. (%)NO. (%)
Extraluminal airExtraluminal air 7/19 (37)7/19 (37)
Oral contrast extravasationOral contrast extravasation 8/19 (42)8/19 (42)
Extraluminal air onlyExtraluminal air only 3/19 (16)3/19 (16)
Oral contrast extravasation onlyOral contrast extravasation only 4/19 (21)4/19 (21)
Both extraluminal air andBoth extraluminal air and
oral contrast extravasationoral contrast extravasation 4/19 (21)4/19 (21)
TOTALTOTAL 11/19 (58)11/19 (58)

 Duodenal perforation extravasates into the rightDuodenal perforation extravasates into the right
anterior pararenal spaceanterior pararenal space
 Duodenal wall may be thickened by edema orDuodenal wall may be thickened by edema or
bloodblood

Jejunal and Ileal PerforationJejunal and Ileal Perforation
 Jejunal and ileal perforation manifests as bowelJejunal and ileal perforation manifests as bowel
wall thickeningwall thickening
 Extraluminal air and fluid may be subtleExtraluminal air and fluid may be subtle
 Lung windows help to disclose extraluminal airLung windows help to disclose extraluminal air

Extraluminal FluidExtraluminal Fluid
 Triangles imply extraluminal fluidTriangles imply extraluminal fluid
 Paracolic gutter fluid and mesenteric fluid mayParacolic gutter fluid and mesenteric fluid may
have different originshave different origins

Small Bowel InjurySmall Bowel Injury
Do not hesitate to repeat scan if the clinicalDo not hesitate to repeat scan if the clinical
condition deterioratescondition deteriorates
Shock and overhydration can cause abnormalShock and overhydration can cause abnormal
appearing small bowelappearing small bowel

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