DAVID SUTTON PICTURES THE ABDOMEN AND MAJOR TRAUMA ONLY FOR STUDY PURPOSE

1. 23
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 23.1 (A, B) Ultrasound of the left
hypochondrium showing the presence of
hemoperitoneum, pleural fluid and a defect in
the left hemidiaphragm more posteriorly,
consistent with diaphragmatic rupture
(arrow).

4. • Fig. 23.2 Multiple splenic injuries in the same
patient. (A) Splenic low attenuation linear defect
due to a splenic laceration. (B) More inferiorly a
splenic fracture with separation of fragments is
present. Hemoperitoneum is localised to the left
upper quadrant. (C) In the splenic bed active
extravasation of contrast is identified.

5. • Fig. 23.3 Intrasplenic haematomas are
characterised by irregular margins and
swelling of the spleen, altering the normal
crescentic contour.

6. • Fig.23.4 Resolving splenic lacerations and
haematomas. A peripheral crescentic low-
attenuation collection is due to a subcapsular
haematoma and, although small, poses a risk
Of delayed rupture.

7. • Fig. 23.5 Normal splenic clefts. These can be
distinguished from lacerations by their
relatively superior location, lobulated contour
and the absence of perisplenic
hemoperitoneum. Note the preservation of
the fat planes around the spleen.

8. • Fig. 23.6 (A, B) Flush DSA aortogram showing
splenic arterial bleeding with a persistent
blush in the spleen on the delayed image.

9. • Fig. 23.7 (A, B) Contrast-enhanced CT: there is
frank arterial bleeding from the splenic artery
associated with a fragmented spleen.
Extensive haemoperitoneum is also present.

10. • Fig. 23.8 (A,B) Motorcyclist after a road traffic
accident. A fractured rib has caused a direct
small peripheral laceration to the right lobe of
the liver.

11. • Fig. 23.9 Multiple right lobe lacerations. This
configuration has been described as a 'bear
claw' appearance.

12. • Fig. 23.10 Subacute subcapsular haematoma
of the liver. The low-attenuation collection
indents the liver margin. Unlike splenic
subcapsular collections, these collections are
not thought to predispose to delayed rupture.

13. • Fig. 23.11 (A) Contrast-enhanced CT: a large
right hepatic lobe contusion with acute
haematoma extending into the right portal
vein. (B) The venous phase of the superior
mesenteric angiogram demonstrates an acute
cut-off to the right portal vein.

14. • Fig. 23.12 (A) Massive central haematoma (grade 4) with
laceration extending through the liver capsule in a patient with a
ruptured liver. (B) The right hepatic artery arises from the superior
mesenteric artery. The angiogram demonstrates areas of
devascularisation and separation by the extrahepatic haematoma
seen on CT. No arterial bleed is seen. (C) The venous phase of the
angiogram shows complete disruption of the portal vein (arrow)
and contrast extravasation (arrowhead).

15. • Fig. 23.12 (A) Massive central haematoma (grade 4) with
laceration extending through the liver capsule in a patient
with a ruptured liver. (B) The right hepatic artery arises
from the superior mesenteric artery. The angiogram
demonstrates areas of devascularisation and separation by
the extrahepatic haematoma seen on CT. No arterial bleed
is seen. (C) The venous phase of the angiogram shows
complete disruption of the portal vein (arrow) and contrast
extravasation (arrowhead).

16. • Fig. 23.13 Periportal low attenuation.
Extensive periportal low attenuation is
identified in a central and peripheral
distribution in an 11 year old. As is frequently
the case, no hepatic laceration was identified.

17. • Fig. 23.14 Embolisation of a traumatic false aneurysm
in a patient with liver laceration. (A) Dynamic CT scan
showing an area of liver laceration. There is abnormal
tubular enhancement in the lacerated area. (B) Hepatic
artery angiogram demonstrates a traumatic false
aneurysm. (C) Embolisation: hepatic arteriogram, again
showing the aneurysm with abnormal vascular blush in
the lacerated liver. (D) A supraselective coaxial
catheterisation of the right hepatic artery leading to
the false aneurysm, which was successfully embolised.

18. • Fig. 23.14 Embolisation of a traumatic false aneurysm in a patient
with liver laceration. (A) Dynamic CT scan showing an area of liver
laceration. There is abnormal tubular enhancement in the lacerated
area. (B) Hepatic artery angiogram demonstrates a traumatic false
aneurysm. (C) Embolisation: hepatic arteriogram, again showing the
aneurysm with abnormal vascular blush in the lacerated liver. (D) A
supraselective coaxial catheterisation of the right hepatic artery
leading to the false aneurysm, which was successfully embolised.

19. • Fig. 23.15 Large irregularly marginated
segmental right lobe contusion. The contusion
extends to the IVC and is associated with only
minimal haemoperitoneum anterior to the liver.
Such injuries may be significantly underestimated
by ultrasound, particularly if the
haemoperitoneum is not detected.

20. • Fig. 23.16 Non-specific findings in an adult male
following a fall. (A). Pericholecystic free fluid.
This finding may be due to gallbladder injury but
is more frequently due to other injuries. (B)
Anterior pararenal haemorrhage. This is a
frequent site of haematoma secondary to renal
injuries but also pancreatic tail injuries. The
visceral injury is often not visible.

21. • Fig. 23.17 Layered high-attenuation
haematoma is present in the injured
gallbladder. Additional active extravasation in
the hepatorenal angle is noted within a
hepatic haematoma.

22. • Fig. 23.18 Laceration recovery. (A) Acute phase
imaging demonstrates a complex laceration
extending to the IVC. Despite this extension the
patient was successfully treated conservatively.
(B) One month after injury the laceration has
almost healed. The splenic size had significantly
increased from the initial scan, presumably due
to reversal of adrenergic stimulation

23. • Fig. 23.19 Air within a hepatic laceration. This
CT was performed a week after a therapeutic
selective embolisation. This finding is well
described in resolving lacerations and does
not necessarily indicate infection. Associated
peritoneal and pleural collections are present.

24. • Fig. 23.20 After a renal biopsy extensive
haemorrhage is present, splitting the renal
fascia (interfascial). In addition, haematoma
has spread to the psoas and left flank soft
tissues.

25. • Fig. 23.21 Renal cell carcinoma detected
incidentally following minimal trauma. A large
anterolateral renal cell carcinoma is present. A
posterolateral subcapsular haematoma
indents the renal contour and displaces the
kidney anteriorly.

26. • Fig. 23.22 Unenhanced CT. Extensive hyper
dense perirenal haematoma is present.
Unenhanced CT is not essential in the analysis
of renal trauma as most significant
haematomas are sufficiently conspicuous on
postcontrast imaging alone.

27. • Fig. 23.23 Central irregular low attenuation of
the left kidney due to a traumatic contusion.
There is associated perirenal haematoma
surrounding the renal margin. Further pararenal
haemorrhage is separated from this haematoma
by perirenal fat bounded by Gerota's fascia.
Intraperitoneal haemorrhage is present in both
flanks.

28. • Fig. 23.24 A segmental peripheral low-
attenuation wedge is noted in the right kidney
consistent with a peripheral infarct. These injuries
are seen relatively frequently post-traumatically
but may also predate the injury in older patients
with concomitant vascular disease.

29. • Fig. 23.25 Well-demarcated area of
hypoperfusion secondary to traumatic
infarction. Haemoperitoneum is present in the
hepatorenal angle

30. • Fig. 23.26 Renal lacerations. Two stabbing
injuries are identified in the same patient. (A)
Superficial laceration limited to the cortex. (B).
Deep laceration extending to the medulla.
Such injuries are more frequently associated
with urinary leakage. Associated perirenal
haematoma is present.

31. • Fig. 23.27 (A-C) Major renal trauma with
multiple devascularised segments. Such
injuries are traditionally treated surgically,
although in haemodynamically stable patients
angiography and embolisation may obviate
the need for nephrectomy.

32. • Fig. 23.28 (A) Contrast-enhanced CT following blunt trauma
demonstrates a largely absent left nephrogram except for
preserved rim cortical perfusion. The left renal artery is dilated.
The right kidney is congenitally absent. (B) Selective arteriography
demonstrates a dissection of the renal artery with poor distal
perfusion. (C) Delayed phase: poor and patchy nephrogram
appearances (Images (A) and (B) reproduced with kind permission
from McAlinden et al 2001.)

33. • Fig. 23.28 (A) Contrast-enhanced CT following blunt trauma
demonstrates a largely absent left nephrogram except for
preserved rim cortical perfusion. The left renal artery is dilated.
The right kidney is congenitally absent. (B) Selective arteriography
demonstrates a dissection of the renal artery with poor distal
perfusion. (C) Delayed phase: poor and patchy nephrogram
appearances (Images (A) and (B) reproduced with kind permission
from McAlinden et al 2001.)

34. • Fig. 23.29 (A) CT following blunt trauma demonstrates a
right renal contusion with perirenal haemorrhage. The
patient was haemodynamicaIly stable and treated
conservatively. (B) Angiography performed for persistent
haematuria demonstrates a traumatic false aneurysm. (C)
Successful embolisation of the supplying branch artery.
(Courtesy of Dr C. Blakeney, Royal London Hospital.)

35. • Fig. 23.29 (A) CT following blunt trauma demonstrates a
right renal contusion with perirenal haemorrhage. The
patient was haemodynamicaIly stable and treated
conservatively. (B) Angiography performed for persistent
haematuria demonstrates a traumatic false aneurysm. (C)
Successful embolisation of the supplying branch artery.
(Courtesy of Dr C. Blakeney, Royal London Hospital.)

37. • Fig. 23.31 Angiography for persistent
haemorrhage demonstrates abnormal
vasculature due to a renal angiomyolipoma.
(Reproduced with kind permission from
McAlinden et al 2001 .)

38. • Fig. 23.32 Contrast cystography. Following
trauma there is an intraperitoneal rupture of the
bladder dome. Contrast is starting to line the
small bowel in the left iliac fossa. (Courtesy of Dr
T. Fotheringham, Royal London Hospital.)

39. • Fig. 23.33 (A) Extra peritoneal bladder base
rupture. Following an ascending urethrogram,
contrast surrounds the bladder base within
the perineum. (B) Contrast has tracked around
the bladder, which still contains urine. There
are associated fractures of the right iliac blade
and of the left pubic rami.

40. • Fig. 23.34 Pancreatic laceration following a go-
karting car accident. Complete transection of the
junction of the body and tail with fragmentation.
The pancreatic duct would almost certainly be
disrupted in such an injury. Associated extensive
peritoneal and retroperitoneal haematoma is
present. Note that despite the significant injury
the splenic vein is not separated from the
pancreas, demonstrating the low sensitivity of
this sign.

41. • Fig. 23.35 Gunshot injury to the abdomen. (A)
There is an intrahepatic contusion with
haemoperitoneum. Within the
haemoperitoneum air bubbles are identified due
to an associated large bowel injury. (B) There is a
further large devascularising injury of the
posterior right kidney but no other bowel injury
localising signs were identified.

42. • Fig. 23.36 Duodenal rupture with leakage
into the right anterior pararenal space.

43. • Fig. 23.37 (A,B) Localised bowel wall
thickening due to small bowel haematoma
following blunt abdominal trauma.

44. Fig. 23.38 Bowel trauma. There is extensive
intraperitoneal free fluid with no evidence on
other images of a solid visceral injury. (A) The
ascending colon demonstrates intense staining of
the wall and lumen consistent with haemorrhage.
(B) More inferiorly a large haematoma
compresses the colonic lumen.

45. Fig. 23.39 Haematoma is present in the
perirectal space secondary to a 20 metre fall
resulting in blunt injury to the rectum.

46. • Fig. 23.40 Bowel findings in a 7 year old following a road
traffic accident. (A) The diffuse fluid dilatation of the small
bowel with brightly enhancing walls suggest 'shock bowel'.
This is supported by the collapsed IVC and the small calibre
aorta. (B) The focal dilatation and thickening of the terminal
ileum with extraluminal air lateral to the colon suggests
bowel trauma with perforation. The findings of trauma and
'shock bowel' may coexist and be difficult to differentiate.

47. • Fig. 23.41 Laceration of the IVC in a child
after a 15 metre fall. Contrast has been
instilled via a femoral line. Active contrast
extravasation into the retroperitoneum is
noted. There is almost no contrast in the
systemic circulation and hence the kidneys.