Abdominal active bleeding in the emergency room: Assessment with 64-slice MDCT

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1 Abdominal active bleeding in the emergency room: Assessment with 64-slice MDCT Poster No.: C-3055 Congress: ECR 2010 Type: Educational Exhibit Topic: Vascular Authors: R. Larrosa, J. M. Mellado, S. Solanas, J. Martin, N. Yanguas, R. Cozcolluela; Tudela/ES Keywords: Abdominal bleeding, Multidetector CT, Abdominal hemorrhage Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 29

2 Learning objectives To review and illustrate, the classic signs of active bleeding as seen on emergent 64slice multidetector CT studies in the evaluation of patients with suspected of abdominal hemorrhage. Background Currently available MDCT offers the combined advantages of high speed, seamless coverage of the entire abdomen, and outstanding spatial resolution, leading to optimal multiplanar reformations and superb volume rendering. These technical advances have significantly improved image quality, and allow superb angiographic studies of the abdominal aorta and splanchnic vessels. Imaging findings OR Procedure details Introduction Abdominal bleeding is a serious medical condition. Causes of abdominal bleeding include trauma, spontaneous bleeding, bleeding tumor, vascular disorders or anticoagulation theraphy. Although bleeding rates are greatly influenced by the severity of damage to vessels, organs and tissues, massive abdominal bleeding may cause exsanguination, often requiring emergency surgery. In spite of improved imaging and prompt treatment efforts, abdominal active bleeding remains a potentially life-threatening disorder. MDCT is being widely used in this clinical setting, as may prove useful by showing signs of active bleeding (Fig. 1) on page 4, bleeding vessels (Fig. 2) on page 5, or vascular injuries (Fig. 3) on page 6. It may also help differentiate active bleeding from pseudoaneurysm (Fig. 4) on page 7, and may provide information regarding clinical status (Fig. 5). on page 9 Page 2 of 29

3 At contrast-enhanced MDCT, active arterial bleeding implies extravasation of iodinated intravascular contrast medium, which is usually shown as a focal area of hyperattenuation within a hematoma (Fig. 1). on page 4 Attenuation measurements can help differentiate among free fluid, free blood, hematoma and active bleeding (Fig. 6 on page 8, Fig. 7). on page 10 Consequently, our objective was to review the variable appearance of active bleeding as seen on emergent 64-slice multidetector CT studies of the abdomen performed at our institution. We separately discuss lesions involving the abdominal organs, the abdominal wall, the pelvis and the retroperitoneum. Abdominal organs Active bleeding may originate from traumatic injuries to solid viscera, such as the liver, the spleen, the kidneys or the pancreas. Active bleeding of solid viscera will often require angiographic or surgical intervention (Fig. 8) on page 11. The spleen is the most frequently injured organ in blunt abdominal trauma (Fig. 9) on page 12. Less commonly, the bladder or the kidneys may bleed into the abdomen, and MDCT may help differentiate between perirenal urinoma and true perirenal active bleeding (Fig. 10 on page 13). Trauma to the solid viscera may cause varying degrees of damage. In subcapsular hematomas bleeding is limited to small areas around the organ. Parenchymal contusions or lacerations are the most common organ injuries. Laceration of hilar vessels or true avulsion of solid organs, such as the spleen, will often require surgical intervention or angiographic embolization. The presence of iodinated contrast material within the parenchyma of the liver or the spleen with adjacent hemoperitoneum may be indicative of arterial injury or pseudoaneurysm formation. The diagnosis of bowel and mesenteric injury is difficult to establish in blunt trauma patients. Traumatic injuries of the bowel include bowel wall discontinuity, extraluminal contrast material, and free intraperitoneal air (Fig. 11 on page 14). Specific signs of mesenteric injury include contrast extravasation next to injured vessel, vessel irregularity, lack of vascular enhancement, change in caliber or intimal flap (Fig. 12 on page 15, Fig. 13 on page 16, Fig.14 on page 17, Fig 15 on page 18). Retroperitoneum Retroperitoneal hematoma is most commonly seen in association with anticoagulation or bleeding abnormalities, and may represent a potentially lethal complication (Fig. 16). on page 19 Spontaneous retroperitoneal bleeding is a clinical entity that can present in Page 3 of 29

4 the absence of specific underlying pathology or trauma (Fig. 17). on page 20It may be the source of significant but occult blood loss. A retroperitoneal hematoma adjacent to an abdominal aortic aneurysm is the most common imaging sign of aortic rupture. An abdominal aortic aneurysm may cause gastrointestinal bleeding, requiring emergent surgery. Secondary aortoenteric fistula is an uncommon but life-threatening complication of aortic reconstructive surgery (Fig. 18) on page 21, causing mortality rates close to 85%. Endoleak is a condition associated with endoluminal vascular grafts. It is defined by the persistence of blood flow outside the lumen of the endoluminal graft but within an aneurysm sac or adjacent vascular segment being treated by the graft (Fig.19). on page 22 Pelvic hemorrhage Arterial hemorrhage is one of the most serious complications associated with pelvic fracture, and can cause life-treatening injuries. Displaced fractures have a high risk of vascular injuries. Diastasis of the pubic symphisis, and obturator ring fracture displacement (# 1cm) increase the probability of severe pelvic hemorrhage. MDCT may help in the preoperative assessment, before endovascular treatment or open surgery is performed (Fig.20 on page 23, Fig 21) on page 24 Abdominal wall Abdominal wall hematoma is a well-known complication of anticoagulation therapy, and represents a potential cause of significant morbidity and mortality. In the majority of these cases, bleeding occurs spontaneously. The iliopsoas and rectus sheath muscles represent the most common sites of bleeding in the abdominal wall (Fig. 22 on page 25, Fig. 23). on page 26 Images for this section: Page 4 of 29

5 Fig. 1: Spontaneous rectus sheath hematoma in an anticoagulated patient. Axial (a) and sagittal reformatted (b) contrast-enhanced MDCT images show a small focus of hyperattenuation (arrows) within the hematoma, suggesting active bleeding. Page 5 of 29

6 Fig. 2: Identify bleeding vessel. Axial contrast-enhanced MDCT scan (a)following cardiac catheterization shows a subacute hematoma within the pectineus muscle (arrowhead). The coronal maximum intensity projection (b), shows active bleeding arising from medial circumflex femoral artery (arrow). Page 6 of 29

7 Fig. 3: Signs of vascular injury. Traumatic mesenteric laceration. Coronal reformatted contrast-enhanced MDCT (a) and maximum-intensity-projection (b) show active bleeding (arrowhead) and irregularity of a mesenteric vessel (arrow). Increased enhancement of the small bowel wall is also seen. Page 7 of 29

8 Fig. 4: Characteristics of active extravasation and pseudoaneurysm Page 8 of 29

9 Fig. 5: Attenuation differences (in Hounsfield units)between active extravasation, hematoma, free blood and free fluid. Page 9 of 29

10 Fig. 6: CT findings in the hypoperfusion complex Page 10 of 29

11 Fig. 7: Attenuation values. Axial contrast-enhanced MDCT scans show different attenuation values in active bleeding (a), hematoma (b), free blood (c), and free fluid (d). Page 11 of 29

12 Fig. 8: Liver laceration in a patient with multiple rib fractures from casual trauma. Axial contrast-enhanced CT images (a, b, c) demonstrate a liver laceration with a small focus of active extravasation (arrows) Page 12 of 29

13 Fig. 9: Abdominal trauma in an anticoagulated patient. Axial contrast-enhanced (a, b) and coronal reformatted (c) MDCT images show a splenic laceration with active bleeding flowing into a large perisplenic hematoma. Extravasation of contrast medium (arrows) is isodense to aortic lumen. Page 13 of 29

14 Fig. 10: Renal laceration. (A,B) Axial contrast-enhanced images obtained in portal (A) and urographic (B) phases demostrate a large perirenal fluid collection (arrow in a), with signs of contast extravasation (in b), suggesting perirenal urinoma. (C) Renal laceration in a different patient. Coronal reformatted contast-enhanced CT image shows a laceration at the lower pole of the left kidney. A focus of active bleeding (arrow) is found within a large perirenal hematoma Page 14 of 29

15 Fig. 11: Massive bleeding from the colon. Coronal maximum-intensity projection (a) and volume-rendering (b) of MDCT angiography reveals a focus of active extravasation in the lumen of the left colon (circles). Patient required emergent surgery, and complete collectomy. Page 15 of 29

16 Fig. 12: Mesenteric injury. Coronal reformatted contrast-enhanced MDCT (a) and maximum-intensity-projection (b) show active bleeding (arrowhead) and irregularity of a mesenteric vessel (arrow). Page 16 of 29

17 Fig. 13: 31-year-old man with blunt abdominal trauma. Axial contrast-enhanced MDCT (a) and coronal maximum-intensity projection (b) show focus of contrast extravasation with fluid collection and adjacent stranding, consistent with mesenteric and epiploic laceration. Signs of bowel shock are also noted. At exploratory laparotomy, a bleeding mesenteric laceration was confirmed. During bleeding containment maneuvers, a short small bowel segment underwent ischemia and was resected. Page 17 of 29

18 Fig. 14: Epiploic hematoma in anticoagulated patient presenting with acute abdominal pain. Axial contrast-enhanced (a), maximum-intensity projection (b) and sagittalreformatted (c) CT images reveal signs of active bleeding (arrows) within an epiploic hematoma. Diagnosis was confirmed at laparoscopic surgery. Page 18 of 29

19 Fig. 15: Spontaneous hemobiia. Endoscopic view (a) shows spontaneous hemorhage through the duodenal papilla. Axial contrast-enhanced CT scan (b) reveals a cystic lesion within the pancreatic body. Maximum-intensity projection of angiographic MDCT (c) reveals a small pseudoaneurysm of the splenic artery, which is confirmed at conventional angiography (d). Partial resection of the body and tail of the pancreas was performed, with excellent clinical outcome. Page 19 of 29

20 Fig. 16: Spontaneous retroperitoneal bleeding in a patient who presented with upper abdominal pain and hypotension. Axial contrast-enhanced CT (a, b) demonstrates a retroperitoneal hematoma containing a small focus of active bleeding. Coronal reformatted image (c) optimally demonstrates the location and extent of the hematoma. Page 20 of 29

21 Fig. 17: Spontaneous extraperitoneal bleeding in an anticoagulated patient. Axial contrast-enhanced CT (a, b, c, d) shows a large hematoma within the left psoas compartiment, extending into the posterior pararenal space, preperitoneal space, pelvic extraperitoneal recesses and peritoneal cavity. Small enhancing vessels and/or bleeding focus are outlined (circles) Page 21 of 29

22 Fig. 18: Secondary aorto-enteric fistula in a patient with prior aortic surgery. Axial contrast-enhanced images (a, b) reveal signs of active bleeding into the duodenal lumen. Aortoenteric fistula is an uncommon but life-threatening complication of aortic reconstructive surgery. Page 22 of 29

23 Fig. 19: Tipe III endoleak. Axial CT angiography (a), coronal maximum-intensity projection (b) and volume-rendering (c) reveal a small focus of active extravasation (arrows) outside the lumen of the endoluminal graft but within the aneurysm sac. Page 23 of 29

24 Fig. 20: Pelvic fracture. Axial (a) and reformatted coronal (b) contrast-enhanced CT images show right obturator ring fracture, extraperitoneal hematoma and intramuscular hematoma. A small focus of active bleeding is seen in the ischiorectal fossa. Patient was treated conservatively. Page 24 of 29

25 Fig. 21: Pelvic fracture (type B, according to Tile classification). Axial contrast-enhanced CT (a) shows pubic diastasis and obturator ring fracture. Volume-rendering (b) also displays mild left sacroiliac diastasis, and bilateral transvese fractures. Maximumintensity projection (c) reveals two small foci of active bleeding in the region of internal pudendal artery (red circle) and iliolumbar artery (yellow circle). Patient underwent percutaneous embolization. Page 25 of 29

26 Fig. 22: Rectus sheath hematoma in an anticoagulated patient. Axial contrast-enhanced CT (a, b) shows a right rectus sheath hematoma, extending into the extraperitoneal espace of Retzius. A small focus of active bleeding is noted within the rectus sheath hematoma. Page 26 of 29

27 Fig. 23: Axial contrast-enhanced CT (a, b) show spontaneous hematoma of the lateral abdominal wall, involving the latissimus dorsi, oblique, and rectus muscles. Coronal reformatted image (c) shows the craniocaudal extension of the hematoma, which contains a small foci of active extravasation (arrow). Page 27 of 29

28 Conclusion 64-slice multidetector CT studies are useful for precise depiction of abdominal active bleeding in many patients. Also, they may help identify the bleeding vessel and the accompanying lesions, thus guiding potentially lifesaving surgical or endovascular repair. Personal Information References 1. Kertesz J, Anderson S, Murakami A, Pieroni S, Rhea J, Soto J. Detection of vascular injuries in patients with blunt pelvic trauma by using 64-channel multidetector CT. Radiographics 2009;29: Hamilton J, Kumaravel M, Censullo M, Cohen A, Kievlan D, West O. Multidetector CT evaluation of active extravasation in blunt abdominal and pelvic trauma patients. Radiographics 2008;28: Lubner M, Menias C, Rucker C, Bhalla S, Peterson C, Wang L, Gratz B. Blood in the Belly: CT Findings of hemoperitoneum. Radiographics 2007; 27: Daly K, Ho C, Persson L, Gay S. Traumatic retroperitoneal injuries: Review of multidetector CT findings. Radiographics 2008;28: Anderson SW, Lucey BC, Rhea J, Soto JA. 64-MDCT in multiple trauma patients: imaging manifestations and clinical implications of active extravasation. Emerg. Radiol 2007;14: Yoon W, Kim JK, Jeong YY, Seo JJ, Park JG, Kang HK. Pelvic arterial hemorrhage in patients with pelvic fractures: detection with contrast-enhanced CT. Radiographics 2004;24(6): Lane MJ, Katz DS, Shah RA, Rubin GD, Brooke Jeffrey R. Active arterial contrast extravasation on helical CT of the abdomen, pelvis and chest. AJR 1998;171: Brooke Jeffrey R, Cardoza JD, Olcott EW. Detection of active intraabdominal arterial hemorrhage: value of dynamic contrast enhanced. AJR 1991;156: Page 28 of 29

29 9. Yoon W, Jeong YY, Shin SS, Lim HS, Son SG, Jang NG, Kim JK, Kang HK. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multidetector row helical CT. Radiology 2006;239(1): Anderson SW, Soto JA, Lucey BC, Burke PA, Hirsch EF, Rhea JT. Blunt trauma: feasibility and clinical utility of pelvic CT angiography performed with 64-detector row CT. Radiology 2008;246(2): Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of Bowel and mesenteric blunt trauma with multidetector CT. Radiographics 2006;26: Page 29 of 29