U Blunt Trauma: Spleen
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1 Nordic Forum - Trauma & Emergency Radiology Acute Abdominal Bleeding: Detection with MDCT Lecture Objectives To review the role of MDCT in the assessment of acute bleeding from solid abdominal organs after blunt or penetrating trauma To discuss the MDCT imaging features of acute bleeding after rupture of an abdominal neoplasm Borut Marincek Institute of Diagnostic Radiology niversity Hospital Zurich, Switzerland To illustrate the value of MDCT in defining the site and cause of acute gastrointestinal bleeding Diagnostic Criteria of Acute Bleeding on CE-MDCT Blunt Trauma: Spleen Evidence of CM pooling caused by vascular or visceral organ pathology Attenuation of CM pooling - similar aorta / major adjacent arteries - greater than surrounding parenchyma Types of CM pooling: - focal, diffuse or jet of extravasated CM surrounded by hematoma Snowboard accident: multiple lacerations, extravasated CM & surrounding hematoma, hemoperitoneum Blunt Trauma: Spleen Blunt Trauma: Kidney Snowboard accident: multiple intrasplenic pseudoaneurysms, extravasated CM; coiling of proximal SA hypotensive hemostasis, reperfusion of SA via gastroepiploic art. & short gastric art. Construction worker, fall from 16 m: injuries spleen, kidney, thoracic aorta, pelvic rim Multiple kidney lacerations, extravasated CM & surrounding hematoma, retro-hemoperitoneum
2 Blunt Trauma: Kidney Blunt Trauma: Mesentery Mesenteric avulsions, jet type CM extravasation Kidney laceration in preexisting hydronephrosis, acute bleeding from capsular artery Acute Bleeding After Blunt Abdominal Trauma Clinical Outcome Acute Bleeding After BAT Prevalence of acute bleeding detected on MDCT after 22/165 pts (13%) acute bleeding on MDCT after BAT (Willmann, AJR 2002) BAT 13-18% (Willmann, AJR 2002; Yao, AJR 2002) Spleen > liver > kidney > adrenal > mesentery MDCT diagnosis requires rapid i.v. (>3.0 ml/sec) CM bolus via automated power injector Exact bleeding rate for diagnosis unknown When visualized on MDCT: significant finding, may mandate immediate surgery or image-guided Emergency therapy 16 (73%) Surgery 13 (59%) Selective 3 (14%) Conservative therapy 6 (27%) Delayed selective 1 (5%) Death 5 (22%) Penetrating Trauma: Spleen Penetrating Trauma: Liver Gunshot 2 days after TIPS procedure
3 Penetrating Trauma: Liver Penetrating Trauma: Liver Leriche syndrome, 1 day after laparotomy and extraanatomic aorto-bifemoral Y-Graft Replaced right hepatic artery Bleeding from falciform ligament, perihepatic & perisplenic hematoma Penetrating Trauma: Liver Penetrating Trauma: Kidney A few hours after ESWL for left-sided kidney stones 2 days after ESWL for right-sided kidney stones Bleeding incidence after ESWL 0.28% (Collado, Scand J rol Nephrol 1999) Spontaneous Rupture HCC Spontaneous Rupture Liver Metastasis ndifferentiated pancreatic carcinoma + oral anticoagulation Incidence spontaneous rupture HCC 3-15% (Lai, Arch Surg 2006)
4 Spontaneous Rupture Renal Arteriopathy Spontaneous Rupture Sporadic Renal AML Polyarteritis nodosa Angiomyolipoma >4 cm Bleeding in 50-60% Spontaneous Rupture TS Associated Renal AML Characteristics of Renal AML Tuberous Sclerosis Associated AML Sporadic AML 20 yo, f: multiple & bilateral tumors Mean age Tumor diameter 9 cm 5 cm Multiple tumors 97% 13% Symptomatic 44% 14% acute hemorrhage (Nelson, J of rol 2002) Spontaneous Rupture Ectopic Pregnancy Acute Abdominal Bleeding: Summary (1) Right tube: ectopic pregnancy Left tube: hydrosalpinx ß-HCG Contrast-enhanced MDCT Rapid, noninvasive, and accurate in localizing acute bleeding from solid organs in traumatic and in non-traumatic conditions Can be used as a guidance for subsequent angiographic intervention
5 Gastrointestinal (GI) Bleeding: Definitions GI Bleeding: Diagnostic Imaging Modalities pper GI bleeding / lower GI bleeding: proximal / distal ligament of Treitz Acute/active/massive: clinically stable - unstable Obscure GI bleeding: clinically stable Persisting or recurring bleeding of unknown origin after negative endoscopy of upper and lower GI tract - Overt: see blood (hematemesis, hematochezia, melena) - Occult: + fecal occult blood testing, do not see blood Small bowel barium examination Enteroclysis Tc-labeled RBC scintigraphy Catheter angiography Wireless capsule endoscopy CT enteroclysis Catheter-directed CT angiography MDCT angiography (American Gastroenterological Association, Gastroenterology 2007;133: ) GI Bleeding: Sensitivity Imaging Modalities GI Bleeding: Comparison of Imaging Modalities Acute GIB MDCT angiography 91-92% 1,2 RBC scintigraphy 93% 3 Catheter angiography 40-90% 4 Iodinated iv contrast Bleeding rate detected ml/min Imaging time Localization Invasive Can treat Obscure GIB 24% % % 5,7 RBC scintigraphy No p to 48 hrs worst No 1. Yoon, Radiology 2006;239: Jaeckle, Eur Radiol 2008;18: Zuckier, Sem Nuc Med 2003;33: Laing, RadioGraphics 2007;27: Saperas, Am J Gastroenterol 2007;102: Lin, Gastroenterol Clin N Am 2005; Neu, Am J Gastroenterol 2005;100: MDCT angiography Catheter angiography Yes Yes p to 1.5 min p to 1 min better best No Yes Obscure GI Bleeding: Etiologies Obscure GI Bleeding: Etiologies Commonly overlooked lesions Small intestinal bleeding pper GI lesions Lower GI lesions Cameron s erosions in Angiectasia large hiatal hernias Neoplasms Fundic varices Peptic ulcer Angiectasia Dieulafoy s lesion Gastric antral vascular ectasia (American Gastroenterological Association, Gastroenterology 2007;133: ) <40 yo >40 yo Tumors Angiectasia lymphoma NSAID enteropathy carcinoid Celiac disease adenocarcinoma Meckel diverticulum ncommon Dieulafoy s lesion Hemobilia Crohn disease Hemosuccus pancreaticus Celiac disease Aortoenteric fistula (American Gastroenterological Association, Gastroenterology 2007;133: )
6 Acute pper & Lower GI Bleeding Aortoduodenal Fistula Melana since 3 weeks, aorta-bifemoral Y-graft 11 years ago Acute = hematemesis, melena or hemochezia within 24 hours before MDCT Severe = hemodynamic instability (systol. pressure <100 / pulse rate >100); mild = no hemodynamic instability MDCT (pts) January May 2006 : 4-row (6), 16-row (11), 64-row (1) MDCT protocol: iv CM, arterial & portal venous phase (additional unenhanced scans in 9 pts), no oral CM Acute pper GI Bleeding: MDCT Detection Aortoduodenal Fistula Blood loss / Pathology 1. Severe / aortoenteric fistula 2. Severe / aortoenteric fistula 3. Severe / aortoenteric fistula 4. Severe / aortoenteric fistula 5. Severe / pseudoaneurysm hepatic art. 6. Mild / pseudoaneurysm hepatic art. 7. Mild / pseudoaneurysm gastroduod. art. 8. Mild / pseudoaneursym lienal art. 9. Severe / arteriobiliary fistula 10. Severe / ischemic anastomotic ulcer Bleeding source biliodigest. anastomosis biliodigest. anastomosis cystojejunal anastomosis Treatment excision stentgraft stentgraft stentgraft coiling coiling coiling coiling - Pseudoaneurysm Hepatic Artery Pseudoaneurysm Hepatic Artery 7 weeks after laparotomy & biliodigestive anastomosis for pancreatic carcinoma Hypovolemic shock non-occlusive mesenteric ischemia & pneumatosis
7 Pseudoaneurysm Hepatic Artery Bleeding Complications after Pancreatic Surgery Postoperative arterial bleeding 3-4% (Sohn, J Gastrointest Surg 2003) Coil-, stent-grafting niversity Hospital Zurich (Pfammatter, CIRSE 2005) N = 11, average delay surgery bleeding = 54 days (range days) Type of surgery: Whipple s procedure 6 Partial pancreatic resection 3 Pancreatic head mobilization 1 Hepaticojejunostomy 1 Presentation of acute bleeding: pper GI 2 Lower GI 3 Intraabdominal 6 Initial diagnosis of bleeding source: MDCT 7 DSA 3 Scintigraphy 1 Pseudoaneurysm Gastroduodenal Artery Pseudoaneurysm Gastroduodenal Artery Chronic tuberculous ulceration of Arterio-biliary Fistula Arterio-biliary Fistula Liver cirrhosis & portal hypertension, 1 week after transjugular liver biopsy Liver cirrhosis & portal hypertension, 1 week after transjugular liver biopsy
8 Penetrating Subacute Duodenal lcer Acute Lower GI Bleeding: MDCT Detection Blood loss / Pathology 1. Severe / mucositis 2. Mild / stromal tumor 3. Mild / neuroendocrine carcinoma 4. Mild / nonocclusive ischemic ulcer 5. Severe / nonocclusive ischemic ulcer 6. Severe / ischemic ulcer 7. Severe / diverticulum 8. Mild / varices Bleeding source jejunum ileum ileum cecum cecum transverse colon sigmoid rectosigmoid Treatment coiling excision excision endoscopical clipping TIPS Arrosion gastroduodenal art. Ischemic Mucositis Jejunum Ischemic Mucositis Jejunum Stromal Tumor Ileum Nonocclusive Ischemic lcer Cecum Anticoagulation, 10 d after myocardial infarction: sepsis, acute abdomen art ven
9 Nonocclusive Ischemic lcer Cecum Ischemic lcer Transverse Colon Nonsteroidal anti-inflammatory drugs (NSAID) since 5 weeks art pv Cardiogenic shock 14 d after myocardial infarction Ischemic lcer Transverse Colon Diverticulum Sigmoid Colon Abdominal aortic aneurysm, Plavix loading dose after coronary stent, diverticulosis of sigmoid colon Sigmoid Diverticulum Ectopic Varices Cecum Coil
10 Acute pper & Lower GI-Bleeding Acute Abdominal Bleeding: Summary (2) niversity Hospital Zurich (N=18) MDCT identification of bleeding source: prospectively 15/18 (83%) retrospectively 3/18 (17%) CM extravsation: 11/11 pts with severe bleeding 1/7 pts with mild bleeding Identification of underlying pathology: 15/18 (83%) Contrast-enhanced MDCT Accurate localization of acute upper GI or lower GI bleeding Plays a complementary role to endoscopy for localization of obscure GI bleeding Can be used as a guidance for subsequent angiographic intervention
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