Imaging in abdominal trauma Dilyana Baleva Medical University Varna Landesklinikum Mistelbach-Gänserndorf
Learning objectives Definition, demographics and etiology Imaging modalities and protocols Common findings Organ specific findings Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 2
Definitions ü Trauma is a physical injury caused by transfer of energy to and within the person involved; kinetic, thermal, radiation ü Trauma is the major cause of death prior to the fourth decade of life ü Men > women, risk-taking behavior (e.g. involving transportation ± alcohol) Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 3
Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 4
Etiology ü Blunt abdominal trauma (BAT) MVA (motor vehicle incidents) 75% fall from height 10% interpersonal violence, blow to the abdomen 12-15% other sports injury ü Penetrating abdominal trauma (PAT) stab injuries gunshot injuries blast injuries ü Penetrating trauma has a much higher rate of fatality overall ü Gunshot wounds have about 8x fatality rate than stab wounds Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 5
Clinical evaluation ü Notoriously unreliable ü Comorbid injuries, present chronic disease ü Limb fractures may mask the abdominal symptoms ü Impairment of consciousness/ communication ü Drug/alcochol contaminaton Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 6
FAST (focused assessment sonography for trauma) ü Four pouches: hepatorenal splenorenal rectovesicular subxyphoid ü Result : positive or negative 2 1 ü Extended FAST hemothorax and pneumothorax detection 3 4 Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 7
FAST Pros Cons ü High specifity and sensitivity in detecting hemoperitoneum (150-300 ml) ü Quick (2 min) ü Cheap ü No radiation ü Helps triaging decisions in trauma patients large hemoperitoneum à laparotomy ü Low sensitivity in detecting specific organ lesions (about 50%) especially bowel damage ü Limited by obese patients ü Cannot detect retroperitoneal hemorrhage < 250 ml ü Lack of clear evidence of contribution to survival rate Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 8
ü Clinical evaluation ü FAST ü Abdominal and Chest X-Ray ü Paracenthesis ü Diagnostic peritoneal lavage ü Diagnostic laparoscopy CAVE: Limitation: retroperitoneal trauma ü CT Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 9
ü Golden standard, working horse for BAT and for penetrating trauma ü Helical CT, MDCT ü Next to ER Contraindications: Clear indication for laparotomy (incl. ++ FAST) Hemodynamically unstable patient Allergy against contrast media There is no life saving imaging! Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 10
CT ü Wet reporting, get involved! ü Closely monitor investigation ü Immediately report important findings ü Final report when time allows Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 11
CT protocol for abdomen CT ü Single bolus injection method 100-150 ml i.v. contrast, acquisition in portovenous phase (ca. 70-80 sek) No oral contrast material +/- Delayed scan (5-10 min) Yes by detected traumatic lesion - urinary tract and collecting system injuries, vascular injuries, pseudoaneurism +/- CT cystography by suspected rupture of the bladder +/- additional scan after rectal contrast filling in penetrating trauma? Arterial scan 25-30 sek not widely applied by severe trauma mechanism (strong deceleration) for better visualization of vessel trauma Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 12
ü Pneumoperitoneum ü Hemoperitoneum ü Hemorrhage ü Contusion ü Laceration ü Devascularisation ü Active bleeding Stephen Ledbetter, Robin Smithuis radiologyassistant. nl Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 13
Pneumoperitoneum ü Air transmitted from the chest in pneumothorax is the most common cause of intraperitoneal air in a trauma patient ü At seat belt trauma and small bowel injury ü Not indicative of hollow organ rupture! ü Lung window! Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 14
Hemoperitoneum ü Unclotted blood 30-40 HE ü Clotted blood 45-70 HE ü Contrast - > 100 HE v Sentinel clot CAVE: Low density (<20HE) by anemia, preexisting ascites Fluid in Douglas space in in reproductive age Small quantity free fluid in 5-10% of BAT, no clinical significance* *Drasin TE, Anderson SW, Asandra A, Rhea JT, Soto JA. MDCT evaluation of blunt abdominal trauma: clinical significance of free intraperitoneal fluid in males with absence of identifiable injury. AJR Am J Roentgenol 2008;191(6):1821 1826. How much blood? Active extravasation? Rate of bleeding? More indicative of needed surgical treatment Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 15
Use narrow window! Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 16
Contrast blush (arterial blush) ü Area of high density, within 10 HU compared to a nearby artery (or aorta) Active arterial extravasation Post-traumatic pseudoaneurysm Post-traumatic AV fistula ü Pseudoaneurysm or AV fistula the contrast will wash away with the bloodstream ü Active arterial extravasation, the contrast will not wash away Delayed scan Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 17
Contrast blush (arterial blush) Andrew Dixon Radiopedia.org Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 18
Shock Hypoperfusion complex: ü Hyperattenuation of the bowel wall (mucosa) Exclude free fluid, mesenterial hematoma, free gas!! ü Non or low enhancement of the spleen ü Hyperattenuation of the adrenal glands, pancreas ü Persistent strong nephrogramm without excretion ü Collapse of the IVC (< 9 mm in at least 3 consecutive slices) best indicatorof hypovolemia ü Small Aorta ü Small SMA with increased enhancement Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 19
Shock Next day Mild hypoattenuation of the renal cortex 10 days later Renal cortical necrosis Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 20
Organ injuries Spleen Liver Kidneys Small bowel and/or mesentery Bladder Colon and/or rectum Pancreas Diaphragm Major vessels Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 21
Spleen ü AAST (American association for surgery in trauma) ü Widely used to grade the injuries of the solid organs ü Accounts for the size and location of lacerations and hematomas ü Unification of the evaluation of severity Does not include active bleeding, contusions, posttraumatic splenic infarcts Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 22
Spleen Fracture reaching two surfaces or >3 cm, Grade III Laceration Grade II ü Splenic preservation is the current standard of care Active bleeding (contrast extravasation) à operative management Shattered spleen Grade V Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 23
Spleen subcapsular hematoma AAST Grade II Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 24
Spleеn lobule versus laceration Invaginated egdes Irregular edges Sharp margins Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 25
Liver ü Second most common in BAT ü 70-90% minor injuries ü Today about 80% is managed non-operatively ü Right lobe >> left lobe, posterior area most common Impact upon outcome: 3 or more segments significant injury Subcapsular location of the lacerations, vs. central Active bleeding Hemoperitoneum Extension to porta hepatis, major vein or gall bladder Choleperitoneum by gallbladder or bile duct rupture (ERCP, biliary scintigraphy) Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 26
Liver Laceration, Grade 3 Laceration, Grade 2 Right lobe devascularisation, Grade 4 Subcapsular hematoma, Grade 4 Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 27
Liver injury or not (only)? Giant hemangioma Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 28
Kidneys ü Third most common in BAT, also common in PAT ü 98% non surgical treatment (NOM) ü Hematuria (gross or microscopic) ü Delayed imaging essential by present injury collecting system! 1 4 2 3 5 AAST Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 29
Kidneys Grade IV Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 30
Kidneys Grade III (AAST) Distal ureter contrasted à partial tear of collecting system, no complete avulsion Delayed phase Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 31
Follow up in 1 month Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 32
Kidneys Large retroperitoneal hematoma Pseudoaneurism Partial devascularisation (infarction) AAST II Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 33
Bladder rupture ü Extra and/or intraperitoneal ü Cystography method of choice 1. Empty the bladder 2. 300-400 ml diluted contrast through Foley catheter 3. CT scan of the pelvis, acquisition may be acquired simultaneously with the delayed phase scan Surgical treatment Intraperioneal rupture Extraperitoneal rupture Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 34
Pancreas ü Rare - BAT (0,2%), 1-2 % in PAT ü Usually of part of package trauma ü Direct signs linear hypodense lacaration, hypodense hematoma, contrast blush, diffuse or focal enlargement ü Indirect signs peripancratic fat stranding, injuries of adjacent structures A pancreatic laceration may be missed on the initial scan thin and multiplanar reconstructions Complementary techniques ERCP Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 35
Pancreas Fracture, AAST III Package injury AAST II + V Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 36
Bowel and mesentery ü More common in PAT, about 5% of BAT ü Peritoneal contamination, surgical repair to prevent peritonitis and septic shock ü Imaging signs: Interloop fluid or hematoma (sentinel hematoma) Mesenteric stranding, air Mesenteric contrast blush Focal bowel wall thickening Bowel wall interruption Free gas Retroperitoneal hematoma by injury of retroperitoneal bowel segment Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 37
Bowel and mesentery A large mesenteric hematoma requires surgical treatment to avoid Vascular compression with bowel ischemia Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 38
Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 39
Bowel and mesentery Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 40
Seatbelt sign Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 41
Diaphragmatic injuries ü Rare, PAT>> BAT, left >> right ü Easily missed, clinically silent ü MPRs!! ü Herniation of abdominal viscera intrathoracic, bowel strangulation ü If undiagnosed high mortality rate Dependant viscera sign Collar sign Dangling diaphragm Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 42
Take home ü There is no life saving imaging! ü CT with KM with at least portovenous phase is the mainstay in the imaging diagnostic. Complementary role FAST, delayed CT scan, arterial CT scan, rectal filling ü AAST ü Actively search for active bleeding (contrast blush!) ü Lung window, narrow window, MPRs ü Decrease in the surgical treatment, armed surveillance ü Surgery needed in hollow organ injury, in active bleeding, intraperitoneal bladder rupture, AAST IV and V for the solid organs ü Trauma is the main cause of death in the young population and source of very high health system costs ü Trauma is avoidable! Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 43
THANK YOU! Emergency Radiology - 6th meeting of the residents in radiology, Acibadem City Clinik Tokuda, Sofia, June 2-3, 2017 44