Abdominal Trauma

by Hetal Verma, MD

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    00:01 So imaging is very important in the diagnosis of abdominal trauma.

    00:04 Patients often present for abdominal trauma and a CT scan is usually the first image that's performed in these patients.

    00:10 It's best evaluated by a contrast enhanced CT and often in patients presenting with trauma, oral contrast is not indicated for a couple of reasons.

    00:20 It doesn't really add much to the scan and also because oral contrast needs to be administered about one a half to two hours prior to the scan and a patient presenting with trauma, we don't wanna wait that long before performing a CT.

    00:32 It's important to remember that without intravenous contrast however parenchymal injury can be missed so it's very important to do a CT scan with intravenous contrast in these patients coming in for trauma.

    00:43 Often times, depending on how severe the trauma is, even in patients that have a contraindication to intravenous contrast such as renal failure, we would still provide the contrast and then deal with the complication afterwards just so that we don't miss an abnormality.

    00:57 So the commonly affected organs of trauma, the liver, spleen, and the kidneys and urinary bladder are the 3 most commonly affected organs.

    01:08 Any organ can be affected by trauma but these are really the ones that we see most often.

    01:13 Liver trauma is actually one of the most deadly causes of abdominal organ injury.

    01:20 It's also the most commonly injured abdominal organ.

    01:23 So what are some imaging findings of liver trauma? You can have a liver laceration, you can have a subcapsular hematoma, we can have an intrahepatic hematoma so it's a collection of blood within the liver, you can have hemoperitoneum and this is usually caused by the liver laceration or the hematoma.

    01:42 It's almost a secondary finding so the bleeding that you have within the liver or surrounding the liver can then extend to the rest of the peritoneal cavity.

    01:49 And you can also have a liver infarction.

    01:51 So let's take a little bit of a better look at some of these findings.

    01:56 Here is a CT scan with contrast of the abdomen and pelvis performed on a patient that presented with a motor vehicle accident.

    02:02 So what do you see here within the liver? Take a good look at this image.

    02:13 You can see that there is actually multiple, irregular low density linear areas that extend out to the periphery from the liver.

    02:21 And this is an example of a liver laceration.

    02:25 So this is an important finding that can be seen in patients presenting with trauma and this eventhough you don't actually see any kind of bleeding surrounding the liver at this time, this can bleed quite significantly and may need to be embolized.

    02:36 Let's take another look at this example.

    02:41 So we have an axial and a coronal CT image and you see this area of high density within a low density collection right here and this is again a patient that's presenting with abdominal trauma.

    02:54 So what does this represent and what is that high density area within that area? So this is an example of an intrahepatic hematoma which is a collection of blood within the liver parenchyma.

    03:07 Initially, it's high density and then eventually it progresses to a low density area.

    03:13 The area of high density within it actually represents active extravasation of contrast and this is very important to recognize because it means there is an actively bleeding artery within this area and needs to be embolized immediately before this patient can have a life threatening bleed.

    03:29 So these are usually taken to interventional radiology and these patients are embolized with coils like we saw before or other types of embolization material that the interventional radiologist uses and the vessel is stopped from bleeding or surgery can be performed to stop the bleeding if interventional radiology is not available.

    03:51 So let's take another look at this image.

    03:53 This is the CT scan and what do you see here? So again, patient is presenting with abdominal trauma and you can see what appears to be normal liver parenchyma here and a lot of abnormality here as well as right here outside of the liver.

    04:08 So what does all this represent? This is an example of a hepatic subcapsular hematoma.

    04:14 So the outside abnormality here is the hematoma and it's a lentiform shaped or lens shaped collection which abuts the liver and can actually push the adjacent liver parenchyma.

    04:24 Adjacent to it within the liver, these linear low density areas represent liver laceration.

    04:30 So splenic trauma is often the result of hemorrhage due to high vascularity of the spleen.

    04:39 This is also a very important finding, the spleen is actually even more vascular than the liver and a trauma to this area can really result in life threatening hemorrhage.

    04:47 So what are some imaging findings of a splenic trauma? Very similar to liver trauma so we can have a splenic laceration, we can have a subcapsular hematoma, we can have a splenic hematoma which is again a hematoma within the splenic parenchyma, and we can have hemoperitoneum again very similar to the liver where any kind of injury to the spleen can bleed and results in blood extending into the peritoneal cavity.

    05:13 So this is an example of a splenic subcapsular hematoma.

    05:17 It's very similar in appearance to hepatic subcapsular hematoma.

    05:22 It's a lentiform shaped collection that abuts the spleen and it actually pushes on the splenic parenchyma so you can see the spleen is almost being pushed out of the way by this collection.

    05:31 Again, this can be very vascular and can bleed quite significantly so this is an important finding to recognize when a patient comes in with trauma.

    05:40 Let's move on to renal trauma.

    05:42 Patients with renal trauma nearly always present with hematuria after traumatic injury. Some of the imaging findings of renal trauma include laceration, subcapsular hematoma, perinephric hematoma, renal contusion which is again a collection of blood within the kidney, or renal infarction which is loss of the blood supply to the kidney resulting in death of the renal tissue. So this is an example of a renal laceration.

    06:15 You can see a low density area within the kidney that extends out to the periphery and results in what looks like a subcapsular hematoma down here.

    06:24 Urinary bladder trauma is also somewhat frequently seen in patients that have pelvic fractures.

    06:35 So this is another important finding to recognize or to be aware of.

    06:38 To evaluate for urinary bladder trauma, a CT cystogram is actually the best study and this is a CT that's performed after injection of contrast into the urinary bladder down through a foley catheter and that helps to fully distend the bladder.

    06:52 You want the bladder to be as fully distended as possible so that you can see any small areas of leakage from it due to trauma.

    06:59 If there is a bladder injury then contrast will extravasate out and there are a couple of different types of extravasation.

    07:05 So the 2 major types are extraperitoneal which is the most common and it occurs after a puncture into the urinary bladder which can happen from a pelvic fracture.

    07:15 And there is intraperitoneal which usually occurs more from a blow to the pelvis without actual direct puncture.

    07:21 So let's take a look at this case.

    07:24 What do you see here? So you can see this is the urinary bladder right here and this image is partially decompressed so it doesn't appear like a full round circle which what a bladder would look like when it's fully distended.

    07:43 Right here you can see the tip of a foley catheter and you can actually see a small amount of air within the urinary bladder which may be seen because of foley catheter insertion.

    07:52 Any kind of manipulation to the bladder can result in a small amount of air within it, but then you see all of these high density anterior to the bladder it actually extends out into the subcutaneous tissues.

    08:03 So this is an example of extraperitoneal bladder rupture.

    08:07 Contrast is seen extravasating out of the extraperitoneal space and it's due to a pelvic fracture that impaled the bladder so we can see contrast air and the tip of the foley catheter within the urinary bladder. So what do you see on this image here? This is a coronal CT scan of the pelvis and a patient that's presenting with trauma.

    08:28 You can see here a normal looking urinary bladder that's filled with contrast.

    08:33 However, it's not fully distended on this image.

    08:36 And then you can see here high density material within the peritoneal cavity that's surrounding all of the structures within the pelvis, so you see a normal loop of small bowel here, you see colon here, and then all around it is high density material.

    08:51 So what does this represent? This is an example of intraperitoneal bladder rupture.

    08:57 So contrast is seen within the intraperitoneal space and it's due to an intraperitoneal bladder rupture which happens from a direct blow to the pelvis.

    09:05 So here's another case of a patient presenting with abdominal trauma.

    09:11 What do we see here? So take a pause, take a good look at this image, and describe the findings here.

    09:26 So here we have a very large splenic hematoma.

    09:30 You have perisplenic hemorrhagic fluid and the reason that we know that this is hemorrhagic fluid is you can see that it's slightly higher density than the density of simple water.

    09:39 If you look here, this is a slightly lower density area while if you look here this is slightly higher density.

    09:45 This right here is normal spleen. There's also, if you look very carefully, a small focus of active extravasation right next to the spleen.

    09:55 Again, this is a very important finding as this needs immediate embolization so that the patient doesn't suffer from life threatening hemorrhage.

    10:01 So we've reviewed some of the common findings of abdominal trauma in this lecture.

    10:06 Again, many organs can be injured with trauma and it's very important to take a look at everything but the most common ones are the ones that we discussed today and the liver and spleen in particular are the ones that are most life threatening.

    About the Lecture

    The lecture Abdominal Trauma by Hetal Verma, MD is from the course Abdominal Radiology. It contains the following chapters:

    • Liver Trauma
    • Splenic and Renal Trauma
    • Urinary Bladder Trauma

    Included Quiz Questions

    1. Patients with high density within a laceration or hematoma need to be urgently embolized.
    2. CT scans should be performed without intravenous and oral contrast.
    3. Lacerations present as high-density linear areas with the liver, spleen or kidney.
    4. The spleen is the most commonly injured abdominal organ.
    5. A CT urogram should be performed to evaluate for urinary bladder injury.
    1. Atrophy
    2. Intrahepatic hematoma
    3. Infarct
    4. Hemoperitoneum
    5. Liver laceration
    1. Subcapsular hematoma
    2. Laceration
    3. Incidental finding
    4. Splenic hematoma
    5. Infarct
    1. Renal laceration
    2. Perinephric hematoma
    3. Renal contusion
    4. Renal infarction
    5. Subcapsular hematoma
    1. Urinary bladder trauma is most commonly found with blunt abdominal trauma.
    2. A CT cystogram is the best study for evaluating a urinary bladder injury.
    3. CT cystogram is performed after injecting contrast into the urinary bladder through a foley catheter to fully distend the bladder.
    4. Extraperitoneal rupture is the most common type of bladder injury.
    5. Intraperitoneal rupture occurs from a blow to the pelvis without a direct puncture.

    Author of lecture Abdominal Trauma

     Hetal Verma, MD

    Hetal Verma, MD

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