1. Consultant Radiologist Riyadh Military Hospital
Abdominal trauma
Role of CT
Dr. Ahmed Refaey
Consultant Radiologist
Riyadh Military Hospital
MBBCh, MS, FRCR

2. Format of the lecture Categorization of abdominal trauma patients
CT technique
CT findings
Illustrated cases

3. Categories of abdominal trauma patients
Category A
- hemodynamically unstable patients
Category B
- hemodynamically stable patients
Category C
- patients with hematuria

4. Category A “hemodynamically unstable”
Need rapid clinical evaluation and immediate resuscitation with volume replacement
If not responding, they should go immediately to OR without imaging
If they respond ( become hemodynamically stable )-- Category B

5. Category B “ hemodynamically stable”
High clinical suspicion of intra-abdominal injury
------ CT not U/S
Low clinical suspicion of intra-abdominal injury
------ U/S not CT

6. High clinical suspicion of intra-abdominal injury

7. don’t ask for U/S
- miss 25% of liver injuries
- miss 62 % of splenic injuries
- most renal injuries
- all pancreatic injuries
- all mesenteric injuries
- all gut injuries
- high proportion of retroperitoneal hematoma

8. Low clinical suspicion of intra-abdominal injury

9. U/S If -ve ------- > release the patient from observation
* If +ve ----- CT

11. Category C “ patient with hematuria”
CT cystograhy

12. Categories of blunt abdominal trauma
Category A
- hemodynamically unstable patients
* no radiological imaging
Category B
- hemodynamically stable patients
* CT – if high suspicion
* US – if low suspicion
Category C
- patients with hematuria
* CT cystography

13. CT technique

14. CT in blunt abdominal trauma with or without oral contrast ?
Oral contrast is unnecessary in CT evaluation in patients with acute blunt abdominal trauma

15. Why no oral contrast ?

16. Extravasation of oral contrast in bowel perforation
 0 % - 19 %
Pneumopertoneum
 50 %
* - small perforations may seal quickly and prevent extravasation of contrast and / or air that could then be detected by CT

17. Time delay to diagnosis
Long transit time  non opacification of distal loops
Aspiration of gastric contrast contents with subsequent pulmonary toxic effects
Interference with the diagnosis of contrast blush

18. Oral contrast is unnecessary in CT evaluation in patients with acute blunt abdominal trauma
96. Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004; 56(2):

19. No Is pneumoperitoneum diagnostic of bowel injury?
it is not diagnostic of bowel injury, since air transmitted from the chest in pneumothorax is the most common cause of intraperitoneal air in a trauma patient

20. The sensitivity of CT scan with OC for detection of bowel injuries does not significantly differ from CT without OC
Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG. Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography. Am J Surg. 1993;166:
Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994;168:

21. Trauma protocol

22. Blunt trauma No oral contrast Venous phase ----- 70 sec
Delayed scan if injury present min

23. CT findings

24. The findings to look for
Hemoperitoneum
Contrast blush
Laceration
Hematomas
Contusion
Pneumoperitoneum
Devascularization of organs
Subcapsular hematoma

25. * Laceration :
linear shaped hypodense lesion
* Hematoma :
oval or round hypodense areas
* Contusion :
vague ,ill-defined hpodense area , that is less perfused

26. Contrast blush An area of high density compared to the nearby
vessel representing active arterial extravasation

29. Illustrated cases

30. Splenic injuries

31. Splenic laceration
hemoperitoneum
No contrast blush
…managed non-operatively

32. Lacerations
Hematoma
Hemoperitoneum
No contrast blush
.. Depending on the clinical condition , the patient will be managed

33. Hemoperitoneum
Laceration
Hematoma
Contrast blush
.. Operative management

35. Liver injuries

36. Green arrow: hematoma
Blue arrow : contusion
Yellow arrow: laceration
hemoperitoneum

37. Hematoma
hemoperitoneum
Contrast blush
… managed operatively

38. Does the presence of contrast blush necissetate operative interference ?No
It depends on if it is associated with hemoperitoneum or no

39. Large subcapsular hematoma
Contrast blush
No hemoperitoneum
… Managed non-operatively

40. Contrast extravasation is of great importance especially if it is associated with hemoperitoneum

42. Splenic contusion with contrast blush

43. Laceration
hematoma

44. Lacerations
Hematoma
Hemoperitoneum
Contrast blush
Managed operatively

45. Avulsed Rt hepatic vein
Perforated duodenum

46. Pancreas

47. Pancreatic injury
Rarely an isolated injury, since the pancreas is protected by the liver, spleen and the bony thorax
Usually part of a” package injury “

49. Isolated injury

50. Left sided package injury

51. Rt sided package injury

52. Bowel injury

53. Diagnostic signs of bowel injury
Specific findings
- Oral CM extravasation
………. RARE…..
0 – 19 %

54. Most common findings
- unexplained intraperitoneal fluid
… 84 %
- pneumoperitoneum
… 50 %

55. Other findings
- mesenteric stranding
- bowel wall thickening :
* diffuse : hypoperfusion
* focal : direct trauma

57. Hypovolemia “ shock bowel syndrome “ “ hypoperfusion complex “
Thickened , enhanced small bowel mucosa
Enhanced adrenal glands
Enhanced pancreas
Non enhanced spleen
Non enhanced kidneys
Small IVC
Small aorta and mesenteric arteries

58. However, if the CT is negative for gut injury in the face of a high clinical suspicion, laparoscopy, surgical exploration, or a period of observation plus repeat CT may be used to further evaluate the patient [62-64].

59. Thickened , enhanced small bowel mucosa

60. Hypodense spleen
Hypodense kidneys
Enhanced adrenals

61. Hypodense spleen
Small IVC
Small bowel mucosal enhancement

63. Management

64. Advantages of CT Decide whether a patient needs
- urgent therapeutic surgury
* active hemorrhage
* gut perforation
- therapeutic angiography + embolization
* active vascular hemorrhage
- non-surgical management

65. Historically liver injury was managed surgically, but at laparotomy it was found that 70% of the bleedings had already stopped by the time the surgeons got there
Patients who went for surgery had more transfusions and more complications than patients who were treated non-operatively

66. Today
80% are managed non-operatively

67. Nowadays there is a trend towards non-operative management of blunt abdominal trauma. More than 50% of splenic injury, 80% of liver injury and virtually all renal injuries are managed non-operatively, because patients proved to have better outcomes on the long term related to visceral salvage.

68. Conclusion

69. Categories of blunt abdominal trauma
Category A
- hemodynamically unstable patients
* no radiological imaging
Category B
- hemodynamically stable patients
* CT – if high suspicion
* US – if low suspicion
Category C
- patients with hematuria
* CT cystography

70. CT protocol No oral contrast Venous phase ----- 70 sec
Delayed scan if injury present min

71. CT is used to evaluate patients with blunt trauma not only initially, but also for follow up, when patients are treated non-operatively.

72. References

73. 1. Pachter HL, Knudson MM, Esrig B, et al
1. Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma 1996; 40(1):31-38.
2. Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg 1995; 221(6):
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76. 16. Davis KA, Fabian TC, Croce MA, et al
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77. Published in 2007 in Radiology assistant

78. Thank you