1. Imaging in abdominal
trauma
S
THIYAGARAJA
N

2. Abdominal trauma
• Trauma causes I0% of deaths
worldwide
• The third commonest cause of death
after malignancy and vascular disease

3. Blunt abdominal trauma
• Vehicular trauma (75%)
• Blow to the abdomen (15%)
• Fall from height (6-9%)
• Others
– Domestic accidents
– Fights
– Iatrogenic cardiopulmonary resuscitation

4. Mechanism of injury
• Direct impact or
movement of organs
• Compressive, stretching
or shearing forces
• Solid Organs > Blood
Loss
• Hollow Organs > Blood
Loss and Peritoneal
Contamination
• Retroperitoneal > Often
asymptomatic initially

5. Penetrating abdominal injury
• Accidental
• Homicidal
• Iatrogenic
• Stab wounds
• Gun shot wounds
• Shrapnel wounds
• Impalements

6. Vectors of Force - Trauma "Packages"
Right-sided Midline Left-sided
R hepatic lobe Left hepatic Spleen
R kidney lobe L kidney
Diaphragm Pancreatic Diaphragm
pancreatic body Pancreatic tail
head Aorta
duodenum Transverse
IVC colon
Duodenum
Small bowel

7. Right-sided Trauma "Package

8. ACR Appropriateness Criteria
Category A
• Hemodynamically unstable
• Clinically obvious major abdominal trauma
• Unresponsive profound hypotension
• Resuscitation with volume replacement.
• Not respond to resuscitation
• Operating room without imaging

9. HEMODYNAMIC STABILITY ?
UNSTABLE
INVESTIGATION AVAILABILITY
FAST DPL
FREE BLOOD
FLUID
NO YES
CONTINUE
RESUSCITATION LAPAROTOMY

10. Category B
• Hemodynamically stable
• Mild to moderate responsive
hypotension
• Significant trauma and have at least
moderate suspicion of intra-abdominal
injury based on clinical signs and
symptoms
• These patients should be evaluated
by imaging

11. Category C
• Hemodynamically stable
• Patients with hematuria after blunt
abdominal trauma
• All patients with gross hematuria and
pelvic fracture require additional
imaging of the bladder to exclude
bladder rupture

12. STABLE
CONSCIOUS , RESPONSIVE
YES NO
SUSPICION OF
ABDOMINAL INJURY
NO YES CT
CLINICAL FOLLOW-UP

13. What is FAST?
Focused Assessment with Sonography for Trauma
• A focused, goal directed, sonographic
examination of the abdomen
• Goal is presence of haemoperitoneum
or haemopericardium
• An extension of clinical examination
• Part of the Primary Survey of any
patient with signs of shock or
suspicion of abdominal injury

14. What FAST is NOT
• A definitive diagnostic investigation
• A substitute for CT
• The answer to all our problems

15. The ABCDE of Trauma
• A - Airway
• B - Breathing
• C - Circulation (FAST)
• D - Disability
• E - Environment and Exposure

16. The FAST examination
• FAST examines four areas for free fluid:
 Perihepatic & hepato-renal space
 Perisplenic
 Pelvis
 Pericardium

17. The perihepatic scan
• The hepatorenal
space (pouch of
Morison)
• most dependent part
of the upper
peritoneal cavity
• The probe is placed
in the right mid- to
posterior axillary line
at the level of the
12th ribs.

18. The perihepatic scan

19. The perihepatic scan
Blood shows as a hypoechoic black stripe between the
capsule liver and the fatty fascia of the kidney

20. Perihepatic
scan

21. Perisplenic window
• Transducer
positioned in left
posterior axillary line
between 10th and
11th ribs with beam in
coronal plane.
• Demonstrates
spleen, kidney and
diaphragm
• May be marred by
acoustic shadows
from ribs
• May be improved by
imaging patient whilst

22. Abnormal perisplenic window

23. The pelvic scan
• The pelvic examination
visualises the cul-de-
sac: the Pouch of
Douglas in females
and the rectovesical
pouch in the male
• Most dependent
portion of the lower
abdomen and pelvis,
where fluid will collect
• The transducer is
placed midline just
superior to the
symphysis pubis

24. The pericardial scan
• The pericardial examination screens for
fluid between the fibrous pericardium and
the heart
• The transducer is placed just to the left of
the xiphisternumand angled upwards under
the costal margin.

25. Subxiphoid view of cardiac anatomy

26. Subxiphoid view
Normal subcostal view of pericardium
Positive FAST demonstrating
pericardial effusion

27. Quantification of hemoperitoneum
Huang and associates scoring systems
• Total Score ranging from 0 to 8
• One point was assigned to each anatomic
site in which free fluid was detected during
the FAST scan
• Fluid of more than 2 mm in depth in the
hepatorenal or the splenorenal space was
given 2 points instead of 1
• Floating loops of bowel were given 1 point
• Scores > 3 required exploratory laparotomy

28. Approximately…
• FAST can detect between 100-250ml
0.5 cm in Morison's Pouch = 500ml
1 cm in Morison's Pouch = 1000ml
CT can detect volumes of free fluid as
low as 100ml

29. FAST: Strengths and Limitations
Strengths Limitations
• Rapid (~2 mins) • Does not typically
• Portable identify source of
• Inexpensive bleeding
• Technically simple, • Requires extensive
easy to train training to assess
parenchyma reliably
• Can be performed • Limited in detecting
serially <250 cc intraperitoneal
• Useful for guiding fluid
triage decisions in • Particularly poor at
trauma patients detecting bowel and
mesentery damage
• Difficult to assess
retroperitoneum
• Limited by habitus in
obese patients

30. Extended FAST (eFAST)
• Evaluation of pneumo and
hemothorax in addition to
intraperitoneal injuries.
• Hemothorax
– Ultrasound is much more sensitive for
detecting pleural fluid and can identify
as little as 20mL in the pleural space
• Pneumothorax
– Using ultrasound to evaluate for a
pneumothorax is a relatively new
concept but it is easy to learn

31. eFAST
Anterior Thoracic Views
• Probe is usually placed on the anterior
chest in the 3-4th intercostal space
and midclavicular line
• When ―Sliding sign‖(seashore sign) is
not present, a pneumothorax is
suspected.
• Comparing one side of the chest to
the other may be helpful.

32. DPL Procedure
• To identify
hollow viscus
injury (stomach,
small bowel,
colon) or
diaphragmatic
injury
• Introduce
catheter
infraumbilically
and infuse fluid

33. DPL
• Highly sensitive to intraperitoneal blood,
but low specificity nontherapeutic
explorations.
• Significant injuries may be missed
– Diaphragm
– Retroperitoneal hematomas
– Renal, pancreatic, duodenal
– Minor intestinal
– Extraperitoneal bladder injuries

34. CT in Abdominal Trauma
• Initial evaluation of
– blunt trauma
– penetrating trauma
• Follow up of non-operative
management
• Rule out Injury

35. Abdominal Trauma Protocol
• Blunt injury -deceleration, crush,
weapon (e.g. bat)
– venous phase ~70 secs
– Delayed scan if injury present; ~3-5 mins
• Penetrating injury: knives, gun
– Same as blunt
– Additional scan after rectal contrast
material

36. • The findings to look for in abdominal
trauma are the following:
– Hemoperitoneum
– Pneumoperitoneum
– Contrast blush consistent with active
extravasation
– Subcapsular hematomas
– Laceration
– Contusions
– Devascularization of organs or parts of
organs

37. CT findings of shock
• Collapse of inferior vena cava
• Small aorta
• Persistent nephrogram without excretion
• Hypodense spleen, without enhancement and
normal vascular pedicle
• Increased enhancement of the small bowel wall
• Increased enhancement of the adrenal glands
• Sometimes findings of right cardiac insufficiency
with reflux into the hepatic veins

38. Hemoperitoneum
Hyperdense intraperitoneal fluid collection
0–20HU Preexisting ascites
Bile
Urine
Digestive fluid
Diluted or old blood
30–45HU Free Unclotted intraperitoneal
blood
45–70HU Clotted blood/sentinel clot sign
hematoma
>100 HU Extravasation of contrast medium
(vascular or urinary)

39. Volume
• Detection of fluid in each paracolic
gutter indicates that atleast 200 ml of
blood must be present in each gutter.
• CT visualisation of blood in the
abdomen and pelvis corresponds with
the amounts of more than 500 ml.

40. SENTINEL CLOT SIGN
• Clotted blood
adjacent to the site
of injury is of higher
attenuation value
than unclotted
blood which flows
away .
• When the source of
intraperitoneal
bleed not evident,
the location of
highest attenuating
blood clot is a clue

41. Ascites – Radiographic findings
• Obliteration of inferior edge of liver
• Widening of distance b/n flank stripe &asding
colon
• AF b/n liver & lateral abd wall may result in
visualization of a lucent band –Hellmer‘s sign
• Dog ear sign or ‗Mickey mouse ears‘ sign(100-
150ml)- fluid density lateral to rectal gas
shadows.
• Separation and floating of bowel loops
• Bulging properitoneal flank stripe
• Poor definition of major abd. organs and psoas
• Overall abdominal haziness

42. PNEUMOPERITONEUM
• FREE AIR SENSITIVITY OF
IMAGING STUDIES
– COMPUTED TOMOGRAPHY- 99%
– AP UPRIGHT CHEST RADIOGRAPH -
76%
– LEFT DECUBITUS ABDOMEN
RADIOGRAPH 80 - 90%
– SUPINE ABDOMEN RADIOGRAPH - 56%

43. Signs of a pneumoperitoneum on the
supine radiograph
Right upper quadrant gas
Perihepatic
Subhepatic
Morrison‘s pouch
Fissure for the ligamentum teres
Rigler‘s (double wall) sign
Ligament visualization
Falciform (ligamentum teres)
Umbilical (inverted V sign) medial and
lateral
Urachus
Triangular air
The cupola sign
Football or air dome

44. Spleen
• The spleen is the most commonly
injured organ in blunt abdominal
trauma
• 40% of all solid organ injuries

45. Plain film findings for spleen
trauma
• left lower rib fracture
• The classic triad indicative of acute splenic
rupture
• Left hemidiaphragm elevation
• Left lower lobe atelectasis
• Pleural effusion

46. Parenchymal Contusion
Hypodense intraparenchymal
area with irregular contours

47. Parenchymal Laceration
• Superficial, linear
hypodensity, usually
less than 3 cm in
length
• Fracture - involves
two visceral
surfaces, or if its
length is more than 3
cm
• Multiple fractures -
Scattered spleen

48. Subcapsular Hematoma
• Crescent-shaped perisplenic
• Compresses the splenic parenchyma

49. Vascular Trauma
• The most dangerous vascular
traumatic lesions are arterial lesions
• Irregular area of increased density
relative to background spleen
• Typically the attenuation value is
within 10 HU of the adjacent artery

50. Delayed splenic rupture
• Bleeding due to splenic injury
occurring more than 48 h after blunt
trauma following an apparently normal
CT examination
• Due to ruptures of subcapsular splenic
haematomas.

51. Splenic CT Injury Grading Scale
Grade I Laceration(s) < 1 cm deep
Subcapsular hematoma < 1cm diameter
Grade II Laceration(s) 1-3 cm deep
Subcapsular or central hematoma l-3cm
diameter
Grade III Laceration(s) 3-10 cm deep
Subcapsular or central hematoma 3-10 cm
diameter
Grade Laceration(s) > 10 cm deep
IV Subcapsular or central hematoma > 10cm
diameter
Grade V Splenic tissue maceration or devascularization

52. A way to remember this system is:
• Grade 1 is less than 1 cm.
• Grade 2 is about 2 cm (1-3 cm).
• Grade 3 is more than 3 cm.
• Grade 4 is more than 10 cm.
• Grade 5 is total devascularization or
maceration.

53. The shortecommings of this grading
scale are:
• Often underestimates injury extent.
• Significant inter observer variability.
• Does not include:
– Active bleeding
– Contusion
– Post-traumatic infarcts
• Most importantly: no predictive value
for non-operative management

54. Contrast blush
• A contrast blush is defined as an area of
high density with density measurements
within 10 HU compared to the nearby
vessel (or aorta).
• The differential diagnosis is:
– Active arterial extravasation
– Post-traumatic pseudoaneurysm
– Post-traumatic AV fistula

55. Splenic CT Injury Grading Scale
Grade I Laceration(s) < 1 cm deep
Subcapsular hematoma < 1cm diameter
Grade II Laceration(s) 1-3 cm deep
Subcapsular or central hematoma l-3cm
diameter
Grade III Laceration(s) 3-10 cm deep
Subcapsular or central hematoma 3-10 cm
diameter
Grade Laceration(s) > 10 cm deep
IV Subcapsular or central hematoma > 10cm
diameter
Grade V Splenic tissue maceration or devascularization

56. American Association for the Surgery of Trauma ( AAST)
organ injury severity scale grading system for splenic injury
Grade 1 Small subcapsular haematoma, less than 10% of
surface area
Grade 2 Moderate subcapsular haematoma on 10 –50% of
surface area; intraparenchymal haematoma less than 5
cm in diameter; capsular laceration less than 1 cm deep
Grade 3 Large or expanding subcapsular haematoma on greater
than 50% of surface area; intraparenchymal
haematoma greater than 5 cm diameter; capsular
laceration 1 –3cm deep
Grade 4 Laceration greater than 3 cm deep; laceration involving
segmental or hilar vessels producing major
devascularization ( >25%)
Grade 5 Shattered spleen; hilar injury that devascularizes the
spleen

57. SPLENIC INJURIES - Management
• Often arterial hemorrhage, therefore nonoperative
management less successful.
• Predictive factors for nonop success:
– Localized trauma to flank/abdomen
– Age<60
– No associated trauma precluding obs
– Transfusion <4u rbcs
– Grade I-III
• Grade IV-V: almost invariably require operative
intervention
• Delayed hemorrhage (hours to weeks post-injury):
8-21%

58. Liver
• The liver is the second most
commonly injured organ in abdominal
trauma.
• Between 70 and 90% of hepatic
injuries are minor
• Right lobe most commonly affected

59. • Associated injuries:
2/3 have hemoperitoneum
45% have associated splenic injury
33% have rib fractures
Duodenal or pancreatic injury
Biliary injury: hematobilia, biloma, biliary
ascites, bile duct disruption
• Ultrasound sensitive for grade 3 or
greater

60. Radiological overview of liver
injury:
• Right lobe> left lobe; 3:1
• Posterior segment most common
(fixed by coronary ligament)
• CT imaging method of choice

61. Features with impact on the
management and the prognosis
• Number of segments involved by the
lacerations (significant if at least three
segments are involved)
• Central or subcapsular location of the
lacerations and contusions
• Extension of lesions within the porta
hepatis or the gallbladder fossa
• Importance of the hemoperitoneum
• Vascular lesions with active bleeding or
sentinel clot sign

62. The CT report should
• Precisely mention the lobar or
segmental
• Superficial or central topography of
the contusions
• Along with their extent and location in
relation to the vascular elements.

63. Classification
(AAST)
I-Subcapsular hematoma<1cm,
superficial laceration<1cm deep.

64. II-Parenchymal laceration 1-3cm deep,
subcapsular hematoma1-3 cm thick.

65. III-Parenchymal laceration> 3cm deep
and subcapsular hematoma> 3cm
diameter.

66. IV-Parenchymal/supcapsular
hematoma> 10cm in diameter, lobar
destruction,

67. V- Global destruction or devascularization
of the liver.

68. VI-Hepatic avulsion

69. Periportal Edema
• Periportal hypodensities running in
parallel to the portal branches
• Causes
– Diffusion from intraparenchymal bleeding
– Dilatation of periportal lymph vessels
– Vascular or focal bile duct dissection

70. Complications
• Biloma
• Delayed hemorrhage
• Hemobilia
• Hepatic infarcts
• Pseudoaneurysm
• AV fistula

71. • Indications for surgical treatment in
liver trauma
– Shock
– Active venous bleeding
– Trauma of the gallbladder
– Choleperitoneum
– Abdominal surgery necessary for other
causes

72. Retroperitoneal Hemorrhage
• Retroperitoneal hemorrhage may
arise from injuries to major vascular
structures, hollow viscera, solid
organs, or musculoskeletal structures
or a combination

73. Small zone I (central)
retroperitoneal hematoma

74. Large zone I (central)
retroperitoneal hematoma
with active extravasation

75. Large zone II (lateral)
retroperitoneal hematoma

76. Pancreas
• Uncommon injury
• 1.1% incidence in penetrating trauma
and only 0.2% in blunt trauma.
• Rarely an isolated injury.
• Usually part of a 'package injury'

77. Laceration of the pancreatic
neck without duct injury

78. Pancreatic transection (neck)
with duct injury

79. Subtle pancreatic contusion

80. Indirect Signs
• Edema with global pancreatic enlargement
and loss of lobulation
• Peripancreatic fat infiltration
• Peripancreatic fluid, especially if it is
located around the SMA or the omental
bursa
• Hematic fluid between the dorsal surface of
the pancreas and the splenic vein
• Thickening of the left anterior pararenal
fascia or fluid in the anterior pararenal
space
• Concomitant duodenal injury

81. AAST GRADING OF PANCREAS INJURY
Type of
Grade Injury Description of Injury
I Hematoma Minor contusion without duct injury
Laceration Superficial injury without duct injury
II Hematoma Major contusion without duct injury or tissue
loss
Laceration Major laceration without duct injury or tissue
loss
III Laceration Distal transection or parenchymal injury with
duct injury
IV Laceration Proximal transection or parenchymal injury
with probable duct injury (not involving
ampulla)b

82. Imaging of Renal Trauma
• Computed tomography (CT) is the
modality of choice in the evaluation of
blunt renal injury
• Injury to the kidney is seen in
approximately 8%– 10% of patients
with blunt or penetrating abdominal
injuries

83. Renal criteria for performing
CT in abdominal trauma
• Macroscopic hematuria
• Microscopic hematuria with shock
• Important renal ecchymosis or fracture of
the lumbar transverse process
• Open trauma involving the retroperitoneum
• Mechanism of deceleration (risk of pedicle
injury)
• In children all types of posttraumatic
hematuria

84. Computed Tomography
• Early and delayed CT scans through the
kidneys are necessary
• Excretory-phase contrast (3min)
• The preferred technique
– Helical CT performed from the dome of the
diaphragm
• Scanning parameters include
– Collimation of 7 mm,
– Pitch of 1.3,
– Image reconstruction intervals of 7 mm.

85. Subcapsular hematoma
(category I)
Crescent shaped hyperdensity, located
in the periphery of the kidney

86. Laceration
• Hypodense, irregularly linear areas,
typically distributed along the vessels
and filled with blood.
• They are best analyzed at arterial
phase
– Superficial (<1 cm from the renal cortex)
– Deep (>1 cm from the renal cortex)
– Renal medulla
– Collecting tubule system

87. Simple renal laceration
(category I)

88. Major renal laceration without
involvement
of the collecting system (category II)

89. Major renal laceration involving
the collecting system (category II)

90. Multiple renal lacerations
(category III)

91. Shattered kidney (category III)

92. Segmental Infarct
• Triangular parenchymal area, with a
widest part at the cortex, which is not
enhanced during the different phases,
with clear delineation

93. Segmental renal infarction
(category II)

94. Traumatic occlusion of the main
renal artery (category III)

95. Traumatic occlusion
of the main renal
artery (category III)

96. Active arterial extravasation
(category III)

97. Vein Pedicle Injury
• Incomplete or absent opacification of
the renal vein
• Persistent nephrogram
• Reduction in excretion
• Nephromegaly

98. Laceration of the renal vein
(category III)

99. Urinoma/Urohematoma
• Presence of a more or less significant
breach of the collecting tube system,
with urine escape reflected by
extravasation of contrast medium on
delayed imaging, in an extrarenal
location

100. Avulsion of the ureteropelvic
junction (category IV)

101. AAST organ injury severity scale grading system for kidney
injury
Grade 1 Contusion or contained and non -expanding
subcapsular haematoma, without parenchymal
laceration; haematuria
Grade 2 Non -expanding, confined, perirenal haematoma or
cortical laceration less than 1 cm deep; no urinary
extravasation
Grade 3 Parenchymal laceration extending more than 1 cm into
cortex; no collecting system rupture or urinary
extravasation
Grade 4 Parenchymal laceration extending through the renal
cortex, medulla and collecting system
Grade 5 Pedicle injury or avulsion of renal hilum that
devascularizes the kidney; completely shattered
kidney;

102. BLADDER INJURY

103. CT Cystography
• Empty the bladder
• Instill the contrast retrograde through
the foley catheter of avg. 350-400 cc
of contrast
• Image the pelvis

104. CT classification
TYPES
1. Bladder contusion
2. Intraperitoneal rupture
3. Interstitial bladder injury
4. Extraperitoneal rupture
A. simple
B. complex (bladder neck involved)
5. Combined bladder injury

105. Intraperitoneal rupture (type 2)
• Cystography
– Contrast in paracolic gutters, around
bowel loops, pouch of Douglas and
intraperitoneal viscera
– ± Pelvic fracture
• CT cystography
– Contrast in paracolic gutters, around
bowel loops, pouch of Douglas and
intraperitoneal viscera

106. Cystogram of intraperitoneal
bladder rupture

107. Extraperitoneal rupture (type 4)
• Cystography
– Simple (type 4A): Flame-shaped
extravasation around bladder
– Complex (type 4B): Extravasation
extends beyond the pelvis
– Extravasation best seen on post-
drainage films

108. • CT cystography
– Perforation by bony spicules
– "Knuckle" of bladder: Trapped bladder by
displaced fracture of anterior pelvic arch
– Simple (type 4A): Extravasation is
confined to perivesical space
– Complex (type 4B): Extravasation extends
beyond perivesical space; thigh, scrotum,
penis, perineum, anterior abdominal wall,
retroperitoneum or hip joint
– "Molar tooth sign": Rounded cephalic
contour (due to vertical perivesicle
components of extraperitoneal fluid)

109. CT of extraperitoneal bladder
rupture
MOLAR TOOTH SIGN

110. Type 5
(combined) rupture.

111. URETHRAL INJURY
• Urethral injury is a
common
complication of
pelvic trauma
• Occurs in as many
as 24% of adults
• With pelvic
fracturesTypically
involve the
proximal (posterior)
portion

112. CLASSIFICATION OF URETHRAL INJURIES
Colapinto & McCallum Goldman & Sandler
Grade I Posterior urethra stretched, but Posterior urethra stretched but
intact intact
Grade II Posterior urethral tear above
intact urogenital diaphragm
(UGD)
Partial or complete posterior
urethral tear above intact UGD
Grade III Posterior urethral tear with Partial or complete tear of
extravasation through torn combined anterior and
UGD posterior urethra with torn UGD
Grade IV — Bladder neck injury with
extension to the urethra
Grade IVa — Injury to bladder base with
extravasation simulating type
IV (pseudo grade IV)
Grade V — Isolated anterior urethral injury

113. Goldman type I injury
Stretching or elongation of the otherwise intact posterior urethra
Intact but stretched urethra

114. Goldman type II injury
Urethral disruption above the urogenital diaphragm while the
membranous segment remains intact
Contrast agent extravasation above the urogenital diaphragm only

115. Goldman type III
Disruption of the membranous urethra, extending below the
urogenital diaphragm and involving the anterior urethra
Contrast agent extravasation below the urogenital diaphragm,
possibly extending to the pelvis or perineum; intact bladder neck

116. Goldman type IV injury
Bladder neck injury extending into the proximal urethra
Extraperitoneal contrast agent extravasation bladder neck disruption

117. Goldman type IVa injury
Bladder base injury simulating a type IV injury
Periurethral contrast agent extravasation; bladder base disruption

118. Intestinal and Mesenteric
Traumas
• Bowel or mesentery injury occurs in
5% of patients with abdominal blunt
trauma
• More common following open trauma,
especially in injuries caused by
firearms

119. • Four CT findings should alert the
radiologist
1. Focal fat infiltration
2. Interloop hematoma (sentinel clot sign)
3. Bowel wall thickening
4. Free intraperitoneal air

120. Small Bowel Injury
• Diffuse circumferential thickening
– Hypoperfused "shock" bowel
• Focal thickening
– Usually non-transmural injury
• Specific findings, rare
– Bowel content extravasation
– Focal bowel wall discontinuity
• Most common finding
– Unexplained non-physiologic free fluid (84%)
– Mesenteric stranding
– Focal bowel thickening
– Interloop fluid
• If in combination, strongly suggestive

121. GI Perforation
The direct CT sign
• Transparietal continuity solution, mainly
located on the mesenteric side of the bowel
• The perforation may occur intraperitoneally
or retroperitoneally

122. Indirect findings of traumatic
bowel perforation
• Peritoneal findings
– Sentinel clot
– Focal mesenteric infiltration
• GI findings
– Pneumoperitoneal air bubbles localized
within the mesentery
– Focal wall thickening

123. Traumatic duodenal
intramural hematoma

124. Periduodenal hemorrhage

125. • Causes of bowel thickening related to
trauma
– Contusion/hematoma
– Perforation
– Distal ischemia due to mesenteric lesion
– Bowel shock
– Secondary to peritonitis
– Bowel spasm

126. GI Ischemia
• Bowel ischemia
– Segmental (distal branch vessel injury)
– Diffuse thickening of small bowel wall -
hypotensive shock bowel
• Typical CT signs
– Lack of parietal enhancement
– Thickening of bowel wall
– Parietal pneumatosis with presence of air
inside the bowel wall
– Air in the mesentery and portal venous
system

127. Role of Interventional
Radiology
• Embolization
– Spleen
– Liver
– Pelvis
• Angioplasty + Stent
– Renal artery dissection

128. Principles of hemostatic
embolization
• Treatment should be derived from the
physiological process of hemostasis
• Resorbable material may be sufficient to
initiate local thrombus
• It should take place at the site of injury
• Minimal tissue loss
• Rebleeding should be avoided by formation
of a stable clot

129. Agents for embolizations
• Gelfoam
– Soaked in an antibiotic solution
– resorable
– Can be cut in variable size
– May result in too distal embolization
– Risks for tissue infarction or late abscess
formation
• Coils
– Have variable size, length, diameter
– Precise targeted delivery
– Expensive
– Need normal coagulation
• Metal stents
– Large-caliber patent artery

130. Spleen Embolization

131. Advantages
• Embolization can decrease the amount
of resuscitation fluid to maintain vital
sign.
• Embolization can decrease shock index
• Operation with adjunct embolization can
decrease the mortality rate
• Early embolization may decrease the
mortality rate
• Embolization is a promising way for
stopping bleeding

132. Reference
• TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID
SUTTON
• Grainger & Allison's Diagnostic Radiology: A
Textbook of Medical Imaging, 4th ed.
• Imaging of Renal Trauma - RadioGraphics 2001;
21:557–574
• Urethral Injuries after Pelvic Trauma -
RadioGraphics 2008; 28:1631–1643
• http://www.radiologyassistant.nl/en/466181ff6107
3
• American College of Radiology - ACR
Appropriateness Criteria
• CT of the Acute Abdomen - Patrice Taourel
• http://www.sonoguide.com/FAST.html

133. Reference
• TEXTBOOK OF RADIOLOGY AND IMAGING by DAVID
SUTTON
• Grainger & Allison's Diagnostic Radiology: A
Textbook of Medical Imaging, 4th ed.
• Imaging of Renal Trauma - RadioGraphics 2001;
21:557–574
• Urethral Injuries after Pelvic Trauma -
• Thank you
RadioGraphics 2008; 28:1631–1643
http://www.radiologyassistant.nl/en/466181ff6107
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• American College of Radiology - ACR
Appropriateness Criteria
• CT of the Acute Abdomen - Patrice Taourel
• http://www.sonoguide.com/FAST.html