Visceral injury without hemoperitoneum: A limitation of screening abdominal sonography for trauma

Abdominal sonography for the detection of hemoperitoneum has become increasingly popular as a screening test for visceral injury after blunt trauma. The purpose of this study was to determine the frequency, severity, and clinical significance (outcome) of abdominal organ injuries that occur without hemoperitoneum on the initial evaluation of blunt abdominal trauma patients.During a 12-month period, 3392 blunt trauma patients were admitted to our center. Sonographic studies were performed as an initial screening evaluation to determine the presence of hemoperitoneum in 772 (22.7%) of these patients. Abdominal visceral injuries were verified by computed tomography (CT) or surgery in 196 (5.8%) of all blunt trauma admissions. Sonography, CT, and operative findings were reviewed to determine the presence or absence of hemoperitoneum in patients with abdominal injury. Patients with abdominal visceral injury without hemoperitoneum were further analyzed to identify the type of injury and the management required.A total of 246 abdominal injuries were identified in 196 patients. Fifty (26%) patients with abdominal visceral injuries diagnosed by admission CT scan had no evidence of hemoperitoneum. Admission sonography performed in 15 (30%) of these 50 patients also showed no evidence of hemoperitoneum. Visceral injuries detected by CT in the patients without hemoperitoneum included 22 of 100 splenic injuries (22%), 18 of 91 hepatic injuries (20%), 12 of 26 renal injuries (46%), and 1 of 9 mesenteric injuries (11%). Surgery was required to manage injuries in 10 of these patients.Up to 26% of blunt trauma patients with abdominal visceral injuries do not have associated hemoperitoneum identified on admission abdominal CT or sonography. Dependence on hemoperitoneum as the sole criterion of abdominal visceral injury after blunt trauma will result in falsely negative examinations and will miss potentially significant injuries.     

Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma.

PURPOSE: To determine, at screening ultrasonography, the prevalence, severity, and clinical outcome of clinically important abdominal visceral injuries, without associated hemoperitoneum, that result from blunt abdominal trauma. MATERIALS AND METHODS: Computed tomography (CT) was performed at admission in 466 patients with visceral injury. A retrospective review was performed of findings from surgery and contrast material-enhanced spiral and conventional CT performed to verify abdominal visceral injuries in 467 (4%) of 11,188 patients with blunt trauma. These patients were admitted to a level 1 trauma center over 33 months to determine the presence of hemoperitoneum and to identify the grade of injury. Medical records of patients with abdominal visceral injury without hemoperitoneum were reviewed for the management required and for results of focused abdominal sonography for trauma (FAST). RESULTS: A total of 575 abdominal visceral injuries were identified at CT and/or surgery. Findings of CT at admission (n = 156) and of surgery (n = 1) revealed no evidence of hemoperitoneum in 157 (34%) patients with abdominal visceral injury; 26 (17%) of whom also had negative FAST studies. Abdominal visceral injuries diagnosed in patients without hemoperitoneum included 57 (27%) of 210 splenic injuries, 71 (34%) of 206 hepatic injuries, 30 (48%) of 63 renal injuries, four (11%) of 35 mesenteric injuries, and two (29%) of seven pancreatic injuries. Surgical and/or angiographic intervention was required in 26 (17%) patients without hemoperitoneum. CONCLUSION: Reliance on the presence of hemoperitoneum as the sole indicator of abdominal visceral injury limits the value of FAST as a screening diagnostic modality for patients who sustain blunt abdominal trauma.     

Computed tomography in hepatic trauma

Twenty-five patients with hepatic injury from blunt upper abdominal trauma were examined by computed tomography (CT). The spectrum of CT findings was recorded, and the size of the hepatic laceration and the associated hemoperitoneum were correlated with the mode of therapy used in each case (operative vs. nonoperative). While the need for surgery correlated roughly with the size of the hepatic laceration, the size of the associated hemoperitoneum was an important modifying factor. Fifteen patients with hepatic lacerations but little or no hemoperitoneum were managed nonoperatively. CT seems to have significant advantages over hepatic scintigraphy, angiography, and diagnostic peritoneal lavage. By combining information on the clinical state of the patient and CT findings, therapy of hepatic injury can be individualized and the incidence of nontherapeutic laparotomies decreased.     

Computed tomography of blunt trauma to the gallbladder

The CT findings are reviewed in two patients with injuries to the gallbladder following blunt abdominal trauma. In one patient with a laceration of the cystic artery a large intraluminal clot was identified within the gallbladder associated with extensive hemoperitoneum. Another patient presented with extensive bile leakage into the peritoneal cavity 72 h after blunt trauma due to laceration of the fundus of the gallbladder. The clinical features of blunt trauma to the gallbladder and the utility of CT in this entity are reviewed.     

Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries Part 1: Liver and spleen

Computed tomography is now widely used in the initial diagnostic workup of adult trauma victims with suspected intra-abdominal injuries. We review the role of CT in the detection and management of blunt visceral injuries in two parts. In the first part we discuss general aspects of performing CT in the setting of abdominal trauma and the diagnostic findings of intra-abdominal hemorrhage and blunt hepatic and splenic injuries. Hepatic and splenic injuries can be detected by means of CT with a high accuracy. The vast majority of hepatic injuries can be successfully managed conservatively, even when CT demonstrates parenchymal damage of more than three segments and major hemoperitoneum. Delayed complications, e. g., formation of biloma or a false aneurysm, can be readily detected on repeat CT studies, although they are quite uncommon. The outcome of conservative treatment of splenic injuries remains unpredictable because delayed splenic rupture may occur even when initial CT shows only minor parenchymal lesions and little or no intraperitoneal hemorrhage. Received 22 July 1997; Revision received 16 October 1997; Accepted 23 October 1997     

A case of acute abdominal aortic dissection caused by blunt trauma

We present the case of an 18-year-old man involved in a fall with blunt abdominal trauma. The patient had hypovolemic shock and findings of an acute abdomen. Initial computed tomography (CT) showed pulmonary contusion, pneumohemothorax, hemoperitoneum, hepatic contusion, right kidney laceration and vascular avulsion, rupture of the mesenteric vein, rupture of the right rectus muscle with bowel hernia, and infrarenal aortic dissection. There were no signs of limb or medullar ischemia. After hemodynamic stabilization and surgical repair of the associated lesions, the dissection was successfully treated with a self-expanding aortic Wallstent. Postprocedure CT showed a well-positioned patent stent and the patient was discharged asymptomatic. Percutaneous endovascular stent implantation is minimally invasive and seems to be a safe treatment for traumatic dissection of the abdominal aorta.     

Penetrating stab wounds to the abdomen: use of serial US and contrast-enhanced CT in stable patients

PURPOSE: To evaluate the usefulness of computed tomography (CT) and ultrasonography (US) for the initial assessment of penetrating abdominal stab wounds in patients who presented to the emergency department without indication for immediate laparotomy. MATERIALS AND METHODS: During 36 months, 32 patients with a penetrating stab wound to the abdomen were examined with serial US (at admission and 12 hours later) and helical CT, with contrast material administered orally, intravenously, and rectally. Presence of hemoperitoneum and integrity of solid and hollow viscera were evaluated with both methods. Sonograms were interpreted by the radiologist who performed the examination, and CT images were independently evaluated by two radiologists. Findings of both techniques were compared with clinical outcome and/or surgical findings. RESULTS: One (3.1%) of 32 patients required surgery: Surgical findings were massive hemoperitoneum and an extensive hepatic laceration. Both US and CT depicted these abnormalities. Thirty-one (96.9%) patients were treated conservatively, without surgery, and remained asymptomatic during 28 days of clinical follow-up after discharge from the hospital. US and/or CT showed intraperitoneal abnormalities in 21 of these patients. In 11 patients, both methods showed no evidence of visceral injury or hemoperitoneum, and none of these patients required surgery. CONCLUSION: Serial US and CT help guide treatment for stable patients with penetrating stab injuries to the abdomen.     

Nonoperative management of hepatic trauma

In an attempt to determine whether selective, nonoperative management of hepatic trauma might be efficacious, a retrospective review of liver injuries was undertaken. Of the 48 patients with liver injuries identified, there were 34 men and 14 women with an average age of 28.5 years. Mechanism of injury consisted of blunt trauma in 23 patients, stab wounds in 14 patients, and 11 patients had gunshot wounds. There were 12 grade I injuries, 15 grade II injuries, 17 grade III injuries, 2 grade IV injuries, and 1 grade V injury. Diagnosis of liver trauma was made at the time of exploratory laparotomy in 15 patients and suggested by abdominal computed tomography (CT) scan in 18 patients; the remaining 15 patients had a positive peritoneal lavage which led to exploratory laparotomy. Following blunt trauma, 14 patients, all of whom underwent diagnostic abdominal CT scans which confirmed hepatic injury, had nonoperative treatment. All patients who received nonoperative management maintained stable vital signs and only five required transfusion. None of the patients who were treated nonoperatively developed complications or required delayed laparotomy. There were no deaths in this group. Of the 34 patients undergoing exploratory laparotomy, 19 required either no treatment or minor hepatorrhaphy. However, 17 of 25 patients with penetrating wounds had associated abdominal injuries which required operative treatment. Based on the information obtained in this review, it is recommended that stable patients with isolated hepatic injuries, secondary to blunt trauma confirmed by CT scan, may be managed nonoperatively. Due to the high frequency of associated injuries found in patients with penetrating trauma, nonoperative therapy is not advised.     

Gallbladder blunt trauma: comparison between radiologic and anatomo-surgical findings

PURPOSE: To assess the diagnostic accuracy and the possible role of ultrasonography (US) and Computed Tomography (CT) in a small group of patients who had a blunt abdominal trauma involving the gallbladder. MATERIAL AND METHODS: We retrospectively reviewed the US and CT findings of five patients with surgically confirmed post-traumatic gallbladder injury. The whole series consisted of 196 consecutive patients submitted to laparotomy for blunt abdominal trauma in the past 7 years. The following US and CT findings were considered at least suggestive of a possible post-traumatic gallbladder injury: pericholecystic fluid collection, ill-defined wall margin, collapsed lumen, high intraluminal density. RESULTS: At surgery, the following findings were observed: gallbladder hematoma (1 case), acute colecystitis (1 cases), gallbladder tear (3 cases), gallbladder tear associated with post-traumatic hepatic injuries (2 cases), duodenal tear (2 cases), hemoperitoneum alone (2 cases), hemoperitoneum associated with choleperitoneum (1 case), choleperitoneum alone (1 case). The US and CT findings were pericholecystic fluid collections (4 cases), ill-defined gallbladder wall margins (3 cases), collapsed lumen with intraluminal high density (1 case) and free intraperitoneal fluid collections (4 cases). They were suggestive of a possible post-traumatic gallbladder injury in all the five patients. CONCLUSIONS: The radiologic findings of our five patients were suggestive of a gallbladder damage but did not permit to distinguish minor from major injuries, the latter requiring surgical treatment. US proves to be a useful screening tool which can also help timing surgery in these patients. CT confirmed the US suspicions and also permitted accurate assessment of associated post-traumatic injuries to the liver and duodenum. Nevertheless, the clinical presentation was the most important factor as to the therapeutic management of these blunt abdominal trauma patients.     

CT在闭合性肝损伤诊断和治疗中的应用价值

目的　评价CT在闭合性肝外伤诊断和治疗中的应用价值。方法　回顾性分析 2 2例闭合性肝损伤患者的CT和临床资料 ,观察CT对闭合性肝损伤诊断的敏感性和特异性 ,并将肝损伤CT表现与手术、临床治疗结果进行对照。结果　 2 2例闭合性肝损伤者 ,CT明确诊断 2 1例 ,1例发现腹腔积液。CT诊断的特异性为 95 .5 % ( 2 1/2 2 )。CT分级 :I级 1例 ,II级 10例 ,III级 8例 ,IV级 2例。 8例行非手术治疗 (II级 3例 ,III级 5例 ) ,成功 7例 ,1例因迟发性肝破裂而非手术疗法失败。 1例复查CT发现肝上胆汁聚积 ,经穿刺引流治愈。 14例行剖腹探查术 ,4例术中发现肝脏仍有活动性出血。结论　CT扫描能明确肝损伤的诊断 ,界定损伤类型及严重程度 ,指导合理地选择手术或非手术疗法 ,并能监测康复过程中并发症的发生     

CT features of blunt abdominal aortic injury

Abdominal aortic injuries are uncommon following blunt trauma, with relatively few reported series in the radiology literature. This study was conducted to identify common locations and imaging features of blunt traumatic abdominal aortic injury, the presence of associated visceral and osseous injuries, and the mechanisms of trauma. A retrospective review of 9,213 trauma registry entries over a 7-year period yielded 103 patients with aortic injuries, 12 of which had direct signs of abdominal segment involvement (dissection flap, focal intimal injury, intramural hematoma, active extravasation of contrast, or pseudoaneurysm formation). The majority (75 %) was isolated to the abdomen-67 % of which was infrarenal, 33 % suprarenal-while the other 25 % was a contiguous extension from a thoracic injury. Abdominal aortic injuries were uncommonly seen in isolation: all but one patient (92 %) demonstrated either retroperitoneal blood or stranding, hemoperitoneum, and/or CT signs of hypoperfusion complex, and only one patient (8 %) had no associated solid organ or skeletal injuries. All patients had a mechanism of injury which involved direct trauma to the abdomen, most commonly a motor vehicle collision. Similar to other recent series, there was an increased rate of abdominal segment injury (11.7 % of all aortic injuries) in this series compared to more remote autopsy series. This difference is likely due to detection of injuries which went undiagnosed before the widespread use of multidetector CT, which has become the standard of care for both acute evaluation following blunt trauma and for follow-up.     

Small bowel rupture after blunt trauma: Computed tomographic signs and their sensitivity

The purpose of this study is to describe the characteristic computed tomographic (CT) signs of small bowel perforation after blunt abdominal trauma and to evaluate their sensitivity. Nineteen preoperative CT scans were obtained from 16 patients with surgically proven small bowel rupture secondary to blunt abdominal trauma. Only the CT findings described in the original CT reports were used. Eleven of 19 CT scans (58 %) had findings that were unequivocal for bowel rupture (i.e., extraluminal air and/or extravasation of oral contrast medium). Seven CT scans (37 %) had findings that were suggestive of severe small bowel injury (i.e., focal small bowel wall thickening and/or free peritoneal fluid without other accompanying organ injuries). In all, 95 % of cases of small bowel rupture had either pathognomonic or suggestive CT findings. One CT scan did not demonstrate small bowel wall thickening, although a hemoperitoneum was present. CT is a sensitive method for suggesting severe small bowel injury and rupture secondary to blunt abdominal trauma.     

Traumatic injuries: role of imaging in the management of the polytrauma victim (conservative expectation)

Abdominal US and CT play an important role in the initial management of blunt trauma in adults. Ultrasound is an excellent method for detection of free intra-abdominal fluid. It is the modality of choice for initial screening and enables selection of hemodynamically unstable trauma victims with severe hemoperitoneum for immediate surgery. However, even in experienced hands, US is not sufficient to rule out organ injuries reliably. Computed tomography, and particularly multislice CT (MSCT), has several major advantages over US and is currently unsurpassed for the detection of blunt visceral injuries in the abdomen. Computed tomography has a high sensitivity for the detection of parenchymal splenic and hepatic injuries. Injuries of the gastrointestinal tract may be detected with good sensitivity provided that adequate examination technique and careful diagnostic interpretation are combined. The value of CT-based injury-grading systems for predicting the outcome of conservative treatment remains unproven; however, demonstration of direct vascular injuries with CT, e.g., the intrasplenic "contrast blush" sign, may indicate a high likelihood that conservative treatment will fail, thus warranting angiographic embolization or surgery. Monitoring of conservatively treated trauma victims by means of repeat CT studies enables early detection of a variety of delayed, clinically silent complications of trauma, e.g., posttraumatic biloma or bowel devascularization. Catheter angiography may be reserved to selected cases with vascular injuries proven on CT.     

Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imaging

Abdominal blunt trauma represents the main cause of death in people of age less than 40 years; the liver injury occurs frequently, with an incidence varying from 3 to 10%. Isolated hepatic lesions are rare and in 77-90% of cases, lesions of other organs and viscera are involved. Right hepatic lobe is a frequent site of injury, because it is the more voluminous portion of liver parenchyma; posterior superior hepatic segments are proximal to fixed anatomical structures such as ribs and spine that may have an important role in determining of the lesion. The coronal ligaments' insertion in this parenchymal region augments the effect of acceleration-deceleration mechanism. Associated lesions usually are homolateral costal fractures, laceration or contusion of the inferior right pulmonary lobe, haemothorax, pneumothorax, renal and/or adrenal lesions. Traumatic lesions of left hepatic lobe are rare and usually associated with direct impact on the superior abdomen, such as in car-crash when the wheel causes a compressive effect on thorax and abdomen. Associated lesions to left hepatic lobe injuries correlated to this mechanism are: sternal fractures, pancreatic, myocardial, gastrointestinal tract injuries. Lesions of the caudal lobe are extremely rare, usually not isolated and noted with other large parenchymal lesions. The Institution of Specialized Trauma Centers and the technical progress in imaging methodology developed in the last years a great reduction of mortality. New diagnostic methodologies allow a reduction of negatives laparotomies and allow the possibility of conservative treatment of numerous traumatic lesions; however, therapy depends from imaging findings and clinical conditions of the patient. Computed tomography (CT) certainly presents a large impact on diagnosis and management of patients with lesions from blunt abdominal traumas. It is important to establish a prognostic criteria allowing decisions for conservative or surgical treatment; CT findings and peritoneal fluid evaluation may be used to make a first differentiation of severity of lesions, but haemodynamic parameters may help the clinician to prefer a conservative treatment. In emergency based hospitals and also in our experience, positive benefits spring from diagnostic accuracy and consequent correct therapeutic management.     

Massive hemoperitoneum due to ruptured inferior phrenic artery pseudoaneurysm after blunt trauma

There had been no previous reports of ruptured pseudoaneurysm of inferior phrenic artery shortly after blunt abdominal trauma. Traumatic arterial pseudoaneurysms are either iatrogenic or the result of penetrating injuries and one of the sequelae of trauma. Post-traumatic pseudoaneurysm develops at varying time intervals after the initial insult. To our knowledge, this is the first report of massive hemoperitoneum caused by ruptured inferior phrenic artery pseudoaneurysm after blunt trauma. Pseudoaneurysm of inferior phrenic artery in patient with diaphragm injury is potentially a life-threatening condition and requires urgent management. Diagnosis of ruptured inferior phrenic artery pseudoaneurysm is based on clinical assessment combined with radiological investigations. We report a case of ruptured left inferior phrenic artery pseudoaneurysm as one aspect of massive hemoperitoneum caused by blunt abdominal trauma.     

CT detection of hepatic and splenic injuries: usefulness of liver window settings

OBJECTIVE. This study was designed to assess the usefulness of liver window settings when performing abdominal CT for the detection and characterization of hepatic and splenic injuries. SUBJECTS AND METHODS. We prospectively evaluated helical abdominal CT scans for hepatic and splenic injuries in 300 consecutive patients with blunt abdominal trauma over a 4-month period. There were 204 males and 96 females with a mean age of 34 years (age range, 1-87 years). For each patient, initial CT diagnosis of hepatic or splenic injury was made from images obtained with standard abdominal window settings. CT scans were then immediately reinterpreted using additional images obtained at narrow window width (liver windows). Changes in conspicuity and characterization of injury were recorded. All CT examinations were performed with helical 7-mm collimation at a pitch of 1.5 after oral ingestion of diluted barium and during bolus IV administration of 125 mL of ioversol at a rate of 2-3 mL/sec. RESULTS. We detected hepatic or splenic injuries in 34 patients (11.3%). There were 19 hepatic injuries and 18 splenic injuries. Three patients had injuries to both liver and spleen. Conspicuity of hepatic or splenic injuries was mildly increased (+1 H) on liver windows in 16 patients, whereas the injury was equally conspicuous on both liver window and standard window images in 19 cases. In no case did review of the liver windows result in a change in grade of injury or reveal an injury that was not seen on standard abdominal window images. The total increased cost for printing liver windows was $5748. CONCLUSION. Routine use of liver window settings for abdominal CT in trauma patients has little clinical usefulness and is not cost-effective.     

The value of non-contrast-enhanced CT in blunt abdominal trauma

The usefulness of non-contrast CT, limited to the upper abdomen, in conjunction with conventional IV contrast-enhanced scanning was studied prospectively in 190 patients who had sustained blunt abdominal trauma. In 78, visceral injuries were confirmed at surgery or at follow-up CT. Of the patients with injuries, 14 (18%) had hyperdense hematomas on the non-contrast studies that became isodense after IV administration of contrast material. These hematomas generally were small and posed an immediate threat to life in only one patient (0.5% of all subjects). In 13% of patients with injury (5% of the total), the additional information did influence treatment planning (surgery in two and intensive conservative treatment in eight). Compared with conventional contrast scanning, the combined non-contrast-contrast technique increased the scanning time only by about 5 1/2 min, but it improved the sensitivity and accuracy of CT in detecting visceral injuries from 74% and 84% to 92% and 91%, respectively (p less than or equal to .003 and p less than or equal to .04). Although contrast-enhanced scanning alone accurately depicts visceral injuries requiring surgical treatment, the incorporation of a non-contrast sequence can detect a subgroup of patients who require intensive conservative management with bed rest and close observation. This additional information can be obtained expeditiously, with minimal additional effort or intervention. The use of non-contrast scanning alone is not recommended.     

钝性脾损伤的CT表现及临床价值

目的评价CT在钝性脾损伤诊断中的价值.方法对36例钝性脾损伤病人进行CT检查并回顾性分析.结果36例中完全性破裂28例,中心破裂5例,包膜下破裂3例.CT表现为脾内血肿,脾撕裂,包膜下血肿,脾周血肿及腹腔积血.同时发现肝、肾、胃、十二指肠、腰椎、肋骨等多发性损伤.31例手术,5例保守治疗.结论CT扫描能正确估计钝性脾损伤的损伤范围和程度,为临床治疗提供重要信息.     

Hepatic and splenic injury in children: role of CT in the decision for laparotomy

Clinical and radiographic records of 274 children who were examined with abdominal computed tomography (CT) after blunt abdominal trauma were retrospectively evaluated to test the hypothesis that CT can assist in decisions to perform laparotomy in children with hepatic or splenic injury. CT demonstrated parenchymal injuries in 36 patients (13%) or 20 livers and 21 spleens. Injury to these organs was categorized as minor (39%), moderate (39%), and severe (21%) according to an assessment of the percentage of parenchymal involvement. Hemoperitoneum was detected in 27 of 36 patients (75%). One of 13 (4.7%) with a moderate to large splenic injury underwent splenorrhaphy because of persistent bleeding. One of 12 (5%) with a moderate to large hepatic injury required late operative intervention due to a large necrotic segment. Both children had a large amount of peritoneal fluid. Two of 16 patients (13%) with moderate to large hemoperitoneum required surgery for liver or splenic injury. The decision for laparotomy should not be based on the extent of injury as shown at CT but on the physiologic condition of the child.     

Blunt trauma to the main hepatic artery.

Two patients are presented who sustained common hepatic artery injuries secondary to blunt trauma. One patient had a laceration and thrombosis of the proximal hepatic artery while the second patient developed a false aneurysm with dissection which necessitated ligation of the hepatic artery.