Author's Accepted Manuscript

Imaging of Blunt Abdominal Solid Organ Trauma

Jeffrey D. Robinson MD, MBA, Claire K. Sandstrom
MD, Bruce E. Lehnert MD, Joel A. Gross MD

www.elsevier.com/locate/enganabound

PII: S0037-198X(15)00063-2
DOI: http://dx.doi.org/10.1053/j.ro.2015.12.003
Reference: YSROE50528

To appear in: Seminar in Roentgenology

Cite this article as: Jeffrey D. Robinson MD, MBA, Claire K. Sandstrom MD, Bruce E.
Lehnert MD, Joel A. Gross MD, Imaging of Blunt Abdominal Solid Organ Trauma,
Seminar in Roentgenology, http://dx.doi.org/10.1053/j.ro.2015.12.003

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 Imaging of Blunt Abdominal Solid Organ Trauma

Jeffrey D. Robinson, MD, MBA1

Claire K. Sandstrom, MD1
Bruce E. Lehnert, MD1
Joel A. Gross, MD1

1From the Emergency Radiology Section, Department of Radiology,

University of Washington

Corresponding Author:
Jeffrey Robinson, MD, MBA
e-mail: Jeff8rob@uw.edu
Phone: 206-744-3561
Mailing address:
325 9th Avenue
Box 359728
Seattle, Washington 98104

Introduction
In the setting of blunt abdominal trauma, diagnostic imaging occupies a crucial
role in detecting and characterizing injuries to the solid organs. Injuries to the
liver, spleen, kidneys, pancreas and adrenals share many common features, but
each has its own unique considerations that require special attention from the
radiologist. This paper will focus initially on the commonalities to solid abdominal
organ injuries, then conclude with sections dedicated to features specific to each
of the solid abdominal viscera.

Common Concepts

Imaging:
While imaging of the acute trauma victim typically begins with plain films of the
chest and pelvis performed during the initial resuscitation, these have limited
utility in diagnosing injuries to the solid abdominal organs.

The Focused Abdominal Sonography for Trauma (FAST) exam can be

performed rapidly at the bedside of virtually any patient. This exam aims to
identify free intraperitoneal fluid inferring the presence of significant intra-
abdominal injury in a hemodynamically unstable patient. It has largely supplanted
diagnostic peritoneal lavage (DPL) as an initial test for hemoperitoneum.1,2
However, FAST (like DPL) relies on the demonstration of free fluid
(hemoperitoneum), a secondary sign of injury, and does not localize the site of
the injury. Additionally, hemoperitoneum can have a variety of appearances at
ultrasound: echogenic clotted blood adjacent to solid organs can be difficult to
differentiate from adipose or adjacent solid organ tissue, even as the serum
pools in the pelvis (Fig 1). Finally, FAST and DPL do not evaluate for
retroperitoneal injuries, which may be associated with substantial blood loss but
do not result in hemoperitoneum.3 False positive FAST results can be seen in
patients with unsuspected ascites.

Computed Tomography (CT) has been the gold standard for non-invasive
evaluation of the stable trauma patient for years.4,5 The development of very
short scan times with multi-detector CT (MDCT) and the ease with which post-
processing can be accomplished have increased its value to a level where some
advocate situating the CT scanner not simply in the Emergency Department, but
in the resuscitation suite itself, thus enabling rapid imaging of unstable patients.6

Imaging protocols are discussed in more detail elsewhere in this issue. In brief,
some authors advocate routine scanning of the abdomen in both the arterial and
portal venous phases in order to detect vascular injuries that may not be seen in
the venous phase.7 Others suggest that in the setting of pelvic fractures identified
in the initial trauma series, arterial phase imaging of the pelvis adds value in the
detection and localization of active bleeding, aiding the interventional radiologist
who will subsequently embolize the bleeding vessels.8,9
At our institution, imaging of blunt polytrauma patients is performed with a whole
body CT technique that includes routine arterial and portal venous phase
acquisitions of the abdomen and portal venous phase acquisition in the pelvis. In
the setting of pelvic fracture, the arterial phase acquisition is extended through
the pelvis. 10 A non-contrast scan is neither necessary for diagnosis, nor
sufficient by itself to exclude injury to the solid organs of the abdomen (Fig 2),
and is not usually obtained. Reviewing the initial images at the CT console, if
possible, allows appropriate selection of patients for delayed imaging, avoiding
both unnecessary radiation exposure and delays in subsequent treatment.

Patient positioning also impacts image quality. The patient should be well
centered in the CT gantry. Beam hardening artifact resulting from positioning of
the patients‘ arms at the sides can obscure pathology (Fig 3). To mitigate this
effect, various arm positions have been proposed, including the anterior
bolstering of arms across the torso performed at our institution.10 Suboptimal
contrast injection technique can obscure both vascular and solid organ injuries
(Fig 4).

Signs of significant injury

Free Fluid
Free fluid may be composed of water, blood, urine, bowel contents or any
combination. Simple serous fluid can be identified by its density near zero
Hounsfield units (HU) at CT. Unclotted blood has a density between 30 and 45
HU, but when separated into serum and clot, the clot can measure between 60
and 100 HU, and the serum from 0 to 20 HU.5,11,12 Extravasated contrast-
enhanced blood will vary in density with the iodine concentration in the blood, but
typically exceeds 180 HU. The highest density hematoma in the peritoneal cavity,
a ‗sentinel clot‘, often localizes adjacent to the site of injury.13 Urinary ascites due
to ureteral or intraperitoneal bladder injury is low density during arterial and portal
venous phase acquisitions and demonstrates increasing density on delayed
imaging as excreted intravenous contrast extravasates through the injury
defect.14 Bowel perforations frequently present with high-density ascites,15 a
nonspecific finding that may be due to the nature of bowel contents or blood from
the injury itself.

Vascular Injuries common to all solid organs

Vascular injuries include pseudoaneurysm (PSA), arteriovenous fistula (AVF),
dissection, spasm or transection. A pseudoaneurysm results from an injury to an
artery involving the intima and media, sparing the adventitia. Localized
enlargement of a blood vessel that tracks the density of major vessels on all
phases of imaging characterizes the pseudoaneurysm. A delayed contrast
phase (5-10min) acquisition can be helpful in the setting of vascular injury to
differentiate between a contained process (such as PSA or AVF) and active
extravasation (such as a vessel transection). This is described in detail below.

An AVF results when an abnormal direct communication occurs between arterial

and venous structures. Most AVFs communicate between arterial and systemic
veins, but because of the dual blood supply of the liver, arterioportal,
arteriohepatic or portohepatic (which is technically venous-venous) fistulas may
occur. When visible, AVFs demonstrate early enhancement of large caliber
draining veins central to the fistula. Arterioportal fistulas have unique findings
described in a later section16
An arterial dissection results from blunt trauma, typically a stretching injury to the
intima and sometimes to the media of larger arteries. Dissections reduce or
occlude flow distally and disrupt the normal laminar flow past the injury,
potentially resulting in in distal embolization of platelet aggregates or more
generalized hypoperfusion. The dissection itself typically appears as an intimal
flap with contrast opacification of the false lumen, as luminal narrowing with a
thrombosed false lumen, or as complete vessel occlusion.

A laceration of an artery or vein is an injury that penetrates all histologic layers of

the vessel wall. It can cause massive hemorrhage, although spasm of the
muscular wall of an artery provides an opportunity to decrease blood loss. An
arterial laceration allows extravasation of contrast-opacified blood in the arterial
phase of imaging, and slight washout on venous phase imaging, because of
continued extravasation of blood after the contrast has passed the arterial phase.
A venous laceration typically will not demonstrate contrast extravasation on
arterial phase imaging, but will appear on the venous phase. Delayed imaging, if
obtained, will show continued accumulation of contrast. A transection is a
laceration that completely separates the proximal and distal portions of the
vessel. Resultant arterial wall muscular spasm can decrease blood flow
significantly or even occlude flow. This can result in delayed hemorrhage from
the injured vessel when vasospasm resolves.

Parenchymal injuries common to all solid organs

A contusion is an area of edema and/or hemorrhage into a soft tissue structure,
due to rupture of small blood vessels that maintains the architectural integrity of
the tissue. A blunt trauma related laceration is a tear in tissue caused by a
shearing or crushing force. A collection of blood within a laceration is a
hematoma.17 A subcapsular hematoma is a collection of blood located between
an organ capsule and the subjacent parenchyma.4 A hematoma localized outside
an organ capsule may be termed a peri-organ hematoma. Finally, if the blood
supply to a structure is traumatically occluded, that structure may undergo
infarction.

Each of these injuries demonstrates characteristic findings at contrast-enhanced

CT. A contusion appears as an ill-defined hypoattenuating zone (Fig 5A). A
laceration (more accurately called a laceration-hematoma complex) is a linear or
branched linear injury surrounded by normally enhancing parenchyma (Fig 5B).
Blood accumulating between the edges of the laceration is a hematoma (Fig 5C).
The density of the hematoma depends on the acuity of the laceration, the rate of
bleeding and whether or not there is active bleeding while the IV contrast is
circulating. Typically, the density of the blood in a laceration is less than that of
the enhanced organ parenchyma at the laceration margin. In the case of a
massive acute hemorrhage, higher-attenuation clot may be seen between the
margins of the laceration (Fig 5E). Active extravasation into a laceration is
denoted by the presence of contrast-enhanced blood within the injury (Fig 5D).
Delayed scans may show diffusion of contrast through the unclotted portion of
the laceration, and/or further accumulation of contrast enhanced blood if the
hemorrhage is ongoing during the scan delay. A subcapsular hematoma is a
lenticular or crescentic collection, bounded by the organ capsule superficially and
displaced or scalloped parenchyma deep to the hematoma (Fig 5E). The smooth
convex outer margin formed by the capsule differentiates this from the peri-organ
hematoma, which has more irregular margins since it is not similarly bounded
(Fig 5F). Infarction is characterized by the absence of contrast enhancement to a
structure that normally should enhance, with the structure maintaining its normal
architecture (Fig 5G). While most injuries result in enlargement of the underlying
tissue due to edema and/or hemorrhage, infarctions typically maintain a normal
size.

Injury grading
The American Association for the Surgery of Trauma (AAST) has developed an
organ injury scaling (OIS) system for injuries to commonly affected organs and
body regions.18 This system provides a common language to describe specific
organ injuries, and is used by trauma surgeons to facilitate decision making and
research.19 Most OIS systems were developed in the 1980‘s and early 1990‘s,
before the modern CT era, and have been occasionally modified. These systems
do not necessarily take into account information available with CT, including
some intraparenchymal injuries not visible on the organ surface. Additional
challenges in the use of this system include ambiguities in the way laceration
length and depth are measured, and exclusion of some vascular injuries.

Pitfalls of Solid Organ Injury Imaging

Accessory fissures or clefts occur in the liver, spleen, kidneys and pancreas and
can be confused with lacerations. A well-defined margin, fat density within the
cleft, and the absence of other signs of injury such as hematoma or mesenteric
stranding support the diagnosis of a cleft (Fig 6).

Inhomogeneous contrast enhancement can simulate injury. In the liver,

hemangiomas may enhance irregularly with regions of peripheral contrast
pooling that can simulate the appearance of a hematoma with active
extravasation. Imaging of the spleen during the arterial phase may result in
heterogeneous enhancement of the spleen related to differential blood flow
through the red and white pulp.20 The relatively low-density linear bands, which
produce a ―serpentine‖ or ―tigroid‖ appearance, may be mistaken for splenic
lacerations. On portal venous phase images, the normal spleen enhances
homogeneously, allowing the reader to exclude injury (Fig. 7).

Liver & Gall Bladder Trauma

The liver is the second most commonly injured organ following blunt abdominal
trauma. 20,21 The right lobe suffers injury far more commonly than the left lobe as
a result of its larger size, position adjacent to posterior ribs and spine, and
fixation by the coronary ligaments.20 21 22

Injuries to the liver differ from those of other solid organs due to the presence of
the portal venous system, the bare area of the liver, the biliary system, and the
gallbladder. The implications of these differences are discussed below.

The treatment of blunt liver injury has evolved over the past century. Observation
and conservative management was the rule in the early 1900‘s.This practice
evolved towards operative intervention (following surgical advances in World War
II) 23, and more recently to the current practice of selective operative and non-
operative management (NOM).24

Patients with hemodynamic instability or peritonitis are selected for urgent

laparotomy. Nonoperative management is the treatment of choice for most other
patients, regardless of injury grade or patient age, as this results in improved
patient outcomes and lower costs. 86% of hepatic injuries are now treated
without operation.24

Contrast enhanced CT is the imaging study of choice, demonstrates a sensitivity

in the mid to high 90% for surgically important injuries of the liver, and in some
centers has had a significant influence in the adoption of conservative
management of stable patients.25

The liver is imaged during the portal venous phase, 70 seconds after the start of
intravenous contrast injection.20 21 Arterial phase imaging is not routinely
obtained, but may be added for specific indications and problem solving and is
becoming more commonly incorporated into routine trauma whole body CT
protocols.
While the 1994 AAST liver injury scale26 is widely used to report the extent of
hepatic injuries, the injury grade was not effective in distinguishing patients
requiring intervention from those in whom conservative management would
suffice.27 In addition, biliary injury is not predicted by the injury grade.

Subcapsular hematomas are assigned Grades I – III based on the amount of

surface area covered (<10%, 10-50%, or >50%). This is usually estimated, as
quantitative methods of measuring the region involved are not (usually) utilized.

Intraparenchymal hematomas are assigned Grade II or III depending on whether

their diameter is less than or greater than 10cm, and whether they are expanding
(which can only be non-invasively determined on delayed CT images, or
suspected if active extravasation is noted).

The most common liver injury is a laceration.20 Lacerations are primarily graded
according to parenchymal depth, as Grade I (< 1cm deep), Grade II (1-3cm deep,
and <10cm in length), or Grade III (>3cm deep) lesions.

Multiple lacerations may run parallel to the hepatic or portal veins, resulting in the
―bear claw‖ sign.21 While the liver is mostly an intraperitoneal structure and
hemorrhage extending beyond the liver capsule usually passes into the
intraperitoneal cavity, it is important to remember the bare area of the liver, as
hemorrhage into this region can result in an extraperitoneal hematoma 22 not
detected on FAST scan or diagnostic peritoneal lavage (DPL).

Grade IV lacerations result from parenchymal disruption of 25-75% of a hepatic

lobe, or 1-3 Couinaud segments within a lobe. Grade V lacerations result from
parenchymal disruption of >75% of a hepatic lobe, or >3 Couinaud segments
within a lobe. Determining the amount of disruption from subjective viewing of a
liver injury can be difficult, and quantitative techniques are not routinely applied to
measure the extent of injury (Fig 8). In addition, different readers may interpret
―disruption‖ differently, resulting in inconsistent grading of these injuries.

Injuries to the central hepatic veins (near the IVC) or to the IVC itself are serious
injuries, and are assigned Grade V. Juxtahepatic IVC bleeding has a mortality
rate of 65% to 100%, due to the complexity of controlling the bleeding;22
therefore, active extravasation from the IVC and draining hepatic veins should be
carefully evaluated. This assessment can be complicated by the need to
differentiate between a collapsed IVC and/or compression from adjacent
hematoma (which are common) and a true vascular injury (which is rare).
Delayed imaging can aid in this decision.

Avulsion of the hepatic hilum is considered a non-survivable injury and

designated a Grade VI injury accordingly.

Additional liver injuries not fully included in the AAST system are described
below.

As with the other organs, the AAST system for the liver does not explicitly or
completely include most hepatic vascular injuries such as active extravasation
and contained vascular lesions.

Due to the dual blood supply of the liver, traumatic fistulas involving the portal
vein may occur in addition to the more typical arteriovenous fistulas seen
elsewhere.22 Arterioportal fistulas are most sensitively identified by transient
hyperenhancement on early phase scanning.16

The biliary system poses unique challenges in the evaluation of hepatic trauma,
as leaked bile cannot be differentiated from serous fluid or blood on CT. As a
result, CT is unable to determine when fluid associated with parenchymal
lacerations represents biliary leakage. High grade liver parenchymal injuries (IV –
VI) and lacerations within 3 cm of the IVC (Fig. 9) are reportedly more likely to be
associated with biliary leak than lower grade injuries or more peripheral
lacerations, and several authors suggest that hepatobiliary scintigraphy should
be considered for these injuries to make the definitive diagnosis.28 29 Delayed
scintigraphy may be necessary to detect slow leaks.

Gallbladder injuries are present in up to 2-3% of patients undergoing exploratory

laparotomy for blunt abdominal trauma, but are rarely identified on CT. Findings
suggestive of, but not specific for, gallbladder injury include pericholecystic fluid
or thickening or poor definition of the gallbladder wall. More concerning findings
include interruption of enhancement of the gallbladder wall, and a collapsed
gallbladder (in a fasting patient) with pericholecystic fluid.29

MRI contrast agents (such as gadoxetic acid) that are excreted into the biliary
system may also be helpful in directly confirming the presence or absence of a
biliary leak, as well as identifying the site of the leak.30
Liver specific potential pitfalls that may cause false positive diagnoses of
lacerations include: congenital clefts or fissures, unenhanced intrahepatic
vessels, and intrahepatic bile ducts (especially if dilated).20 22 Fatty liver
parenchyma may be isodense to typically low attenuation lacerations,20 making
them difficult to identify (Fig. 10). Narrow windows may improve visualization of
these lacerations.20 Multiple phases of contrast enhancement may also help in
detection.

After initial evaluation of the acute traumatic event, routine follow up imaging of
liver injuries is not indicated. Although the complication rate of NOM increases
with higher grades of injury (1% for grade III, 21% for grade IV, and 63% for
grade V), follow up imaging of liver injuries is only indicated if clinical or
laboratory changes raise concern.24

Splenic Trauma
The spleen is reported to be the most commonly injured solid organ following
blunt trauma, although some references suggest that the liver is actually more
commonly injured.20 31 32 This discrepancy may be due to the tendency for
splenic injuries to be more clinically apparent than hepatic injuries, making them
appear more common before the widespread use of CT.32

Regardless of which organ has the distinction of highest incidence of injury, the
spleen is critical to evaluate as trauma frequently results in clinically significant
injury.32 Secondary to its abundant vascular supply and relatively large size,20 life
threatening hemorrhage can accompany splenic injuries.

Accurate evaluation of splenic injuries is essential to allow optimal management

of the patient. Prior to the mid 1970‘s, splenic injury was frequently treated with
splenectomy, and the exact characterization of the injury was less important.
With the increased recognition of the spleen‘s immunologic importance, there
has been a significant change to NOM of the spleen, and accurate
characterization of injuries is critical to determine which patients can be treated
without intervention, and which patients may require intervention.33 Treatment of
significant injuries with catheter angiography and embolization has reduced the
rate of failure of NOM and allowed treatment of injuries that previously would
have necessitated splenectomy. 20,34

Contrast enhanced MDCT is the imaging method of choice for evaluating blunt
splenic trauma, with a reported sensitivity of up to 98%.20 35 The spleen was
traditionally imaged during the portal venous phase, along with the remainder of
the abdomen and pelvis. Over the past decade or so, there have been numerous
recommendations to perform arterial phase imaging as well, to increase
detection of vascular injuries.20 36 37 34

In one study,36 59% of contained vascular injuries (CVI), such as

pseudoaneurysms and arteriovenous fistulas, were only visualized on arterial
phase CT and not on portal venous or delayed phases (Fig. 11). While the
arterial phase was valuable for CVI, it cannot replace the portal venous phase.
Arterial phase images were inferior to portal venous phase images for evaluation
of active bleeding and parenchymal disruption, so dual phase imaging is
recommended by some.36 37

This focus on vascular injuries (CVI and extravasation) is due to the common
belief that all or most of these lesions should be treated with angioembolization
or surgery.20 34 38 If this were indeed appropriate, then it would be reasonable to
perform dual phase imaging in all trauma patients, despite the extra radiation
burden.

Our local experience prior to the introduction of whole body CT protocols for blunt
trauma, however, has demonstrated few complications in patients imaged with
only portal venous phase images (in whom we presumably missed a number of
―minor‖ vascular injuries), possibly because small pseudoaneurysms may
thrombose spontaneously.20 Active extravasation also often resolves
spontaneously with time, and observation with repeat imaging may be a more
appropriate course of treatment in stable patients.39 This course may reduce
overall costs as well as the complications of angioembolization which occur in
more than 20% of patients.39

Our current whole body CT protocol includes arterial phase imaging of the chest
and abdomen, to include the spleen (in addition to portal venous phase images
of the abdomen and pelvis). Single phase portal venous imaging is less
commonly performed and is currently reserved for isolated blunt abdominal
trauma.

The spleen demonstrates similar injuries to other organs, including lacerations,

hematomas, infarctions, active extravasation, and CVI.

While the 1994 AAST spleen injury scale26 is widely used to report the extent of
splenic injuries, it does not include important vascular injuries. A modified grading
scale has been proposed,34 which includes these vascular injuries and better
predicts patients who may need arteriography or splenic interventions, but it has
not gained wide acceptance.

Subcapsular hematomas are assigned Grades I –III, based on the amount of

surface area covered (<10%, 10-50%, or >50%).

Intraparenchymal hematomas are assigned Grade II or III, depending on whether

the diameter is less than or greater than 5cm, and whether they are expanding.

Ruptured or expanding subcapsular or parenchymal hematomas of any size are

assigned Grade III.

Lacerations are primarily graded according to parenchymal depth, as Grade I (<

1cm deep), Grade II (1-3cm deep), or Grade III (>3cm deep) lesions.

Grade IV injuries include lacerations of segmental or hilar vessels that result in

devascularization of more than 25% of the spleen.

Grade V injuries include hilar devascularization of the spleen or a shattered

spleen.

A follow-up CT is not routinely indicated in asymptomatic patients.35 On CT

follow-up, lacerations decrease in size, prominence and number over weeks to
months.35 Patients who have been treated with angioembolization may normally
demonstrate small amounts of gas within the spleen soon after the intervention.35
Increasing amounts of gas should raise concern for infection. New ―cysts‖ may
be identified, corresponding to the pseudocysts resulting from prior intrasplenic
hematoma, and which account for 80% of cystic structures in the spleen.20
Multiple splenules may be seen following removal of a shattered spleen, typically
in the left upper quadrant, but sometimes more distally (and even in different
compartments, such as the thoracic cavity). These may be mistaken for lymph
nodes or other soft tissue masses, but appear and enhance similar to the spleen.
They represent small fragments of splenic tissue that remain viable in the patient
and enlarge following splenectomy (Fig.12). If concern remains about their true
identify, splenic tissue (and the diagnosis of splenosis) can be confirmed using
superparamagnetic iron oxide colloid-enhanced MRI or radiolabeled sulfur colloid
imaging.22
Renal Trauma
The kidneys are relatively sheltered from injury by their deep retroperitoneal
location under the posterior ribs. Preexisting renal and urinary tract anomalies,
including horseshoe kidney (Fig 13), ureteropelvic junction obstruction, and
ectopic renal position predispose to injury with minor trauma.40

Renal lacerations generally result in falsely negative FAST because the

associated hemorrhage or urine extravasation is retroperitoneal (Fig 14).41
Contrast-enhanced CT remains the gold standard for detection and
characterization of renal trauma in hemodynamically stable patients,42 with
delayed imaging to assess for involvement of the urinary collecting system. 42 The
degree of hematuria does not correlate with the severity of injury, and some
important injuries—renal pedicle injuries, renal arterial thrombosis, and
ureteropelvic junction disruption—may not have hematuria.43

Renal injuries are most frequently classified by the 1995 AAST renal injury
scale.44 Newer classification systems have been proposed45 but have not gained
wide acceptance.

An isolated extraparenchymal hematoma without renal laceration is described as

Grade I if it is subcapsular or Grade II if it is perirenal. A parenchymal contusion
is also given a grade of I. Particular to the renal contusion is the appearance of
ill-defined areas of retained contrast in the renal parenchyma on delayed phase
CT imaging. 46,47

According to AAST, lacerations are primarily graded according to parenchymal

depth, as Grade II (< 1cm deep), Grade III (>1cm deep), or Grade IV (laceration
of cortex, medulla, and renal collecting system) lesions (Fig 15-16).48 Extensive
lacerations that shatter the kidney are given a grade of V.

Vascular pedicle injuries are either Grade IV (main renal artery or venous injury
with contained hemorrhage) or Grade V (avulsion of renal hilum with
devascularized kidney).

Features that may change management but that are not reflected in the renal
OIS system include avulsion of the ureteropelvic junction, proximal collecting
system laceration (with urine leak) without parenchymal laceration, and
pseudoaneurysm not involving the main renal vessels.
Nearly any grade of renal injury, excluding those with vascular injuries, can be
treated conservatively in hemodynamically stable patients. Surgery may be
indicated when the kidney is shattered (Grade V) or is actively bleeding with
hemodynamic instability (Fig 17),43 and renal exploration frequently results in
nephrectomy.42 Angioembolization presents an alternative to surgical control in
some patients with vascular injuries.49 Injury characteristics that suggest higher
risk of significant hemorrhage include large perirenal hematoma (defined as >3.5
cm from the renal capsule to the hematoma edge), active vascular contrast
extravasation (Fig 17), and medial laceration site.50 Relative indications for
intervention also include ongoing bleeding, renal pelvis or ureteral injury, and
urinary extravasation in a patient with devitalized fragments (Fig 16C).51

In addition to parenchymal and vascular injuries, the kidney is subject to injuries

to the collecting system and renal pelvis, which result in urine extravasation. It
can be difficult to differentiate extravasated urine from hemorrhage on portal
venous phase CT imaging, so delayed imaging at 5-10 minutes post contrast
injection is vital when deep renal laceration, perinephric hematoma and stranding
or low-density retroperitoneal fluid is detected (Fig 16).52 Renal pelvis or proximal
ureteral avulsions warrant prompt intervention, while parenchymal collecting
system injuries will usually resolve spontaneously with conservative
management.42 A follow-up CT, typically consisting of low-dose non contrast and
5-10 minute delayed contrast phase acquisitions, at least 48 hours after trauma
is suggested in grade IV and V injuries treated conservatively, as complications
of urinoma or hemorrhage are more likely in these patients.42 Rarely, a urinary
leak will be masked on the initial CT with delayed detection when CT is repeated
several days later (Fig 16).53

Pancreatic Trauma

The pancreas is well protected by overlying tissues and thus is infrequently

injured. However, during blunt abdominal trauma, the pancreas can be crushed
against the vertebral column.54 The observed higher incidence of pancreatic
injuries in children is presumably due to less overlying protective tissue. 54

Pancreatic injuries are frequently missed on FAST exam due to the

retroperitoneal location.55 Classic dogma is that some pancreatic injuries can be
subtle or occult on CT imaging within 12 hours of initial trauma,56 and therefore
repeat scan at 12-24 hours may be helpful in some patients. Although often
used for screening, pancreatic enzymes can be normal within 3-6 hours of initial
pancreatic trauma,55 and mild elevations in serum amylase can be seen with
pancreatic and/or bowel injury.55

High mortality of patients with pancreatic injuries is often attributed to other

abdominal and extra-abdominal injuries, which commonly coexist, rather than the
pancreatic injury itself.57 Nevertheless, pancreatic injuries can lead to major
complications if unrecognized. Complications of pancreatic trauma include
recurrent pancreatitis, pancreatic duct stricture, pseudocyst, fistula, and
abscess.57,58 Morbidity increases if treatment is delayed more than 24 hours,58
although delay in diagnosis may not affect mortality or hospital length of stay. 57

Pancreatic injuries include contusion and laceration, and the most important
immediate concern is leak of pancreatic enzymes into the peripancreatic tissues.
Direct CT signs of pancreatic injury include focal enlargement, transection (Fig
18), or laceration.59 Nonspecific findings of pancreatic injury include
peripancreatic fluid (Fig 18), fluid between the splenic vein and pancreas (Fig
19), and main pancreatic duct dilation.59 Low density (<20HU) peripancreatic fluid
can also be seen in hypovolemic shock-bowel complex60 and aggressive fluid
resuscitation (Fig 20), simulating injury.61

Pancreatic injuries are most often classified by the 1990 AAST pancreas injury
scale, differentiating low grade injuries (contusion or laceration) without duct
disruption (Grade I or II) from higher grade injuries involving the pancreatic duct
(Grade III-V).62 Lacerations involving more than 50% of the parenchymal
thickness are presumed to involve the main pancreatic duct, even when the duct
itself is not visualized by CT (Fig 18). MDCT (16- and 64-slice scanners) had
high specificity for pancreatic ductal involvement but limited sensitivity for
pancreatic injury and pancreatic ductal injury in one multicenter trial.63 The higher
spatial resolution of modern scanners may give higher sensitivity.64 Pancreatic
MRI and MRCP may increase diagnostic confidence and provide additional
information when pancreatic injury is first detected on MDCT.65

Superficial pancreatic injuries are usually treated conservatively, with low clinical
threshold to repeat imaging. Deep lacerations of the pancreatic tail or neck with
ductal involvement (Grade III) are usually treated with distal pancreatectomy
(without or with splenic salvage), whereas pancreatic head injuries (Grade IV or
V) are very challenging to treat surgically (Fig 21).66
Adrenal Trauma

The adrenal glands are rarely affected by trauma due to their small size and
deep, protected location within the retroperitoneum. However, when adrenal
injuries occur, they are more likely to be associated with major trauma and
multiple other organ injuries.67-69 Most cases are unilateral and occur more often
on the right.67-69 Although adrenal trauma can usually be treated nonoperatively,
bilateral adrenal damage can cause adrenal insufficiency.67 Active bleeding may
be controlled surgically or endovascularly.68

CT findings of adrenal injury include focal hematoma or mass, usually measuring

up to 4 cm and distorting the adrenal parenchyma (Fig 22). A diffusely indistinct
or enlarged adrenal gland, or adrenal hemorrhage in an otherwise normal sized
gland may also be observed.67,69 Secondary signs of adrenal injury include
periadrenal fat stranding, present in most but not all patients, retroperitoneal
hemorrhage, and diaphragmatic crural thickening.67

Isolated adrenal injuries are rare. If an isolated adrenal mass is detected in the
setting of trauma without other organ injuries, periadrenal stranding, or
hematoma, non-traumatic etiologies should be considered. These include
adrenal adenoma (Fig 23), metastases, pheochromocytoma, and adrenocortical
carcinoma. Follow-up imaging with adrenal protocol CT or MR is encouraged in
several weeks to months for suspected non-traumatic etiologies.67

Conclusion
Traumatic injuries to the solid abdominal organs share many common features.
Imaging findings of vascular and parenchymal injury apply to all organs, and
result in similar CT appearances wherever they occur. However, each organ has
unique features that require additional considerations when evaluating the patient
after blunt trauma. Liver injuries may involve the biliary tract, and its dual blood
supply allows for unique fistulas. Urine extravasation can result from injuries to
the renal collecting system. Pancreatic injuries may be occult at initial imaging.
Adrenal injuries can be difficult to differentiate from masses, and may require
follow-up imaging to diagnose.
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Table 1: CT density of typical body fluids
Fluid Density (HU)
Simple fluid 0 - 10
Bile -80 - 20
Urine 0 - 20
Contrast-opacified urine 14 80 – 200
Unenhanced unclotted blood 5 30 - 45
Clotted blood 70 58 - 94
Serum 11 0 - 20
Contrast-enhanced blood 5 180 or higher

9,12
Table 2: Typical vascular injury appearances on various phases of imaging
Injury Definition Arterial Venous Delayed
Pseudo- Injury contained by Increased Density tracks No change in size or
aneurysm adventitia/perivascular (sometimes adjacent arteries shape
fibrous tissue eccentric) caliber.
Density tracks
adjacent arteries
Arteriovenous Direct arterial-venous Early venous Enlarged veins. No change
fistula communication enhancement, Density tracks
enlarged veins adjacent arteries
Arterioportal Direct connection Hyper-
fistula between hepatic enhancement of
artery and portal liver supplied by
venous branches the affected portal
branch
Dissection Injury to the intima Decreased caliber, Density tracks No change
and sometimes media irregular cross aorta
section, may have
distal occlusion or
embolism, may
see intimal flap
Spasm Circumferential Decreased caliber, Density may track No change
smooth muscle regular cross aorta or may be
contraction section, may have increased due to
distal occlusion absence of outflow
for contrast-
enhanced blood
Laceration Injury including all Irregular cross Arterial: more Arterial: decrease in
three histological section, variable extravasation, contrast density from
layers of an artery or size stable or slightly dilution with
vein, allowing Arterial: active decreased density unpopacified blood
extravasation extravasation of Venous: new Venous: additional
contrast enhancing extravasation, stable
Venous: extravasation or decreased density
hematoma, but no
enhancement
Transection Injury resulting in Arterial: abrupt Arterial: more Arterial: decrease in
 complete discontinuity termination, active extravasation, contrast density from
of vessel extravasation stable or slightly dilution with
Venous: decreased density unopacified blood
hematoma, but no Venous: new Venous: additional
enhancement enhancing extravasation, stable
extravasation or decreased density

Solid Organ Injury Figures and Legends

Fig. 1. Hemoperitoneum in a car crash victim. A. Sagittal sonographic image

shows clotted blood in the hepatorenal space (arrow) adjacent to the liver. The

similarity of its echotexture to that of the liver makes its identification difficult. B.

Transverse image in the same patient shows the serum collecting in the pelvis

with bowel loops (arrowheads) suspended in the fluid.

A B

Fig. 2. Hemoperitoneum in a 34-year-old male after a bicycle crash. A. Axial

noncontrast CT performed at an outside facility. The original interpretation

identified hemoperitoneum, but incorrectly attributed it to a splenic injury. B. A

repeat trauma CT with contrast shows a liver laceration (arrowheads) as the

etiology of the hemorrhage.

a b

Fig. 3. Axial contrast-enhanced CT shows streak artifact caused by patient

positioning with the arms at the side. Beam hardening causes this artifact which

can reduce the conspicuity of both intraperitoneal and retroperitoneal structures

in the posterior part of the abdomen, such as liver, spleen and kidney.

Fig. 4. Splenic laceration in a 17-year-old male after a motor vehicle crash. A.

Contrast-enhanced CT from outside facility performed with low contrast infusion

rate shows uniform enhancement of the spleen. B. Repeat scan with higher

contrast infusion rate shows splenic lacerations (arrowheads).

a b

Fig. 5. Contrast-enhanced CT images of solid organ injury types. A. Renal

contusion (arrow), identified by lower density than adjacent parenchyma and ill-

defined margins. B. Linear hypoattenuating lacerations of the liver (arrow) and

kidney (arrowheads). C. Liver laceration containing low-density hematoma

displacing the disrupted parenchymal margins (arrow). D. Multiple splenic

lacerations with a focus of active extravasation (arrow). E. Splenic subcapsular

hematoma with smooth margin of splenic capsule (solid arrows), displaced

splenic parenchymal margin (open arrow), and hyperdense clot (arrowhead)

within the hematoma. F. Perinephric hematoma (arrowheads) largely bounded by

Gerota‘s fascia. G. Renal infarct (arrow).

a b c
d e f

Fig. 6. Pancreatic cleft in an 18-year-old female who skied into a tree. Axial

contrast-enhanced CT shows a linear low-density finding surgically proven to be

a pancreatic cleft (arrowheads).

Fig. 7. Heterogeneous splenic enhancement in a 38-year-old female pedestrian

following motor vehicle crash. Axial (A) and coronal (B) arterial phase contrast-

enhanced CT shows heterogeneous splenic enhancement with multiple low

attenuation regions (arrowheads) that could represent splenic lacerations. Axial

(C) and coronal (D) portal venous phase images show homogeneous

enhancement of the spleen without low attenuation regions concerning for injury.

A B

C D

Fig. 8. Liver laceration in an 8-year-old male following sledding accident. A.

Coronal contrast-enhanced CT shows lacerations throughout segment 7 of the

liver. B. Lacerations extend into segment 8 (between arrows). While this would
most likely be called a Grade IV laceration, if the injury extended into all four

segments of the right lobe, even to a minor degree, it could also be classified as

Grade V.

A B

Fig. 9. Liver laceration in a 51-year-old female following motor vehicle crash. A.

Axial contrast-enhanced CT shows a liver laceration adjacent to the hepatic IVC.

B. Sagittal contrast-enhanced CT shows the same laceration less than 3cm from

the IVC. Despite the proximity of the laceration to the IVC, this patient had no

clinical or laboratory findings concerning for biliary leak, and no additional

imaging was obtained or clinically indicated.

A B
A B
Fig. 10. Hepatic subcapsular hematoma in a 24-year-old male after a fall

A. Portal venous phase contrast-enhanced CT shows active extravasation (black

arrowhead) into a subcapsular hematoma. A subtle area of decreased

attenuation adjacent to this injury (white arrowheads) suggests a laceration, but a

laceration is difficult to identify secondary to diffuse fatty liver infiltration, which

decreases liver attenuation and the difference in density between

lacerations/hemorrhage and normally enhancing parenchyma. In fact, the liver

attenuation is almost exactly the same as that of hemoperitoneum (black arrow),

and a laceration filled with blood of similar attenuation would be invisible on these

images. B. Delayed phase CT shows decreased conspicuity of the suspected

liver laceration, but increased conspicuity of the subcapsular hematoma (black

arrowheads), which compresses and deforms the underlying liver.

A B

Fig. 11. Splenic pseudoaneurysms in a 47-year-old male unrestrained driver

following high speed motor vehicle crash. Axial (A) and coronal (B) arterial phase

contrast-enhanced CT shows 2 small foci of attenuation (black arrowheads)

similar to that of the aorta, which are not visible on axial (C) and coronal (D)

portal venous phase images, consistent with small pseudoaneurysms. This

lesion would have been missed if only portal venous phase images were

obtained.

A B

C D

Fig. 12. Splenosis in a 77-year-old male after a fall. A. Axial portal venous phase

contrast-enhanced CT shows several small soft tissue structures (arrows)

adjacent to the stomach and posteromedial left hemidiaphragm. B. Similar

findings along the right abdominal wall raise the possibility of a neoplastic

process versus regenerative splenules. C. Coronal MPR shows no spleen

adjacent to the tail of the pancreas (arrow) or in the left upper quadrant. A history

of remote splenic trauma and splenectomy support the diagnosis of splenosis.

A B C

Fig. 13. Horseshoe kidney with laceration in a 42-year-old man after motorcycle

crash. Axial contrast-enhanced CT of the mid abdomen shows a horseshoe

kidney with full-thickness laceration (arrow) of the isthmus with perinephric

hematoma.
Fig. 14. Left renal laceration in a hypotensive 50-year-old man hit by a car. A.

Longitudinal ultrasound image from FAST shows left kidney (K) and spleen (S)

but no abnormal fluid in the left upper quadrant. The FAST was ultimately

negative. B. Subsequent axial contrast-enhanced CT of the left kidney shows

laceration of the medial kidney (arrowhead) and associated perinephric

hematoma (arrows).

Fig. 15. Grade 3 renal laceration in a 46-year-old man after fall. Axial portal

venous phase CT image of the left kidney shows laceration (black arrowhead)

greater than 1 cm in parenchymal depth in the medial left kidney. Accompanying

hemorrhage results in subcapsular hematoma (C) and perinephric hematoma

(arrows). No collecting system extravasation was detected on delayed images

(not shown).
Fig. 16. High-grade renal injury in a 14-year-old boy after fall from mountain

bike. A. Initial axial corticomedullary phase CT of the left kidney shows multiple

deep lacerations (white arrows). B. Delayed image obtained 10 minutes after

contrast injection shows no evidence of urine leak. This injury is therefore given

an OIS grade of III. C. Repeat scan performed 2 days later now shows multiple

sites of urine extravasation (arrows), upgrading this injury to OIS grade IV. A

filling defect (asterisk) between the contrast-opacified urine may represent blood

clot or devascularized parenchyma. Urinary extravasation with devitalized

fragments is a relative indication for surgery.

Fig. 17. Shattered kidney in a 30-year-old man after motor vehicle crash. A.

Axial arterial-phase CT through the left kidney shows a very large perinephric

hematoma (H) anteromedially displacing the left kidney, which is shattered by

numerous deep lacerations (arrowhead) containing multiple foci of active arterial

extravasation (white arrows). B. In the portal venous phase, the brisk arterial

extravasation spreads throughout the hematoma around the left kidney (black

arrows). Patient underwent immediate left nephrectomy.

Fig. 18. Pancreatic neck transection in a 27-year-old woman after skiing into a

tree. Axial portal venous phase CT in axial (A) and coronal (B) planes through

the pancreas shows ill-defined low-attenuation defect (black arrows) through the

pancreatic neck. The depth of the laceration is greater than 50% of the

parenchyma, suggesting disruption of the main pancreatic duct. Peripancreatic

fluid (white arrowheads) is a nonspecific sign of pancreatic injury.

Fig. 19. Fluid between pancreatic body and splenic vein in a 35-year-old man

after rodeo accident. A. Axial portal venous phase CT of the pancreas shows

intermediate density fluid (black arrowhead) separating the splenic vein from the

pancreatic body. Subtle hypoattenuation of the pancreatic body could indicate

contusion, and a superficial defect in the anterior pancreatic body (open arrow)

was indeterminate for a laceration or fluid within a normal parenchymal cleft. B.

Axial image from a repeat CT scan with thinner slices obtained 6 hours later

shows a full-thickness laceration (white arrows) of the pancreatic body. Patient

underwent distal pancreatectomy.

Fig. 20. Peripancreatic fluid from aggressive fluid resuscitation in a 17-year-old

burn victim with respiratory failure but no abdominal trauma. Axial portal venous

phase CT of the pancreas shows low attenuation fluid (arrows) surrounding the

pancreas. Note multiple normal parenchymal clefts.

Fig. 21. Pancreatic head laceration in a 39-year-old woman after motor vehicle

crash. Axial portal venous phase CT of the abdomen shows multiple irregular,

poorly defined lacerations (arrow) through the head of the pancreas. Adjacent

free fluid (arrowheads) is seen predominantly in the right retroperitoneum. A

drain was placed along the pancreatic head, but no excision was performed. The

patient went on to require multiple retroperitoneal explorations and repeated

drainage of necrotic material.

Fig. 22. Adrenal hematoma in a 26-year-old man after motor vehicle crash.

Axial portal venous phase CT of the upper abdomen shows a hematoma (H)
arising from the right adrenal gland, with the body of the adrenal (black

arrowhead) still visualized and periadrenal stranding (black arrow). The patient

also has a posterior hepatic laceration, partially visualized here (open arrow).

Fig. 23. Adrenal adenoma incidentally discovered in a 53-year-old man after

high speed motorcycle crash. A. Initial axial portal venous phase CT of the

upper abdomen shows a small nodule (arrow) on the right adrenal gland. Small

size, well-defined margins, absence of periadrenal hematoma or stranding, and

lack of nearby organ injuries argued against adrenal hematoma. B. Three

weeks later, the adrenal mass (arrow) is characterized as a lipid-poor adenoma

by washout criteria.