ABDOMINAL TRAUMA-

SOLID ORGAN INJURIES

Dr. Aakanksha Gupta

Moderator- Prof. Dr. Sohan Singh
Outline

 Solid Organ
 Liver
 Spleen
 Kidney
 Pancreas
 Hollow Organ
 Bowel and Mesentery
 Bladder
 Hypovolemic Shock Complex
FAST: Focused Assessment
with Sonography in Trauma

 a decision-making tool to help determine the

need for transfer to the operating room, CT
scanner or angiography suite.
FAST

 FAST examines four areas for free fluid:

 Morrison’s Pouch
 Perisplenic
 Pelvis
 +/-Pericardium
 Morrison’s Pouch

 probe is placed in the right mid- to posterior axillary

line at the level of the 11th and 12th ribs
Perisplenic

 transducer is placed on
the left posterior
axillary line region
between the 10th and
11th ribs.
Pelvic

 transducer is placed
midline just superior to
the symphysis pubis.
Pericardial

 transducer is placed
just to the left of the
xiphisternum and
angled upwards under
the costal margin
How good is FAST?

 As a decision making tool for identifying the

need for laparotomy in hypotensive patients
(Systolic BP < 90), FAST has:
 a sensitivity of 92%,
 specificity of 96%
 Accuracy 93%
Blunt vs Penetrating

 Important to know the mechanism. It will tell

us where to look
 Penetrating Trauma i.e. stab wound requires
us to carefully look at the wound tract.
 Blunt trauma: knowing what side was injured
or seeing subcutaneous edema helps us focus
our search
Hemoperitoneum

 When seen in a trauma setting the search is

on for the source.
 Specific signs may point out the source:
 Sentinel clot
 Extravasation of IV contrast
 Location
Peritoneal Spaces

 Supine abdomen: most dependant location is

 Hepatorenal fossa (Morrison’s pouch)
 Pelvic cul-de-sac (Pouch of Douglas) or
retrovesicular fossa*

*May be the only location you find blood without

hematoma around the source organ.
Hemoperitoneum

 Unclotted blood usually has a measured

attenuation of 30-45 HU.
 Attenuation can be significantly less in a
patient with anemia or older hemorrhage.
 Blood will settle and will get a hematocrit
level.
Hematocrit Effect
Sentinel Clot

 Highest attenuation hematoma aka Sentinel

clot is that closest to the site of bleeding.
Sentinel Clot Sign
Mesenteric Fluid

 Hemorrhage from bowel or mesentery

typically flows between bowel loops.
 Mesenteric fluid has a characteristically
triangular shape due to the leaves of the
mesentery.
Mesenteric Tear
SOLID ORGANS

Liver
Spleen
Kidney
Pancreas
CT Protocol

 Blunt Trauma
 Scan the entire abdomen in portal venous phase
(70 secs.)
 Delayed scan, if the injury is present (3-5 mins)
 NO ORAL CONTRAST IS ADMINISTERED
 Penetrating trauma
 Same as in blunt trauma
 Additional scan after rectal contrast (if there is
no need of immediate surgery on the initial scan)
Liver
 commonly injured in both blunt and
penetrating trauma
 2nd most commonly involved organ
 Involved in 20-30% cases of blunt abdominal
trauma
 Most are self limiting and are often watched
by the surgeon.
 Especially if stable and no other injuries are found
on CT
 Look for vascular injury (especially venous-
active extravasation)
Liver

 Clincal Findings:

RUQ pain
R shoulder pain
Hypotension
Shock
Traumatic Liver Imaging

 Plain film: not useful

 US: hemoperitoneum
 CT: imaging modality of choice
 Angiography: to detect vascular
complications and for therapeutic
embolization
CT Imaging of Liver Injury

 Spectrum of injury:
 Contusions
 Subcapsular hematoma
 Intraparenchymal hematoma
 Linear or stellate lacerations
 Complete hepatic fracture
 Classification of Hepatic
Injuries
 Grade I
 Capsular avulsion, superficial laceration(s) <1cm deep,
subcapsular hematoma <1cm in maximum thickness,
periportal blood tracking only
 Grade II
 Laceration(s) 1-3 cm deep, central-subcapsular
hematoma(s) 1-3 cm in diameter
 Grade III
 Laceration >3 cm deep, central-subcapsular hemotoma(s)
greater than 3 cm in diameter
 Grade IV
 Massive central-subcapsular hematoma >10 cm, lobar
tissue destruction (maceration) or devascularization
 Grade V
 Bilobar tissue destruction (maceration) or
devascularization
Grade I hepatic injury. A focal capsular tear
in the posterior right hepatic lobe with an
associated small perihepatic hemorrhage.
Grade II hepatic injury. Hepatic laceration less
than 3 cm in depth in the posterior right hepatic lobe (arrow) &
the small fluid collection in the hepatorenal fossa.

-A lentiform, low-attenuation fluid collection between the liver

capsule and enhancing liver parenchyma, a finding that suggests
subcapsular hematoma. Note also the rib fracture.
Grade III hepatic injury. Subcapsular hematoma >3cm
in diameter in the right hepatic lobe (arrows). Note
the high-attenuation foci within the hematoma
(arrowhead).
Hepatic lacerations > 3 cm in parenchymal depth, with
a focus of active hemorrhage (arrowhead).
Grade IV hepatic injury. A ruptured intraparenchymal
hematoma with active bleeding in the right hepatic
lobe. Note also the associated large hemoperitoneum.

Multiple hepatic lacerations in the right hepatic

lobe, resulting in parenchymal disruption of about 50%
of the lobe.
Grade V hepatic injury. Large intraparenchymal hematoma
and lacerations that involve the entire right hepatic
lobe and medial left hepatic lobe.

Deep hepatic laceration extending into the major

hepatic veins. Note the discontinuity of the left
hepatic vein, a finding that indicates laceration. This
finding was confirmed at surgery.
Contrast Enhanced Ct-
Intraparenchymal Hematoma
Contrast Enhanced Ct-
Intraparenchymal Hematoma

Grade IV injury
Liver Contusions
Liver Contusions

Grade I injury
Subcapsular Hematoma with Liver Laceration/Periportal
Edema
Subcapsular Hematoma with Liver Laceration/Periportal
Edema

Grade IV injury
Subcapsular Hematoma with Liver Laceration/Periportal
Edema

Likeliest cause in trauma is overtransfusion

during resuscitation.
Hepatic Lacerations

 Most common liver injury

 Intact vs. disrupted capsule
 Disrupted capsule often accompanied by
hemoperitoneum
 Differentiate from hepatic fissures by their
irregular edges, location and blood density
(30-40 HU)
 Typically runs parallel to hepatic vein or
posterior segment of R portal vein
Hepatic Lacerations –cont’d
 Stellate pattern: seen in massive trauma,
complex multiple lacerations
 Multiple radiating lacerations- ‘bear claw
appearance’
 Fluid in R paracolic gutter if ant surface lacerated
 Extraperitoneal hemorrhage if laceration
involves bare liver surface between the coronary
ligaments (“Halo sign”)
 Hepatic fracture: laceration extending from one
liver surface to other
 Liver Laceration

Single hepatic laceration along the fissure of the ligamentum

teres. Lacerations commonly occur along natural planes of
hepatic vessels and fissures.
 Liver Lacerations with Active Extravasation

Axial multidetector CT scan shows focal contrast material

extravasation (arrow), which has higher attenuation than that
of intrahepatic vascular structures and the enhanced hepatic
parenchyma. The finding represents active hemorrhage.
Injury to Intrahepatic
Biliary Tree

 Mechanism: laceration extending into bile

duct
 Intrahepatic and intaperitoneal fluid can
represent bile (0-5HU)
 Biloma (collection of bile)
Hepatic Vascular
Complications
 Pseudoaneurysm & contrast extravasation
 Juxtahepatic venous injury: including tear
of IVC or hepatic veins
 Hepatic avulsion: devascularization, no
contrast enhancement of liver on contrast-
enhanced CT
Pitfalls in hepatic injury
imaging:
 False-positive interpretation of lacerations
 Streak artefacts from nasogastric tube
 Dense oral contrast
 Poor breath-holding
 Diaphragmatic slip insertions
 False positive for hematomas
 Small areas of low attenuation d/t beam
hardening effects of overlying ribs
 Can be missed in very fatty liver
Managemnet:
 Historically liver injury was managed
surgically, but at laparotomy it was found
that 70% of the bleedings had already
stopped by the time the surgeons got there.
 Non-operative management(NOM) – has
been successful in 90% patients.
 Lesser risk of delayed rupture/ severe h’ge than in
splenic injuries
 Dual blood supply protects liver from traumatic
regional infarction
 Angiography and embolisation- have improved
the success rate of NOM.
Spleen
 Most frequently injured organ in blunt trauma
(about 40%)
 Seen in 25% patients with left renal trauma & 45%
with hepatic trauma
 Contributory factors-
 Injury from fractured ribs
 Intra-abdominal compression
 Rich vascular supply
 Splenomegaly/ splenic disease
 Injury may be contusion, hematoma or laceration.
 Traditionally treated with splenectomy now a
selective approach is used
Traumatic Splenic Injury

 Imaging
 Plain film: not useful
 US: hemoperitoneum
 Contrast-enhanced CT: imaging
modality of choice
 Angiography: therapeutic embolization
Imaging protocol:

 Optimal time for detection of intrasplenic

injuries- 50-60sec- uniform enhancemnet of
spleen
 Earlier arterial phase- for active extravasation
or traumatic pseudoaneurysms/ AV fistulas.

Beware of-
Congenital splenic clefts- may simulate
lacerations
 Classification of Splenic
Injury
 Grade I
 Small capsular laceration and/or parenchymal laceration
smaller than 1 cm
 Small subcapsular hematoma smaller than 1 cm
 Grade II
 Parenchymal laceration 1-3 cm
 Central or subcapsular hematoma 1-3 cm
 Grade III
 Parenchymal laceration deeper than 3 cm and less than 10cm
 Central or subcapsular hematoma 3-10 cm
 Grade IV
 Fragmentation spleen (>3 segments) / Shattered spleen
 Splenic tissue maceration/ devascularisation(non-enhancing
spleen)
Grade I injury: Multiple poorly defined areas of
decreased attenuation. They are not linear so
they are not lacerations.
This is the classic presentation of contusions.
Grade II splenic laceration (<3cm) without free intra
peritoneal blood. Areas of high attenuation are seen
within and represent a posttraumatic vascular lesion.

Selective splenic arteriogram shows an arteriovenous

fistula in the midpole of spleen, which was embolized
successfully with microcoils.
Grade III splenic injury: Round and oval
hypodense areas consistent with
intrasplenic hematoma (>3cm).
No active bleed.
Grade III splenic injury: Areas of enhancing
splenic parenchyma within the low-attenuating
grade III splenic laceration (>3cm).
Grade IV splenic injury: Parenchymal lacerations.

There is also active bleeding with a contrast blush

with the density within the range of the density of
the aorta. Also hemoperitoneum, so this patient
will probably need surgery.
Grade IV - Splenic Rupture with Perisplenic hematoma

Vascular contrast material extravasation- focal areas of

enhancement in the intrasplenic/perisplenic hematoma which are
higher in attenuation than adjacent normal splenic parenchyma.
Grade IV- Splenic Rupture with Active Extravasation
Management protocol:

Depends on:
 Patient’s hemodynamic stability after initial
resuscitation
 CT severity grade
 Associated intra-abdominal injuries
 Patient’s age
 In children:
 hemodynamic state is a better predictor
 NOM(non-operative management) has a
better outcome and is usually undertaken
 Thicker splenic capsule and vascular supply
more sensitive to adrenergic stimulation
 In adults:
 Only 15-30% are appropriate for NOM
 Wait n watch is risky- delayed surgical
intervention can result in lesser splenic salvage
 Angiography and embolisation- improve the
success of NOM even in high-grade injuries
 Angiography- more accurately predicts need
for surgery
 In >55 years:
 Only 9% success rate with NOM
 Intervention is choice of treatment mostly
Pancreas

 Rarely Injured
 Usually injured in penetrating trauma
 Crush injuries (hitting handlebars)

 4% overall incidence.
 1.1% incidence in penetrating trauma and
only 0.2% in blunt trauma. Rarely an
isolated injury. Usually part of a 'package
injury
pancreas

early diagnosis is crucial,

since delayed complications
such as fistula, abscess,
sepsis, and hemorrhage
may lead to significant
mortality
Traumatic Pancreatic Injury

 Imaging:
 US: limited use
 Contrast-enhanced CT: modality of
choice
 ERCP: to demonstrate pancreatic
duct anatomy prior to pancreatic
surgery
 MRCP
 Classification Pancreatic
Injuries (OIS classes)
Grade Injury Description
I Hematoma Minor contusion without duct injury
Laceration Superficial laceration without duct injury
II Hematoma Major contusion without duct injury
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 involving the ampulla or bile duct
V Disruption Massive disruption of the pancreatic head
Grade I pancreatic injury in a patient who experienced blunt abdominal
trauma. Axial CT image shows a minor contusion of the pancreatic body .
There is no pancreatic duct injury and no active bleeding. Note the
hematoma of the anterior abdominal wall at the site of the injury
Grade II pancreatic injury: tail contusion & peripancreatic haematoma
bilateral adrenal contusions
Grade II pancreatic injury: tail contusion & peripancreatic haematoma
Left renal subcapsular hematoma
Grade III pancreatic injury: Pancreatic body contusion
transection across the pancreatic body
Grade III pancreatic injury:

•Parenchymal contusion
•Distal Duct disruption
•Distal transection
Grade III pancreatic injury:

•Distal transection
•Active extravasation of contrast
•Splenic and hepatic injuries
Grade III pancreatic injury:

•Distal transection & Active extravasation of contrast

•Splenic and hepatic injuries
Grade IV pancreatic injury:
proximal pancreatic transection & a large peripancreatic hematoma.
active bleeding
Grade IV
pancreatic
injury:

•proximal
pancreatic
transection at
neck

•Duct
disruption

•peripancreatic
hematoma.
 Management

OIS grade 1 and 2 - Conservative

(NOM)

OIS grade 3 to 5 - Operative

Ductal disruption

High risk of psedocyst /abcess/ fistula formation

Surgery mandatory