maging of Blunt Abdominal Trauma. Luana Stanescu, MD, Joel A. Gross, MD, Michelle Bittle, MD, and F.A. Mann, MD
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solated blunt abdominal trauma (BAT) represents about5% of annual trauma mortality from blunt trauma. As part
f multiple-site injury (polytrauma), BAT contributes an-ther 15% of trauma mortality.1 Exsanguination accounts for0 to 90% of acute deaths from abdominal injury. More than5% of such cases are amenable to surgery, and recent yearsave seen safe extension of nonoperative, image-guidedreatments to most victims of blunt-force trauma.2-21 Earlyecognition and treatment decisions have been greatly im-acted by increasingly sophisticated cross-sectional imagingnd image-guided, minimally invasive therapies.22-32
lunt Disruptionsf the Diaphragm,bdominal Wall, and Flank
he diagnosis of diaphragm rupture is often missed. A highndex of suspicion for diaphragmatic ruptures is warranted inppropriate clinical circumstances, such as lateral impact ve-icle crashes, especially when left-sided, and direct frontal
mpacts. Classical findings are present in less than 40% ofeft-sided and less than 15% of right-sided diaphragm rup-ures.33-37 Diagnostic peritoneal lavage (DPL) is falsely nega-ive in 10 to 15% of cases.37-41
Delayed diagnoses are not uncommon: 10 to 15% of casesresent with more than 24 hours delay,33,35,37,42 especially ifhe commonly associated intrathoracic (�90%) and intraab-ominal (�60%) injuries require endotracheal intubationnd positive-pressure ventilation.37,43 It is believed that theositive intrathoracic pressure prevents or limits herniationf abdominal contents through the diaphragm. New, unilat-ral “elevation” of hemidiaphragm following extubation mayepresent herniation of abdominal contents through a previ-usly unrecognized diaphragm rupture.Conventional radiography (chest radiographs with enteral
ube placement; fluoroscopy) is abnormal in 60 to 90% ofcute traumatic diaphragmatic ruptures, but most findingsre nonspecific and cannot be distinguished from hemotho-
arborview Medical Center, University of Washington, Seattle, Washing-ton.
ax, atelectasis, etc. Sensitivity is 46% in detecting left-sidediaphragm ruptures and only 17% for right-sided ruptures.44
here are two classical chest radiographic findings describedor diaphragmatic rupture: intrathoracical herniation of aollow viscus, with or without a collar sign (narrowed waistf a herniated intraabdominal organ due to compression as itqueezes through the diaphragmatic rupture), and detectionf a nasogastric tube above the left hemidiaphragm.45
In case series reports, diagnostic accuracy of computedomography (CT) was equivalent, but not clearly superior, toonventional radiographic techniques.46 Thin-cut CT withultiplanar reformations is expected to improve sensitiv-
ty.47 At CT, the so-called “dependent viscera” sign (intraab-ominal contents abutting the posterior thoracic wall, espe-ially where the scan level is in the upper third of the liver orpleen) and the “collar” sign are nearly 100% specific. Otherndings, such as the “discontinuous” and thickened dia-hragm signs, show intermediate sensitivity and specificity40 to 75%).46,48 Among reported series in which magneticesonance imaging (MRI) depicted no diaphragmatic disrup-ions, no delayed diagnoses have been reported.49-51
Injuries to the muscles and fascia surrounding the perito-eum may result in three types of injuries: the most commonre type I, small defects, usually located in the lower abdom-nal wall secondary to bicycle handlebar blunt trauma. TypeI includes larger abdominal wall defects after high-energynjuries like motor vehicle accident (MVA) or a fall fromeight, while type III are associated with intraabdominal her-iations in the retroperitoneum following deceleration inju-ies.52 Contained hematomas also occur and do not typicallyequire intervention, but may require embolization for ex-anding hematomas.53-55 High-energy abdominal wall her-ias, open or closed, almost always require surgical interven-ion.56-62
njuries to the Solidntraperitoneal Organsemodynamic instability and evidence of on-going blood
oss are the strongest indicators for the need of interventionn spleen and liver injuries.8,24,63 Among hemodynamicallynstable patients that are not taken immediately to the oper-ting suite, focused abdominal sonography for trauma
FAST) and DPL are diagnostically equivalent in detecting
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Imaging of blunt abdominal trauma 197
urgically important intraperitoneal hemorrhage due to solidrgan injury(ie, selecting patients in whom laparotomy isherapeutic).64
Among hemodynamically stable patients, adjunctive diag-ostic tests and serial physical examinations support nonop-rative management.65-72 CT shows sensitivity in the mid toigh 90% in the detection of surgically important injuries ofhe liver (Fig. 1) and spleen (Fig. 2).73,74
Although useful for epidemiologic studies, CT grading ofiver and spleen injuries based on morphology of woundsoes not reliably predict the specific outcome in individualases.66,75-77 On the other hand, active hemorrhage shown byT (Fig. 3) commonly leads to endovascular or surgical in-
erventions whether bleeding is “focal ”(intraparenchymal:
Figure 1 A 42-year-old female sustained a grade IV liver lCT scan through the liver at the level of portal vein showsto the portal veins and IVC. (B) Contrast-enhanced axialhematoma. No evidence of active vascular extravasation
Figure 2 A 60-year-old male status post fall from ladderliver (A) and at the level of splenic vein (B) demonstratethe liver and the spleen, but the fluid around the spleen
hemoperitoneum was found at surgery.
seudoaneurysms versus arteriovenous fistula), “diffuse”free-flowing intraperitoneal fluid), or multifocal (most com-only seen in pelvic retroperitoneum in patients sustainingelvic ring disruptions).10,78-84
Extravasated contrast appears as relatively discrete con-rast collections that increase or “pool” on delayed imagingnd measures within 10 to 20 HU of density of an adjacentajor artery or aorta, during the vascular phase of imaging.With current generation CT scanners, contrast-en-
anced CT does not reliably distinguish between pseudo-neurysm (�70% believed to progress to rupture indults) and AV fistula (natural history is uncertain).28,84-86
arenchymal vascular lesions more often resolve sponta-eously in children, and expectant observation may be
n in a fall from a building. (A) Contrast-enhanced axialacerations involving the dome of the liver and extendingn shows small thrombus in IVC (arrow) and perihepatic
) Contrast-enhanced CT scan through the dome of thesive lacerations of spleen. Fluid is present around bother, indicating sentinel clot (arrow). More than 1 liter of
aceratiodeep lCT sca
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referable to urgent intervention.87 Notably, larger pro-ortions of blunt trauma patients show extravasationhen multidetector CT is used with higher injection rates
�2.5 ml/s) of intravenous contrast and scanning in earlyo mid portal venous phases.74,84,88-92
Patients in whom CT detects multiorgan “package” inju-ies (eg, spleen and left kidney; left lobe of the liver; andancreas) are more likely to undergo surgical intervention.93
n addition, liver lacerations that involve the hilum, particu-arly those associated with partial avulsion of the gall bladder,
ay benefit from repeated CT scanning or ultrasound,holescintigraphy, or direct cholangiography to detect possi-le biliary complications (Fig. 4).94-99
Liver lacerations involving the hepatic veins, especiallyhen associated with large regions (�10 cm) of focal hy-operfusion, are associated with injuries to the retrohe-atic vena cava that commonly require interventionFig. 5).92,100,101
During postinjury monitoring, serial CT scans do not ap-ear to be useful in altering therapy or determining the timeor return to full activities for patients without increasingbdominal pain, falling hematocrit, or clinical features of in-raabdominal sepsis.102,103 Nonetheless, if serial follow-upmaging is believed to be indicated in specific cases, ultra-ound is a more cost-effective alternative than CT.104
lunt Injuries to Retroperitoneum:uodenum and Pancreas,drenals; Kidneys andreters; and Great Vessels
etroperitoneal injuries are sometimes suspected based onlinical history, physical examination findings, and labora-
igure 3 A 43-year-old male status post motor vehicle crash (MVC).ontrast-enhanced axial CT scan through liver and spleen showsnterior splenic laceration with active extravasation (long arrow).ontrast extends into lateral perisplenic hematoma (short arrow).wo liters of hemoperitoneum was present at surgery.
ory tests (eg, microscopic hematuria),105 but often are oc-
ult. CT is the diagnostic procedure of choice, as neitherAST nor DPL adequately assess the retroperitoneum.106
onventional radiographic procedures (upper gastrointesti-al positive-contrast fluoroscopy, intravenous, or retrogradeyelography) may be helpful in secondary or follow-up eval-ations of individuals known to have sustained injuries to theuodenum and upper urinary tracts, respectively.107-110
In adults, the duodenum and pancreas are rarely injured insolation.111,112 However, children and adolescents may sus-ain isolated duodenal, or duodenal and pancreatic injuries,specially from bicycle handlebar goring mechanismsFig. 6).113
Pancreatic injuries range from contusions to lacerations,ractures, and duodenal-pancreatic disjunctions.114 The ma-ority (�50%) of pancreatic injuries are contusions, hemato-
as, or superficial capsular lacerations. An additional 20 to5% represent deeper pancreatic parenchymal lacerationsithout involvement of a major pancreatic duct.115 Injuries
o the main pancreatic duct and combined pancreatico-duo-enal injuries necessitate intervention and are often associ-ted with complicated treatment courses.114,116-119
Compared with its performance at detecting acute injurieso intraperitoneal solid organs, CT is relatively insensitive tocute pancreatic injuries, even to severe injuries completelyisrupting the main pancreatic duct or pancreatico-duodenal
unction.120-123 Direct signs include a fracture plane travers-ng the neck, body, or tail of the pancreas, or separation of theuodenum from the head of the pancreas. Indirect findingsn intravenous contrast-enhanced CT include heterogeneousnhancement or focal enlargement of the pancreatic paren-hyma and fluid around the pancreas, especially posteriorly,here it may separate the pancreas from the splenicein.94,120,124,125 Definitive diagnosis and staging of main pan-reatic duct injuries require either intraoperative, endo-copic, or MR cholangio-pancreatography.116,120,126,127
The range of duodenal injuries includes contusion, muralematoma, and lacerations (partial versus through-and-hrough).118,124,128-131 CT depiction of retroperitoneal fluiddjacent to the duodenum, especially when seen in conjunc-ion with retroperitoneal gas, suggests duodenal injury.130,132
ntravenous contrast-enhanced CT may also demonstratesymmetric mural enhancement, and duodenal hema-oma.130,133 Where intravenous contrast extravasation ishown, delayed images (5 to 30 minutes) facilitate distinctionetween medical and surgical bleeding (increased “pooling”f contrast on delayed images) and may facilitate the decisionf whether and how to intervene.130,134 Oral contrast may beelpful in delineating both pancreatic and duodenal pathol-gy. While controversy exists as to whether positive or neg-tive alimentary (eg, water) contrast provides more diagnos-ic information,128,135-139 we favor water orally or per enteralube. Although extraluminal positive enteral contrast canake a specific diagnosis of bowel rupture by CT, it is rare
hat this would be the only finding leading to surgical explo-ation, and positive contrast limits evaluation of wall anducosal abnormalities (such as absent perfusion, which is
etter visualized with negative contrast agents).
Renal parenchymal injuries (Fig. 7), whether isolated or
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Imaging of blunt abdominal trauma 199
ombined with retro- and intraperitoneal injuries, are moreommon than duodenal or pancreatic injuries.140-142 Inter-entions are more often required when the collecting systemsr ureters are injured, and when renal injuries are combinedith pancreatic or bowel injuries.142 Even when FAST or DPL
Figure 5 A 69-year-old female status post MVC. (A) Axiaactive vascular extravasation (arrow) in the region of t
intraperitoneal accumulation of extravasated contrast inferiorl
re “negative,” contrast-enhanced CT is indicated for grossematuria (all age groups); children (�15 years old) withigh levels of microscopic hematuria (�50 red blood cellser high-powered field, or 3� or greater on urine dipstick),egardless of their hemodynamic status; and adults with he-
igure 4 A 7-year-old girl in high-speed MVC, front unrestrainedassenger. (A) Initial contrast-enhanced axial CT scan shows deep
iver lacerations extending to portal vein, porta hepatis, and gall-ladder fossa. Spleen is poorly perfused, which can be a sign ofypovolemia. Large hemoperitoneum is present. (B) Initial contrast-nhanced axial CT scan shows that anterior gallbladder wall doesot enhance (arrows). (C) Follow-up contrast-enhanced axial CTcan obtained 16 days later shows large biloma along inferior sur-ace of left lobe of liver.
st-enhanced CT scan at the level of the pancreas showstal triad. (B) Axial contrast-enhanced CT scan shows
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200 A.L. Stanescu et al
aturia (1� or greater on urine dipstick, or �50� red bloodells per high-powered field) who have any documented sys-olic hypotension (�90 mm Hg).140,143-148
Dynamic contrast-enhanced CT ideally shows clinicallymportant renal vascular (vascular pedicle injuries includingissection, thrombosis, pseudoaneurysms, and AV fistulae),arenchymal (parenchymal lacerations), and collecting sys-em injuries.109,142,149,150 When low- or iso-osmolar intrave-ous contrast agents are employed, imaging during late pa-enchymal phase and after a 5- to 10-minute delay detects theresence of virtually all important upper urinary tract inju-ies.151 Repeated CT scanning 24 to 72 hours after traumaids in detection of complications among patients with high-rade renal injuries.152
Indirect intravenous contrast-enhanced CT findings ofpper urinary tract injury include perinephric strandingnd hematoma, and heterogenous parenchymal enhance-ent.153-156 Medial perinephric hematomas, especiallyhen large and extending into the root of the mesentery,
re associated with renal venous and uretero-pelvic junc-ion (UPJ) injuries.144 Otherwise, the location and size oferinephric hematoma poorly correlates with the severity
igure 7 A 29-year-old male status post MVC. (A) Axial contrast-nhanced CT scan in the interpolar region of right kidney showseep lacerations. (B) Axial contrast-enhanced CT scan at the level ofight upper pole shows active vascular extravasation (arrow). (C)xial contrast-enhanced CT scan delayed images show diffusionnd dilution of extravasated contrast within perinephric hematomat the same level as (A). Angiography demonstrated arterial extrav-sation, which was successfully embolized.
igure 6 A 11-year-old male with bicycle handlebar trauma to upperbdomen. IV contrast-enhanced axial CT scan at the level of secondnd third portions of duodenum shows retroperitoneal periduode-al hemorrhage with focal bowel thickening and discontinuity at
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Imaging of blunt abdominal trauma 201
f parenchymal injury or the need to intervene. However,arge subcapsular hematomas can be associated with sub-equent hypertension (Page kidney).157
Direct intravenous contrast-enhanced CT findings of renalnjury include parenchymal lacerations and vascular and/orrinary extravasations; the latter two necessitate interventionr follow-up imaging.144,156,158 The frequency, timing, andptimal methods for follow-up examination remain subjectsf debate. Our practice is to perform a portal venous phase ofhe abdomen and pelvis, followed by 10-minute delayed im-ges in patients with renal injuries or where unexplaineduid is found adjacent to the kidney, ureter, or bladder.Bladder ruptures may be intra- or extraperitoneal, or a
ombination.159-163 Almost all extraperitoneal bladder rup-ures (Fig. 8) are associated with high-energy osseous disrup-ions of the pelvic ring.162,164 Classical CT patterns of extra-eritoneal extravasation are “molar tooth” configuration ofontrast extravasation in the prevesical space (Fig. 8A); ab-ominal wall extension of the contrast (Fig. 8B); or, in casesith serious fascial plane disruptions, extension to scrotum,
nd/or thigh (Fig. 8C). d
Although most intraperitoneal ruptures are also associatedith high-energy osseous disruptions of the pelvis or acetab-lum, an over-distended bladder rising out of the true pelvisay rupture from direct blunt-force impact without pelvic
racture.164 Contrast extravasation can be detected in para-olic gutters (Fig. 9A), inferior peritoneal recesses (rectoves-cal/rectouterine, vesicouterine) (Fig. 9B), or surrounding theiver edge (Fig. 9C).
With combined intra- and extraperitoneal bladder rup-ure, if one component is large and the other is small, contrastay exit only through the larger defect, leaving the other
omponent undiscovered.Hematuria associated with high-energy pelvic ring disrup-
ions, especially if perivesical hematoma or bladder wallhickening is present, warrants positive-contrast cystogra-hy, which should not be considered adequate to exclude
njury unless intravesical pressure reaches at least 40mH2O.162,163,165 Delayed images of the pelvis, with passivelling of the bladder by renal excretion of contrast, are notdequate to evaluate for bladder injury, as the extent of blad-
igure 8 (A) A 40-year-old male status post three-story fall. Axial CTystogram scan at the level of acetabular roof shows “molar tooth”onfiguration of contrast extravasation into the prevesical space. (B)45-year-old male involved in a motorcycle accident (MCA). AxialT cystogram scan at the level of pubic symphysis shows anteriorladder wall rupture with a large amount of contrast and smallmount of air extending to the abdominal wall. (C) A 45-year-oldale in MCA. Axial CT cystogram scan at the level of upper thighs
hows contrast extending into scrotum, outlining testicles, and toascial planes of the left leg.
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202 A.L. Stanescu et al
With the advent of CT, adrenal injuries are now recog-ized as the most common retroperitoneal injury.166,167
he right adrenal is injured much more often than the left,nd bilateral adrenal hemorrhage is relatively rare.167,168
n association also exists between right adrenal hemor-hage and liver lacerations involving the bare area.169 De-pite their frequency, adrenal hemorrhages very rarely re-uire treatment. Embolization may be done for large,ctive extravasations associated with ongoing hemody-amic consequences.170,171
Adrenocortical replacement therapy may be needed forypoadrenalism, a very infrequent consequence of bilateraldrenal hemorrhage.172
CT findings of adrenal injuries (Fig. 10) typically dem-nstrate irregular, globular enlargement of the gland, typ-cally measuring 40 to 70 HU.173 However, definite dis-inction from preexisting nontraumatic adrenal path-logy may require targeted follow-up CT, ultrasound, or
Figure 9 (A) A 25-year-old female in car versus pedestrian accident.Axial CT cystogram scan at the level of L2-L3 shows intraperitonealcontrast in right paracolic gutter and around small bowel loops. (B)A 33-year-old male in MCA. Axial CT cystogram scan at the level ofacetabular roof identifies intraperitoneal contrast in rectovesical re-cess (long arrow) and the right and left anterolateral inferior perito-neal recesses (short arrow). (C) A 51-year-old male post forkliftinjury to the pelvis. Axial abdominal CT scan at the level of Mori-son’s pouch following CT cystogram shows intraperitoneal contrastsurrounding the liver edge.
RI.174 s
igure 10 A 63-year-old male in MCA. Axial IV enhanced CT chest can shows new, bilateral adrenal hemorrhage.
he small bowel sustains surgically important blunt injuryore frequently than the colon.175 The spectrum of bowel
njuries includes wall contusions, serosal injuries (“desero-alization”), perforations and transections, mesenteric rents,nd hematomas.176,177 When mural disruption occurs in theroximal gastrointestinal tract (stomach through proximal
ejunum), leakage of alimentary tract contents into the peri-oneum induces acute chemical peritonitis and related clini-al findings.178 Distal small bowel and colon spillage tend toresent later as peritoneal sepsis.177 Delays in diagnosis ofowel injury are associated with complicated clinical coursesnd increased mortality.179,180 Serial physical evaluation ofhe abdomen alone (ie, without adjunctive diagnostic tests,uch as CT, ultrasound or US, DPL) may be associated with24-hour delay in diagnosis of surgically important bowel
njuries in 10 to 15% of individuals with distracting injuries,uch as femur fractures.181 DPL remains a somewhat moreensitive test than CT for isolated hollow viscus injury, evenith intravenous and alimentary contrast enhancement,
hin-sections, and multidetector technologies.180,182,183 How-ver, less than 1% of surgically important blunt-force hollowisceral injuries occurring in adults are found in the absencef other, often more obvious and clinically immediate, intra-bdominal injuries.176 Conventional radiography, ultra-ound, and MRI have little or no role in the routine diagnosisf bowel injuries.184
CT performed without oral or intravenous contrast en-ancement may show intramural hematoma as focal, asym-etric hyperdensity within bowel wall with adjacent mesen-
eric edema (“misty mesentery”).128,185 Bowel contusion maye suggested on intravenous contrast-enhanced CT by focalFig. 11) or multifocal (Fig. 12) bowel thickening and mural
igure 11 A 38-year-old restrained driver, lapbelt only, in high-peed MVC. Axial contrast-enhanced abdominal CT scan at the levelf mid-abdomen shows focal thickening of jejunum in left abdo-
en. h
nhancement. Oral contrast (positive or negative) may helpn appreciation of intramural hematomas.186,187
In contrast, diffuse bowel wall thickening and enhance-ent (Fig. 13), especially associated with slit-like infrahe-atic inferior vena cava and hypodense and contractedpleen, suggests under-resuscitation and the so-called hypo-erfusion or shock bowel syndrome.188-190 Spillage of posi-ive alimentary contrast or contents and free intraabdominalas are diagnostic of bowel perforation.132,191-194
While use of oral positive contrast appears to beafe,138,195,196 its use does not seem to be diagnostically essen-ial and may delay imaging in acutely ill patients.135,136 Theombination of triangular interloop collections within theesentery and abnormal-appearing bowel wall strongly sug-
ests transmural bowel injury (Fig. 14).133
Likewise, nonphysiologic amounts of free intraperitonealuid (�75 mL in minimally resuscitated women of child-
igure 12 A 10-year-old girl involved in high-speed MVC, seat beltign. Contrast-enhanced axial abdominal CT scan at the level ofid-abdomen (inferior pole of right kidney) shows free intraperito-eal fluid with multiple focal thickening in the jejunum and cecum.
igure 13 A 23-year-old female, high-speed motorcycle crash. Axialontrast-enhanced abdominal CT scan at the level of renal hilumhows diffuse bowel thickening consistent with shock bowel, he-operitoneum, and slit-like IVC; also noted is injury to right renal
ilum.
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earing age, �25 mL in minimally resuscitated adult males,nd �25 mL in children) without evidence for intraperito-eal solid organ injury suggests occult hollow viscus injurynd should lead to additional diagnostic testing or serial ex-minations.179,197,198
Acute abdominal compartment syndrome (ACS), a poten-ially treatable and often fatal complication of trauma, is aanifestation of shock-related capillary leak and is not un-
ommon among severely injured patients who have receivedigorous fluid resuscitation.199 Although ACS may be seen inhe absence of significant intraabdominal injury, hemody-amically significant major intraabdominal trauma is a com-on antecedent. Findings at intravenous contrast-enhancedT include slit-like infrahepatic vena cava, marked diffusedema and dense mural/mucosal staining of the bowel, flat-ening of the kidneys, expansion of the intraperitoneal spacecircular cross-section of the abdomen at the level of the renaleins, elevation of the diaphragms that may invert to effacehe left and right cardiac ventricles, distension of the com-on femoral veins, and bilateral inguinal “hernias”).200-203
njuries to thebdominal Aorta and Its Mainributaries, and the Vena Cava
raumatic disruption of the midline great vessels is rare. Bothlinically and at imaging, the presence of a midline hema-oma surrounding the aorta and infrahepatic vena cava war-ants careful attention. Aortic injuries are commonly associ-ted with lapbelt injuries (thoracolumbar spine distractionnjuries) and may present with an acute aortic syn-rome.204-207 Infrahepatic vena cava injuries are suggested byurrounding pericaval or juxtacaval hematoma, contour ir-egularity, and indistinct contrast interface with irregular lu-en margins or contrast-extravasation on contrast-enhanced
igure 14 A 54-year-old in MVC crash. Axial contrast-enhanced ab-ominal CT scan at the level of lower abdomen shows abnormalhickening of the jejunum with triangular-shaped areas of mesen-eric and interloop fluid (arrow).
T.208,209
onclusionsmaging modalities of choice in evaluating blunt trauma pa-ients are CT and FAST. Intravenously contrast-enhanced CTemains the most common and efficacious means of correctlyategorizing patients into those likely manageable with non-perative techniques and those who need surgery. The in-reasing tendency of nonoperative management requiresarly identification of the lesions, which is provided by thencreasing sophistication of the CT techniques. CT also pro-ides a very important tool in following up the patients andetecting complications not initially diagnosed.
cknowledgmentse thank Dr Lee B. Talner for proofreading the manuscript
nd Dr Harigovinda R. Challa for case contributions.
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