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Abdominal trauma

Abdominal trauma . Role of CT. Dr. Ahmed Refaey. Consultant Radiologist Riyadh Military Hospital. MBBCh, MS, FRCR. Format of the lecture. Categorization of abdominal trauma patients CT technique CT findings Illustrated cases. Categories of abdominal trauma patients. Category A

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Abdominal trauma

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  1. Abdominal trauma Role of CT Dr. Ahmed Refaey Consultant Radiologist Riyadh Military Hospital MBBCh, MS, FRCR

  2. Format of the lecture • Categorization of abdominal trauma patients • CT technique • CT findings • Illustrated cases

  3. Categories of abdominal trauma patients • Category A - hemodynamically unstable patients • Category B - hemodynamically stable patients • Category C - patients with hematuria

  4. Category A“hemodynamicallyunstable” • Need rapid clinical evaluation and immediate resuscitation with volume replacement • If not responding, they should go immediately to ORwithout imaging • If they respond ( become hemodynamically stable )-- Category B

  5. Category B“hemodynamically stable” • High clinical suspicion of intra-abdominal injury ------ CT not U/S • Low clinical suspicion of intra-abdominal injury ------ U/S not CT

  6. High clinical suspicion of intra-abdominal injury

  7. don’t ask forU/S - miss 25% of liver injuries - miss 62 % of splenic injuries - most renal injuries - all pancreatic injuries - all mesenteric injuries - all gut injuries - high proportion of retroperitoneal hematoma

  8. Low clinical suspicion of intra-abdominal injury

  9. U/S • If -ve ------- > release the patient from observation * If +ve ----- CT

  10. Category C“ patient withhematuria” • CT cystograhy

  11. Categories of blunt abdominal trauma • Category A - hemodynamically unstable patients * no radiological imaging • Category B - hemodynamically stable patients * CT – if high suspicion * US – if low suspicion • Category C - patients with hematuria * CT cystography

  12. CT technique

  13. CT in blunt abdominal trauma with or without oral contrast ? • Oral contrast is unnecessary in CT evaluation in patients with acute blunt abdominal trauma

  14. Why no oral contrast ?

  15. Extravasation of oral contrast in bowel perforation -------- 0 % - 19 % • Pneumopertoneum -------- 50 % * - small perforations may seal quickly and prevent extravasation of contrast and / or air that could then be detected by CT

  16. Time delay to diagnosis • Long transit time  non opacification of distal loops • Aspiration of gastric contrast contents with subsequent pulmonary toxic effects • Interference with the diagnosis of contrast blush

  17. Oral contrast is unnecessary in CT evaluation in patients with acute blunt abdominal trauma • 96. Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004; 56(2):314-322.

  18. Is pneumoperitoneum diagnostic of bowel injury? • No it is not diagnostic of bowel injury, since air transmitted from the chest in pneumothorax is the most common cause of intraperitoneal air in a trauma patient

  19. The sensitivity of CT scan with OC for detection of bowel injuries does not significantly differ from CT without OC • Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG. Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography. Am J Surg. 1993;166:680-685 • Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994;168:670-675.

  20. Trauma protocol

  21. Blunt trauma • No oral contrast • Venous phase ----- 70 sec • Delayed scan if injury present --- 3-5 min

  22. CT findings

  23. The findings to look for • Hemoperitoneum • Contrast blush • Laceration • Hematomas • Contusion • Pneumoperitoneum • Devascularization of organs • Subcapsular hematoma

  24. * Laceration : linear shaped hypodense lesion * Hematoma : oval or round hypodense areas * Contusion : vague ,ill-defined hpodense area , that is less perfused

  25. Contrast blush • An area of high density compared to the nearby vessel representing active arterial extravasation

  26. Illustrated cases

  27. Splenic injuries

  28. Splenic laceration • hemoperitoneum • No contrast blush …managed non-operatively

  29. Lacerations Hematoma Hemoperitoneum No contrast blush .. Depending on the clinical condition , the patient will be managed

  30. Hemoperitoneum • Laceration • Hematoma • Contrast blush .. Operative management

  31. Liver injuries

  32. Green arrow: hematoma Blue arrow : contusion Yellow arrow: laceration hemoperitoneum

  33. Hematoma • hemoperitoneum • Contrast blush … managed operatively

  34. Does the presence of contrast blush necissetate operative interference ? • No It depends on if it is associated with hemoperitoneum or no

  35. Large subcapsular hematoma • Contrast blush • No hemoperitoneum … Managed non-operatively

  36. Contrast extravasation is of great importance especially if it is associated with hemoperitoneum

  37. Splenic contusion with contrast blush

  38. Laceration • hematoma

  39. Lacerations Hematoma Hemoperitoneum Contrast blush Managed operatively

  40. Avulsed Rt hepatic vein Perforated duodenum

  41. Pancreas

  42. Pancreatic injury • Rarely an isolated injury, since the pancreas is protected by the liver, spleen and the bony thorax • Usually part of a” package injury “

  43. Isolated injury

  44. Left sided package injury

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