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CT OF ABDOMINAL TRAUMA: A STEP-BY-STEP APPROACH

Robert A. Halvorsen, Jr., M.D.

ABSTRACT Patients subjected to trauma to the abdomen and pelvis suffer a wide variety of injuries, many of which can be detected by computed tomography (CT). This article provides a rigorous step-by-step routine useful in the interpretation of these studies, in order to decrease the number of missed traumatic lesions. The routine includes (1) search for pneumothorax and pneumoperitoneum using lung windows for lower thorax and upper abdominal sections and soft tissue windows for lower abdominal and pelvic sections; (2) search of left paracolic gutter and spleen for blood or laceration; (3) search of right paracolic gutter and liver, for blood or laceration; (4) upper abdominal survey evaluating duodenum and pancreas; (5) retroperitoneal survey of kidneys, adrenals, IVC and aorta for evidence of bleeding, laceration, hematoma, urinoma or signs of hypotension; (6) search of GI tract and mesentery for extravasation or hematoma; (7) muscle survey including psoas, iliopsoas, rectus abdominus and buttocks for hematoma; (8) bone survey including ribs, transverse processes, sacrum, and SI joints and hips for fracture; (9) lowest section search for thigh hematoma. This pictorial essay illustrates examples of trauma found in each of these steps as well as potential pitfalls in the interpretation of CT of the abdomen and pelvis in the traumatized patient. Key Words Trauma, computed retroperitoneum. tomography, abdomen, pelvis, peritoneum,

INTRODUCTION

Trauma is a significant public health problem representing the third leading cause of death in the United States. Trauma is the leading cause of mortality in the under 40 population [1]. This pictorial essay is intended to review major findings on abdominal CT in the traumatized patient. Common mistakes and pitfalls in interpretation along with a step-by-step technique useful for the interpretation of the trauma CT will be described.

INDICATIONS FOR CT The primary role of CT is to assess the severity of abdominal injuries in order to help the trauma surgeon decide if emergent surgery is necessary. Therefore, if surgery is mandatory due to the severity of the abdominal trauma, then CT is generally avoided. For instance, hypotensive patients or those that are hemodynamically unstable generally are not candidates for CT evaluation as operative intervention is mandatory. In hemodynamically stable patients, indications for an abdominal CT include a clinical examination suggesting significant blunt abdominal trauma or an equivocal clinical examination of the abdomen [1]. Trauma patients in whom a clinical examination is impossible due to altered mental status because of either head trauma or intoxication often warrant abdominal CT to exclude abdominal pathology. Patients who have sustained penetrating trauma to the peritoneum require operative evaluation, not CT. However, penetrating retroperitoneal trauma in the hemodynamically stable patient does not always require surgical intervention. Therefore, patients with penetrating retroperitoneal wounds are appropriately evaluated by CT to determine the extent of injury.

MECHANISM Appropriate and detailed clinical history is often helpful in the interpretation of CT. The simple description of "motor vehicle accident" is inadequate. Knowledge of the actual mechanism, i.e. roll-over, ejected from car, lap belt without shoulder belt, etc., is helpful in the evaluation of the traumatized patient. For example, the history, "fall", is inadequate, as the pathophysiology of trauma depends on how the blow is inflicted. A patient who falls and lands

on his or her feet will often sustain calcaneal, hip, pelvic or spine fractures. A patient with an abdominal impact will have a deceleration injury similar to a head-on motor vehicle accident with splenic, hepatic, or duodenal injuries, while a patient who lands on his or her back may have cardiac lacerations or diaphragmatic rupture.

SFGH ROUTINE The interpretation of the trauma CT requires attention to detail. We have found that use of a rigorous routine in the interpretation of these studies significantly diminishes missed traumatic lesions. Our routine consists of evaluation the following: 1. Rule out pneumothorax, pneumoperitoneum 2. Spleen and left paracolic gutter 3. Liver and right paracolic gutter 4. Upper abdominal survey including duodenum and pancreas 5. Retroperitoneal survey: kidneys, adrenals, IVC and aorta 6. GI tract and mesentery 7. Muscle survey: psoas, iliopsoas, rectus abdominus, buttocks 8. Bone survey: ribs, transverse processes, sacrum, SI joints, hips 9. Lowest section: search for thigh hematoma 1. Pneumathorax/Pneumoperitoneum In our experience the most frequently overlooked finding in trauma CT is a pneumo-thorax. We use lung windows to search for pneumothorax as well as pneumo-peritoneum in the upper abdominal slices. Our routine for filming includes lung windows only on sections that contain lung. In order to detect a pneumoperitoneum on lower abdominal and pelvic CT sections we routinely use soft tissue window setting. Proper filming technique is important in order to ensure that fat can be differentiated from air. If both fat and air are filmed to look black, small extraluminal gas collections will be overlooked. Remember that pneumoperitoneum may be small in amount and have the appearance of a bubble [2]. While large amounts of pneumoperitoneal gas

may be found in the midline, it is not unusual to see small bubbles of free air laterally or caught in mesenteric loops. 2. Spleen Survey We evaluate the spleen twice. First, we look within the splenic parenchyma for any areas of low density. Second, we look around the periphery of the spleen for subtle lacerations or perisplenic blood. After searching the immediate perisplenic space, we then look in the left paracolic gutter inferior to the spleen for small amounts of blood. Federle et al. described their experience at San Francisco General Hospital in 1987 [2]. They reviewed 56 cases of splenic injury and found that CT was effective with only one false-negative and three cases of false-positive CT findings. CT detected hemoperitoneum in 98%, perisplenic clot in 85%, splenic lacerations in 71%, subcapsular hematoma in 24%, and an inhomogeneous splenic parenchyma in 15%. An important conclusion from this study is that splenic laceration is not always detectable on CT despite the fact that there is significant trauma to the spleen. As laceration was seen in only 71%, approximately one-fourth of patients that required splenic surgery had no detectable splenic laceration on CT. Of more importance than detecting a laceration, is the identification of the "sentinel clot" [3]. Sentinel clot represents thrombosed blood adjacent to the bleeding site. A sentinel clot may be the only clue to a significant splenic injury. The CT number of clotted blood is high with a CT number greater than 60 H [3] and is usually found near the site of bleeding. When intraabdominal fluid is encountered in the trauma CT patient, analysis of the density of the fluid is extremely helpful [4-7] (Table 1). Table 1: Intraabdominal Fluid CT Density in Hounsfield Units (H) Arterial bleed [7] Clotted blood [4] Serous blood [5] Small bowel contents [6] Ascites 80130 H 60 H 25 H -10 +20 H -10 +20 H

Hemoperitomeum in the acute setting yields an abdominal fluid with a range generally from 30-45 H [5]. Generally, the CT number of the fluid will remain above 30 H for 48 hours. Occasionally, a hematocrit phenomena or fluid-fluid level can be identified in a patient in whom clotting has not occurred, and is often found in the paracolic gutters. The identification of the sentinel clots is often the most helpful finding to identify the site of bleeding. 3. Liver Survey The liver is the most commonly traumatized organ in trauma patients when both blunt and penetrating trauma is considered, while in blunt trauma patients the spleen is the most commonly injured organ [8, 9]. Our survey of the liver is similar to that of the spleen with an initial review of the deep hepatic parenchyma in the search for laceration or hematoma. A second review of each slice containing liver evaluates the margin of the liver in the search for subtle lacerations and perihepatic blood. Then, we look in of the right paracolic gutter for small amounts of blood. 4. Upper Abdominal Survey We check the scout films for gastric distention. Excessive gastric distention may be a sign of an obstruction from a duodenal hematoma. Duodenal hematomas may be subtle with only mild thickening of the duodenal wall. Periduodenal fluid suggests a tear of the serosal surface of the duodenum. Pancreatic lacerations are often difficult to diagnose on the immediate CT study [10, 11]. Often the only findings detectable are subtle inhomogeneity of the pancreas or perhaps some thickening of Gerota's fascia due to early traumatic pancreatitis. It is not unusual to have difficulty making the diagnosis of traumatic pancreatitis on the initial examination, requiring a follow-up CT in two to four days to confirm the diagnosis. The clinical diagnosis of pancreatic trauma is also difficult, as serum amylase may be normal in a patient with pancreatic trauma and the amylase may be elevated due to other injuries such as facial trauma involving salivary glands. Pancreatic trauma is of significant concern in the abdominal trauma patient with pancreatic trauma occurring in 3-12% of patients with blunt injuries to the abdomen [10]. The death rate from pancreatic trauma is 16-20%. Pancreatic

lacerations tend to occur at the junction of the head and body or the body and tail due to shearing injuries with compression against the spine. The severity of pancreatic trauma is dependent upon the depth of the laceration and the status of the pancreatic duct. A transected pancreatic duct requires surgical repair. If CT is indeterminate for pancreatic ductal laceration, then an emergency ERCP may be indicated to assess the integrity of the pancreatic duct. 5. Retroperitoneal Survey Indications for CT evaluation of the patient with suspected retroperitoneal injury vary with the mechanism and severity of injury. Retroperitoneal penetrating wounds in the region of the kidneys warrant a CT. With blunt trauma the relative role of CT versus IVP is somewhat controversial. In some institutions an IVP is used only in unstable patients to ascertain whether both kidneys are functioning before these patients are taken to the operation room. In the blunt trauma patient with suspected renal injury, CT is indicated with gross hematuria or with microscopic hematuria in a patient with hypotension. The kidneys and adrenals need to be evaluated for traumatic derangement. An IVP can be used in place of CT if there is a low index of suspicion for renal involvement. In a review of 10 years' experience with 1,146 patients, Mee et al. described their experience in patients with blunt or penetrating injuries to the kidneys [12]. In the patients who had suffered blunt trauma (1,107 patients), 44 patients had suffered significant renal injury. Of the 812 patients with microscopic hematuria and no shock, none had a significant injury suggesting that CT may not be warranted in patients without shock and with only microscopic hematuria. However, with penetrating wounds they found that 88 patients had significant injuries, 64 of whom required surgical repair. "Many" had little or no hematuria in the 138 patients studied who had suffered penetrating wounds. Renal injuries can be classified as mild, intermediate, and major injuries [1]. Mild injuries represent the majority of cases (85%), consist of lesions such as contusion, perirenal hematomas or small infarcts, and require only conservative management. Intermediate injuries represent only 10% of renal injuries and consist of lacerations including those that extend into the collecting system, and fractures of the kidney (defined as a laceration that

extends from one surface to another). The treatment for intermediate renal injuries is often non-surgical. Major injuries of the kidneys occur less frequently (5%) and consist of renal pedicle injuries, shattered kidneys, and uretero-pelvic junction (UPJ) avulsions, which require surgical treatment. Renal pedicle injuries can be either arterial or venous. Kidneys without arterial blood supply demonstrate essentially no renal enhancement on CT except for a thin cortical rim of preserved enhancement due to capsular arteries. Renal vein trauma is missed more frequently than arterial injuries, and CT findings include a swollen non-enhancing kidney, sometimes with a thick rim of enhancement. Occasionally, a thrombus is detectable within the renal vein on CT. With renal trauma, CT findings include laceration, fracture and perirenal blood as well as perirenal urinoma. A finite period of time following the trauma is required for enough extravasated urine to accumulate to be detectable by CT. A delayed CT obtained a few minutes later than the initial enhanced CT allows time for extravasated iodinated contrast to accommodate facilitating identification of the leaking urine. After evaluating the kidney and adrenals for hematoma, it is important to examine the size of the inferior vena cava (IVC) and aorta. Patients who are hypotensive on the CT table will demonstrate diminished caliber of the aorta and IVC. Shock is divided into three categories: compensated, uncompensated, and irreversible shock [13]. Compensated shock suggests a normal blood pressure. Hypotension is generally considered to be present when an adult's systolic blood pressure in the adult is less than 100, or a child's is less than 80. CT findings suggestive of uncompensated or irreversible shock include a collapsed inferior vena cava or small-caliber aorta [14]. If flattening of the IVC is noted on at least three slices in the infrahepatic IVC, then shock should be suggested. Remember that one deep inspiration can also produce a flattened cava mimicking the appearance of shock. The aorta is considered small if it measures less than 6 mm in AP diameter measured at level 1 cm below the take-off of the superior mesenteric artery. 6. Bowel Survey

While bowel trauma is infrequent, representing only 5% of patients with blunt injuries to the abdomen it has a significant mortality [15]. If patients with bowel laceration are treated with surgical repair within 24 hours of the injury, the mortality is only 5% but the mortality increases to 65% with late treatment. Injuries to bowel from blunt trauma tend to occur at transition points where bowel enters or leaves the retroperitoneum, as shearing injuries occur at these locations. Such sites include the ligament of Treitz, the ileocecal valve, and the hepatic and splenic flexures of the colon. Bowel trauma is a pitfall of abdominal CT. Patients with significant bowel injury may have CT findings that are subtle or non-existent [2, 15]. Traumatized bowel may demonstrate a thickened wall, a sentinel clot, or appear normal on CT. Complete transmural laceration of the bowel does not necessarily produce bowel wall thickening; approximately 25% of cases will still have normal bowel wall thickness by CT. Therefore, a normal appearing bowel wall on CT does not exclude an injury. Occasionally, extraluminal air can be identified. The presence of extraluminal air is of low sensitivity in the diagnosis of small bowel injury because the proximal small bowel often contains little of no air. Extravasation of oral contrast is diagnostic of bowel laceration but is rarely seen. Focal mesenteric infiltration or edema can suggest adjacent bowel trauma but is non-specific. Occasionally the only sign of a bowel injury is mesenteric fluid or blood. When the CT density of fluid is high, a sentinel clot is obvious and the diagnosis is straight forward. However, when the density of the fluid approaches that of water, the mesenteric fluid may represent either extravasated fluid from the small bowel lumen or an incidental, non-traumatic fluid collection such as ascites. However, ascites is often found in the paracolic gutters or in the pelvis, while traumatic fluid collections from bowel more frequently have an interloop or mesenteric location. 7. Muscle Survey Part of the routine in every case should be the evaluation of the psoas and iliopsoas muscles for hematomas. We always look at the rectus abdominus muscle for asymmetry in order to detect rectus sheath hematomas. Remember to look at the buttocks as relatively large hematomas can be present in the buttocks and not be evident clinically.

8. Bone Survey Any patients with atelectasis or pneumothorax should have a careful examination for rib fractures on CT. Remember to look at all of the transverse processes of the lumbar spine. Subtle fractures of transverse processes are frequently overlooked on CT and may be a warning sign for a significant retroperitoneal injury. Another pitfall in the interpretation of trauma CT is the subtle "buckle" fracture of the sacrum. Evaluation of the flat-appearing sacrum at S2 is helpful in the detection of buckle fractures. 9. Lowest Cut The last and lowest section on the CT examination should be evaluated for hematomas of the thigh.

CONCLUSION The use of a rigorous and routine survey while interpreting CT of the abdomen and pelvis in patients with trauma will greatly diminish errors in interpretation.

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SUGGESTED READING 1. Wolffman NT, Bechtold RE, Scharling ES, et al. Blunt upper abdominal trauma: evaluation by CT. AJR 1992; 158:493-501 Mirvis SE, Gens DR, Shanmuganathan K Rupture of the bowel after blunt abdominal trauma: diagnosis with CT. AJR 1992; 1569:1217-1221 Federle MP, Griffiths B, Minagi H, et al. Splenic trauma: evaluation with CT. Radiology 1987; 162:69-71 Orwig D, Federle M Localized Clotted Blood as Evidence of Visceral Trauma on CT: The Sentinel Clot Sign. AJR 1989; 153:747-749 Federle MP, Jeffrey RB Jr. Hemoperitoneum Studies by Computed Tomography. Radiology 1983; 148:187-192 Nghiem HV, Jeffrey RB Jr., Mindelzun RE CT of blunt trauma to the bowel and mesentery. AJR 1993; 160:53-58 Jeffrey RB Jr., Cardoza JD, Olcott EW Detection of Active Intraabdominal Arterial Hemorrhage: Value of Dynamic Contrast-Enhanced CT. AJR 1991; 156:725-729 Becker CD, Spring P, Glttli A, Schweizer Blunt splenic trauma in adults: can CT findings be used to determine the need for surgery? AJR 1994; 162:343-347

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Patten RM, Spear RP, Vincent LM, et al. Traumatic laceration of the liver limited to the bare area: CT findings in 25 patients. AJR 1993; 160:1019-1022 Jeffrey RB Jr., Federle MP, Crass RA Computed tomography of pancreatic trauma. Radiology 1993; 147:491-494 Dodds WJ, Taylor AJ, Erickson SJ, Lawson TL Traumatic fracture of the pancreas: CT characteristics. J Comput Assist Tomogr 1990; 14:375-378 Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR Journal of Urology 1989; 141:1095-1098 Guyton AC Circulatory Shock and Physiology of Its Treatment. In: Guyton AC (ed.), Textbook of Medical Physiology. 8th Edition. Philadelphia: Saunders, 1991; 263-271 Jeffrey RB Jr., Federle MP The collapsed inferior vena cava: CT evidence of hypovolemia. AJR 1988; 150:431-432 Rizzo MJ, Federle MP, Griffiths BG Bowel and Mesenteric Injury Following Blunt Abdominal Trauma: Evaluation with CT. Radiology 1989; 173:143-148 Donohue JH, Federle MP, Griffiths BG, Trunkey DD Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries. J Trauma 1987; 27:11-14

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