Radiologic Assessment of Penetrating Abdominal Trauma

Radiologic Assessment ofRadiologic Assessment of Penetrating Abdominal TraumaPenetrating Abdominal Trauma

John D. Gleason, Harvard Medical School, Year IIIGillian Lieberman, MD

John D. GleasonGillian Lieberman, MD March 2002

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BackgroundBackground

• All penetrating abdominal injuries must be surgically explored.

John D. GleasonGillian Lieberman, MD

• Fact: Based on war experience, surgeons in the 1950s surgically explored all penetrating abdominal trauma. Studies during the 1960s began looking at selective observation of some patients. Today, aided by modern imaging, many patients can be observed.

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Classification of Penetrating TraumaClassification of Penetrating Trauma• Gunshot wound (GSW) vs. stab wound (SW)

– Over 95% of GSWs penetrating the peritoneum require laparotomy

– About 50% of SWs go on to laparotomy

• Anterior vs. posterior stab wounds– 35% of anterior wounds do not have fascial

penetration– Posterior wounds are more likely to cause

retroperitoneal injury

John D. GleasonGillian Lieberman, MD

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Menu of TestsMenu of Tests

• Plain film- useful but insufficient for trauma evaluation

• CT• US• Peritoneal Lavage

John D. GleasonGillian Lieberman, MD

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CTCTPros:

– can evaluate retroperitoneum, pancreas, liver, kidneys, duodenum

– roughly quantify hemoperitoneum– grade injuries to solid organs and follow over time

Cons:– insensitive at detecting bowel and diaphragmatic

injuries (improved with triple contrast and coronal reconstruction)

– requires transporting patient to radiology, time consuming (poor for unstable patients)

John D. GleasonGillian Lieberman, MD

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UltrasoundUltrasound

Pros:– can be done rapidly in the trauma bay

good for detecting free abdominal fluid orpericardial tamponade

Cons:– inferior to CT for identifying and grading

solid organ injury & retroperitoneal trauma– also poor at diagnosing bowel injury

John D. GleasonGillian Lieberman, MD

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Diagnostic Peritoneal Lavage

Pros:– can be done rapidly in the trauma bay– can sometimes detect bowel contents

Cons:– cannot quantify hemoperitoneum (small, self-limited

lacerations may test positive)– no indication of source of bleeding– does not address retroperitoneal injuries

John D. GleasonGillian Lieberman, MD

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AlgorithmAlgorithmAbdominal Stab Wound

Unstable Stable

Anterior Posterior

Local Wound Exploration CTObserve

Discharge DPL or CT

Observe Ex Lap

Ex Lapor

FAST

John D. GleasonGillian Lieberman, MD

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Our Patient, M.R.Our Patient, M.R.

• M.R. is an 18-yo male who presents to the ED with a stab wound to the right back.

• A&O, c/o RLQ and R back pain.• Vitals: 180, 130/80, 18, 100% RA.• Hct 36.• No PMH/PSH.

John D. GleasonGillian Lieberman, MD

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AlgorithmAlgorithmAbdominal Stab Wound

Unstable Stable

Anterior Posterior

Local Wound Exploration CTObserve

Discharge DPL or CT

Observe Ex Lap

Ex Lapor

FAST

John D. GleasonGillian Lieberman, MD

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AlgorithmAlgorithmAbdominal Stab Wound

Unstable Stable

Anterior Posterior

Local Wound Exploration CTObserve

Discharge DPL or CT

Observe Ex Lap

Ex Lapor

FAST

John D. GleasonGillian Lieberman, MD

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Chest FilmChest Film

Limited evaluation asRight costophrenicangle cut off

Limited evaluation asRight costophrenicangle cut off

Findings

• No PTX• No left-sided

effusion• Normal

mediastinum• No abdominal

free air

John D. GleasonGillian Lieberman, MD

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

Fluid consistent with

Hematoma

Fluid consistent with

Hematoma

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

HematomaHematoma

ActiveBleedingActiveBleeding

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

HematomaHematoma

ActiveBleedingActiveBleeding

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

HematomaHematoma

ActiveBleedingActiveBleeding

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

HematomaHematoma

ActiveBleedingActiveBleeding

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

HematomaHematoma

ActiveBleedingActiveBleeding

BIDMC PACS

Kidney displaced anteriorly

Kidney displaced anteriorly

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

HematomaHematoma

ActiveBleeding

- vs -Collecting duct injury

ActiveBleeding

- vs -Collecting duct injury

BIDMC PACS

Kidney displaced anteriorly

Kidney displaced anteriorly

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

ActiveBleeding

- vs -Collecting duct injury

ActiveBleeding

- vs -Collecting duct injury

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

ActiveBleeding

- vs -Collecting duct injury

ActiveBleeding

- vs -Collecting duct injury

BIDMC PACS

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Abdominal CTAbdominal CT

John D. GleasonGillian Lieberman, MD

BIDMC PACS

Path of stab wound

Path of stab wound

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Pelvic CTPelvic CT

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BIDMC PACS

UretersUreters

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Initial CT FindingsInitial CT Findings

• Lacerations to liver and right kidney• Intra-abdominal and retroperitoneal

hemorrhage• Active extravasation of contrast• Patient clinically stable so nothing

warranted immediate surgery

John D. GleasonGillian Lieberman, MD

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AlgorithmAlgorithmAbdominal Stab Wound

Unstable Stable

Anterior Posterior

Local Wound Exploration CTObserve

Discharge Diagnostic Peritoneal Lavage

Observe Ex Lap

Ex Lapor

FAST

John D. GleasonGillian Lieberman, MD

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Further Evaluation of Renal InjuryFurther Evaluation of Renal Injury

• A CT urogram was ordered to determine whether the perirenal fluid was blood versus urine from a collecting duct injury

• To determine the source of the perirenal contrast extravasation, a CT urogram was performed 12 hours later.

John D. GleasonGillian Lieberman, MD

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CT CT UrogramUrogram: 12 hours later: 12 hours laterJohn D. GleasonGillian Lieberman, MD

R KidneyR Kidney

BIDMC PACS

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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD

R KidneyR Kidney

UreterUreter

BIDMC PACS

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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD

R KidneyR Kidney

UreterUreter

Collecting system Collecting system

BIDMC PACS

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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD

R KidneyR Kidney

UreterUreter

Collecting system Collecting system

BIDMC PACS

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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD

R KidneyR Kidney

Collecting system Collecting system

BIDMC PACS

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CT CT UrogramUrogram FindingsFindings

• Large right perirenal organizing hematoma• No evidence of extravasation of contrast

material• No injury to right collecting system

John D. GleasonGillian Lieberman, MD

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M.R.M.R.’’ss Hospital CourseHospital Course

• His Hct stabilized at 26, tolerated regular diet.

• Hepatobiliary scan revealed no leakage.• Discharged on hospital day 4 with follow-

up in trauma clinic in one week.

John D. GleasonGillian Lieberman, MD

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FollowFollow--up CTup CTOriginal CT Follow-up CT at 11 days

John D. GleasonGillian Lieberman, MD

BIDMC PACSBIDMC PACS

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Ultrasound Approach to the Ultrasound Approach to the Unstable PatientUnstable Patient

John D. GleasonGillian Lieberman, MD

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FASTFAST

• Focused Assessment with Sonography for Trauma• Performed early during resuscitation only to

identify evidence of injury (hemoperitoneum).• Four areas of attention: perihepatic, perisplenic,

pelvic and pericardial.• Well established for detecting surgical

hemoperitoneum in patients with blunt trauma (Sn 81-88%, Sp 97-100%). A recent study for penetrating trauma showed Sn 46% and Sp 94%.

John D. GleasonGillian Lieberman, MD

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PerihepaticPerihepatic FASTFAST

John D. GleasonGillian Lieberman, MD

• Hepatorenal space (Morison’s Pouch) is the most dependent area of the right upper quadrant.

• Look for hypoechoic stripe between capsule of liver and Gerota’s fascia of kidney.

Transducer in the right mid- to posterior axillary line at the level of the 11th and 12th ribs.

http://www.trauma.org/radiology/FASTruq.html

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PerihepaticPerihepatic FASTFAST

John D. GleasonGillian Lieberman, MD

Normal Perihepatic FAST Positive Perihepatic FAST

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PerihepaticPerihepatic FASTFAST

http://www.trauma.org/radiology/FASTruq.html

Normal Perihepatic FAST Positive Perihepatic FAST

John D. GleasonGillian Lieberman, MD

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PerisplenicPerisplenic FASTFAST

John D. GleasonGillian Lieberman, MD

• In the LUQ, the perisplenic area is dependent.

• Look for hypoechoic area near the spleen and kidney.

Transducer in the left posterior axillary line region between the 10th and 11th ribs.

http://www.trauma.org/radiology/FASTluq.html

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PerisplenicPerisplenic FASTFAST

Normal Perisplenic FAST Positive Perisplenic FAST

John D. GleasonGillian Lieberman, MD

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PerisplenicPerisplenic FASTFAST

Normal Perisplenic FAST Positive Perisplenic FAST

http://www.trauma.org/ortho/fastluq.html

John D. GleasonGillian Lieberman, MD

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Pelvic FASTPelvic FAST

John D. GleasonGillian Lieberman, MD

• In the pelvis, the rectovesicular or rectouterine area is most dependent (pouch of Douglas).

• Look for hypoechoic area near the bladder or uterus.Transducer is midline just superior to the

symphysis pubis.

http://www.trauma.org/radiology/FASTpelvis.html

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Pelvic FASTPelvic FAST

John D. GleasonGillian Lieberman, MD

Normal Perihepatic FAST Positive Perihepatic FAST

“Mickey Mouse ears”

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Pelvic FASTPelvic FAST

Normal Pelvic FAST Positive Pelvic FAST

http://www.trauma.org/ortho/fastpelvis.html

John D. GleasonGillian Lieberman, MD

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SubxiphoidSubxiphoid FASTFAST

John D. GleasonGillian Lieberman, MD

• The subxiphoid view inspects the heart for tamponade.

• Pericardial tamponade will appear as a hypoechoic region within the pericardial space between the visceral and parietal pericardia.

Transducer is to the left of the xiphoid process and angled upward under the costal margin.

http://www.trauma.org/radiology/FASTpericardium.html

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SubxiphoidSubxiphoid FASTFAST

John D. GleasonGillian Lieberman, MD

Normal Subxiphoid FAST Positive Subxiphoid FAST

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SubxiphoidSubxiphoid FASTFAST

Normal Subxiphoid FAST Positive Subxiphoid FAST

http://www.trauma.org/radiology/FASTpericardium.html

John D. GleasonGillian Lieberman, MD

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SummarySummary

• CT is the test of choice for assessing the degree of abdominal injury in a stable patient with penetrating abdominal trauma.

• US can be helpful in detecting free abdominal fluid in an unstable patient.

• Some patients can be successfully observed based on clinical and radiologic findings.

John D. GleasonGillian Lieberman, MD

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ReferencesReferences• Brant WE, Helms CA: Fundamentals of Diagnostic Radiology, ed 2. Baltimore, Williams &

Wilkins, 1999, pp 831-858.• Chiu WC, Shanmuganathan K, et al. Determining the need for laparotomy in penetrating torso

trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography. J Trauma. 2001;51:860-869.

• Exsanguinating pelvic trauma. http://www.trauma.org/ortho/pelvis.html• Feliciano DV, Moore EE, Mattox KL: Trauma, ed 3. Stamford, Appleton & Lange, 1995, pp

441-459, • Ng A. Trauma ultrasonography: the FAST and beyond.

http://www.trauma.org/radiology/FASTintro.html• Scalea TM, Rodriguez A, et al. Focused assessment with sonography for trauma (FAST):

results from an international consensus conference. J Trauma. 1999;46:466-472.• Shatz DV, Kirton OC, et al: Manual of Trauma and Emergency Surgery. Philadelphia, W.B.

Saunders Company, 2000, pp 119-143.• Udobi KF, Rodriguez A, et al. Role of ultrasonography in penetrating abdominal trauma: a

prospective clinical study. J Trauma. 2001;50:475-479.

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AcknowledgementsAcknowledgements

• Maria-Candida Albano, MD• Ravi Thakur, MD• Wayne Monsky, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras and Cara Lyn D’amour

our Webmasters

John D. GleasonGillian Lieberman, MD