Blunt Abdominal Trauma:

Injury to the Epigastrium

Mria

Nmethy, Harvard Medical School, Year III
Gillian Lieberman, MD
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
2
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Blunt Abdominal Trauma (BAT)

Trauma is the leading cause of death in the
United States in persons under 45 years of
age

Because it primarily affects the young, trauma
causes more lost years of productive life than
cancer and cardiovascular disease combined

Blunt trauma accounts for 2/3 of all injuries

Majority of abdominal injuries are due to blunt
trauma; 10% of trauma fatalities are due to
abdominal injury
3
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Mechanisms of injury

Compression: direct blow or against a fixed object
(seat belt, spinal column)

Generally results in tears or subcapsular

hematomas in
solid organs

Increased intraluminal

pressure can cause rupture of
hollow organs

Deceleration: stretching and linear shearing
between fixed and movable structures

Rupture of supporting elements at junction between fixed
and free segments of organs

Thrombosis of vessels contained within supporting
elements
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Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Injuries resulting from blunt
abdominal trauma

Common:

Liver

most commonly injured in all abdominal trauma
(blunt and penetrating)

Spleen

most commonly injured organ in blunt trauma

Kidney

increasing frequency (increased detection)

Bladder (extraperitoneal)

Rare:

Pancreas

Adrenal

Bowel

Bladder (intraperitoneal)
5
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
First, a brief review of retroperitonal
anatomy.
Note the crowding of the numerous soft
organs in the epigastrium, with little
bony protection. Unlike small bowel,
these organs are fixed in place, and
so cannot move out of the path of
blunt traumatic forces.
6
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Abdominal Retroperitoneum
Netter FH. Atlas of Human Anatomy, 2
nd
ed.
Pancreas
Duodenum
(retroperitoneal)
Right kidney
Left kidney
Inferior vena cava
Abdominal aorta
7
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Epigastric

region
Netter FH. Atlas of Human Anatomy, 2
nd
ed.
IVC
Right adrenal
Right kidney
Duodenum
Transverse colon
Abdominal
aorta
Left adrenal
Pancreas
Left kidney
8
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Options for evaluating BAT

Plain film

Difficult to evaluate soft-tissue injury

May reveal free intraperitoneal

air or signs of
bowel obstruction

Deep peritoneal lavage

Rapid detection of hemoperitoneum

Invasive

Risk of visceral and vascular injury
9
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Options for evaluating BAT

CT gold standard for BAT evaluation

MDCT: high-resolution images and reconstructions
allow improved detection and management of soft-

tissue injury, hemorrhage, etc

Ultrasound

increasing use

Safe for unstable patients; decreased costs

Limitations: fluid-filled bowel versus hemoperitoneum;
extraperitoneal

fluid versus intraperitoneal

fluid; cystic
masses can look like fluid collections; obesity

MRI

not used in initial evaluation of BAT
10
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Our Patient
JO, a 23-yr-old woman kicked in the
stomach by a horse

Imaging at outside hospital
suggested pancreatic injury; JO was
transferred to BIDMC for more
complete evaluation
11
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Initial plain films were normal
Images from PACS, BIDMC
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Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
CT: the diagnostic modality of
choice in initial evaluation of
blunt abdominal trauma
13
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
CT: pre-contrast
Images from PACS, BIDMC
Mesenteric hematoma
Blood attenuation in
duodenal wall
14
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Post-contrast: Pancreatic injury
Images from PACS, BIDMC
Fluid surrounding pancreas
Blood surrounding pancreatic head
15
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Pancreatic injury in BAT

Epi: uncommon

seen in 0.2-12% of blunt trauma

associated visceral injuries are very common (50-90% of
patients)

Mechanism:

compression against vertebral column

shear across pancreatic neck

Sequelae:

Ductal

leakage pancreatitis, which can
lead to pseudocysts, fistulas and abscesses (20%
mortality)

Grading: based on injury to main pancreatic duct:

minor injuries usually heal spontaneously and are treated
conservatively

injuries involving main pancreatic duct require surgical
intervention
16
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
CT findings in pancreatic injury

CT sens/spec for pancreatic injury over 80%;
dependence on interpreter experience and timing of
evaluation

Contusion: areas of low attenuation with
heterogeneous foci and diffuse enlargement of
pancreas

Laceration: areas of linear, irregular low attenuation
within normal parenchyma

Nonspecific: thickening of anterior pararenal

fascia;
blood/fluid tracking along mesenteric vessels; fluid in
lesser sac; fluid between pancreas and splenic

vein
17
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Image from PACS, BIDMC Image from PACS, BIDMC
Ischemic kidney
Extravasation

of IV contrast
Renal injury
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Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Renal injury
Right kidney
Left kidney
Images from PACS, BIDMC
Ischemic kidney
19
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Renal injury in BAT

Epi:

Seen in 10% of trauma patients; blunt trauma
accounts for 80% of renal injuries

Left-sided predominance (1.3:1)

thought to be due to
anatomic protection of right renal artery beneath inferior
vena cava and duodenum

Mechanism:

sudden deceleration/direct blow can cause renal
dislocation

stretching of renal arteries can cause immediate avulsion
or delayed thrombosis

Sequelae: 80% are contusions/minor lacerations
that heal spontaneously; persistent bleeding or
complete infarction require surgical intervention
20
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
CT findings in renal injury

CT important in both diagnosis and patient
management: provides both functional and
morphologic information

Absence of contrast nephrogram

reveals
devascularized

areas

Helical CT can image specific renal artery injury

Contusion: delayed and non-homogenous excretion
of contrast material

Laceration: linear or wedge-shaped hypodensity

Fracture: involvement of full depth of renal
parenchyma + disruption of collecting system
21
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Duodenal hematoma
Image from PACS, BIDMC
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Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Duodenal injury in BAT

Epi: Bowel injury seen in 4-5% of major BAT;
associated non-bowel injuries in 50%

Retroperitoneal duodenum most common site of injury

Duodenal hematomas are very uncommon!

Mechanism:

Compression between spine and impacting body;

Shearing at fixed points (e.g. ligament of Treitz)

Sequelae:

Duodenal hematoma: resolves in 1-3 weeks

Duodenal perforation: surgical intervention required
23
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
CT findings in duodenal injury

Nonspecific (perforation vs. hematoma):

Thickening of duodenal wall

Presence of fluid in right anterior pararenal

space

Specific to perforation: Extraluminal

gas and/or
oral contrast in right anterior pararenal

space

Duodenal hematoma:

Initial heterogeneous, high attenuation region in
duodenal wall due to blood accumulation

Isodensity, then hypodensity

as clot resolves
24
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Intraperitoneal

bleeding
Uterus
Air in rectum
Intraperitoneal

blood
in Douglas

pouch
(HU = 50)
Image from PACS, BIDMC
25
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Intraperitoneal

fluid in BAT

Is often sole finding on CT in blunt
abdominal trauma

Tracks down right and left paracolic

gutters into pelvic reflection of peritoneum

Large amounts of blood can accumulate in
pelvis without significant hemoperitoneum

apparent in upper abdomen
26
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
CT: detection of intraperitoneal

fluid

CT very sensitive for detecting even small
amounts of intraperitoneal

fluid or hemorrhage

Sentinel clot

sign: with multiple sites of
hemoperitoneum, blood with highest CT
attenuation is in proximity of site of hemorrhage

Blood attenuation on CT:

Free blood: 20-45 HU

Clotted blood: 40-100 HU

Active bleeding: within 10 HU of contrast density
inside adjacent major vessel
27
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
How extensive was the pancreatic
injury?
The role of MRI
28
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
MRI: characterization of soft tissue injury

MRI is more sensitive for soft tissue
anatomy and pathology

No advantage over CT in initial evaluation,
but can be invaluable in characterization of
subtle soft tissue injury, as in the pancreas

Role of MRCP: evaluate damage to
pancreatic duct

key factor in surgical
versus conservative treatment
29
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Pancreatic injury: characterization with MRI
Images from PACS, BIDMC
Lacerations in head
of pancreas
Pancreatic head
contusion
Laceration in body
of pancreas
30
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Duodenal hematoma on MRI
Image from PACS, BIDMC
31
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Sequelae

JO was admitted to BIDMC one day after the injury

Her intra-abdominal injuries were managed
conservatively (MRCP did not show laceration of
pancreatic duct)

PICC line was placed on day two post-injury; initial
inappropriate placement corrected on day three

Follow-up CT imaging was performed 10 days after
initial CT

the findings?
32
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
10-day follow-up: Pancreatic pseudocyst
Image from PACS, BIDMC
Pseudocyst
Pancreatic tissue
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Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Pancreatic pseudocyst
Image from PACS, BIDMC
34
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Why did the kidney not infarct completely??

Initial work-up demonstrated ischemic
lower pole in left kidney

Extravasation

of IV contrast into peritoneal
cavity would suggest transection

of renal
artery

Follow-up CT indicated improved
perfusion of lower renal pole

Interesting anatomy
35
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Bilateral accessory renal arteries
Image from PACS, BIDMC
36
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Accessory renal arteries

Transection

of inferior accessory renal
artery originating from common iliac artery,
leading to contrast extravasation

and
infarct of inferior renal pole

Development of collateral perfusion from
main renal artery and remaining accessory
renal artery
37
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Our patients course

JO had a stable hospital course, and was
discharged home 13 days after admission

Incidental note: JO received a PICC line
for parenteral

nutrition. Initial follow-up
CXR revealed inappropriate positioning of
the line.
38
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
PICC line terminating in L jugular vein
Image from PACS, BIDMC
39
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
The PICC line was repositioned, and
subsequently revealed some more
interesting anatomy.
40
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
A Left-sided SVC!
Image from PACS, BIDMC
41
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
Acknowledgements

Michael Goldfinger, MD

Gillian Lieberman, MD

Pamela Lepkowski

Larry Barbaras, Webmaster
42
Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
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Mria Nmethy, HMS III
Gillian Lieberman, MD
November 2004
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