Radiography

Findings

Plain radiographic findings are nonspecific, but they are useful in evaluating rib and
spinal injuries in patients with blunt abdominal trauma. Fractures of the right lower ribs
should suggest the possibility of underlying liver injury. Pneumoperitoneum, major
diaphragmatic injury, gross organ displacement, and metallic foreign bodies may be
identified.14

Degree of Confidence

Plain radiographs are sensitive and specific in demonstrating skeletal injuries and usually
are the first radiologic examination performed in patients in whom liver trauma is
suspected. Radiographs may initially depict opaque foreign bodies, such as bullets or
shrapnel.

False Positives/Negatives

Because plain radiography is performed in a traumatized patient, an optimal-quality

radiograph is not always possible. Fractures and a pneumoperitoneum may be missed.

Computed Tomography

A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver
injury after minor blunt abdominal trauma. Nonenhanced axial CT scan at
the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.

[ CLOSE WINDOW ]

A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver
injury after minor blunt abdominal trauma. Nonenhanced axial CT scan at
the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.
A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver
injury after minor blunt abdominal trauma. Diagram of the CT scan in
Image above.

[ CLOSE WINDOW ]

A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver
injury after minor blunt abdominal trauma. Diagram of the CT scan in
Image above.

Findings

CT scanning, particularly contrast-enhanced CT scanning, is accurate in localizing the

site and extent of liver injuries and associated trauma, providing vital information for
treatment in patients.10,11 Spiral CT scanning is the preferred scanning technique, if
available. Multidetector-row CT scanning offers the further advantages of fast scanning
times (allowing scanning during specific phases of intravenous contrast enhancement)
and the acquisition of thin sections over a large area (allowing high-quality multiplanar
reconstruction).15 CT scanning without intravenous contrast enhancement is of limited
value in hepatic trauma, but it can be useful in identifying or following up a
hemoperitoneum.

CT scans can be used to monitor healing. Trauma to the liver may result in subcapsular or
intrahepatic hematoma, contusion, vascular injury, or biliary disruption.16 CT scan criteria
for staging liver trauma based on the AAST liver injury scale include the following:

• Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular

avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated
periportal blood tracking (See Images below and Images 1 and 2 in Multimedia)
o

Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to

the right upper quadrant of the abdomen. Axial, contrast-enhanced
computed tomography (CT) scan demonstrates a small, crescent-
shaped subcapsular and parenchymal hematoma less than 1 cm thick.

[ CLOSE WINDOW ]
 Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to
the right upper quadrant of the abdomen. Axial, contrast-enhanced
computed tomography (CT) scan demonstrates a small, crescent-
shaped subcapsular and parenchymal hematoma less than 1 cm thick.

Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to

the right upper quadrant of the abdomen. Diagram of the CT scan in
Image above.

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Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to

the right upper quadrant of the abdomen. Diagram of the CT scan in
Image above.

• Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular

hematomas 1-3 cm thick (See Images below and Images 5-8 in Multimedia)
o

A 20-year-old man with systemic lupus erythematosus presented with

grade 2 liver injury after minor blunt abdominal trauma.
Nonenhanced axial CT scan at the level of the hepatic veins shows a
subcapsular hematoma 3 cm thick.

[ CLOSE WINDOW ]

A 20-year-old man with systemic lupus erythematosus presented with

grade 2 liver injury after minor blunt abdominal trauma.
Nonenhanced axial CT scan at the level of the hepatic veins shows a
subcapsular hematoma 3 cm thick.

o
 A 20-year-old man with systemic lupus erythematosus presented with
grade 2 liver injury after minor blunt abdominal trauma. Diagram of
the CT scan in Image above.

[ CLOSE WINDOW ]

A 20-year-old man with systemic lupus erythematosus presented with

grade 2 liver injury after minor blunt abdominal trauma. Diagram of
the CT scan in Image above.

A 20-year-old man with systemic lupus erythematosus presented with

grade 2 liver injury after minor blunt abdominal trauma (same
patient as in Images above). Axial CT image through the inferior
aspect of the right lobe of the liver demonstrates multiple low-
attenuation lesions in the liver consistent with parenchymal contusion.

[ CLOSE WINDOW ]

A 20-year-old man with systemic lupus erythematosus presented with

grade 2 liver injury after minor blunt abdominal trauma (same
patient as in Images above). Axial CT image through the inferior
aspect of the right lobe of the liver demonstrates multiple low-
attenuation lesions in the liver consistent with parenchymal contusion.

A 20-year-old man with systemic lupus erythematosus presented with

grade 2 liver injury after minor blunt abdominal trauma (same
patient as in Images above). Diagram of the CT scan in Image 7.

[ CLOSE WINDOW ]
 A 20-year-old man with systemic lupus erythematosus presented with
grade 2 liver injury after minor blunt abdominal trauma (same
patient as in Images above). Diagram of the CT scan in Image 7.

• Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or

subcapsular hematoma more than 3 cm in diameter (See Images below and
Images 12 and 13 in Multimedia)
o

Grade 3 liver injury in a 22-year-old woman after blunt abdominal

trauma. Contrast-enhanced axial CT scan through the upper
abdomen shows a 4-cm-thick subcapsular hematoma associated with
parenchymal hematoma and laceration in segments 6 and 7 of the
right lobe of the liver. Free fluid is seen around the spleen and left
lobe of the liver consistent with hemoperitoneum.

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Grade 3 liver injury in a 22-year-old woman after blunt abdominal

trauma. Contrast-enhanced axial CT scan through the upper
abdomen shows a 4-cm-thick subcapsular hematoma associated with
parenchymal hematoma and laceration in segments 6 and 7 of the
right lobe of the liver. Free fluid is seen around the spleen and left
lobe of the liver consistent with hemoperitoneum.

Grade 3 liver injury in a 22-year-old woman after blunt abdominal

trauma. Diagram of the CT scan in Image above.

[ CLOSE WINDOW ]
 Grade 3 liver injury in a 22-year-old woman after blunt abdominal
trauma. Diagram of the CT scan in Image above.

• Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar

destruction, or devascularization (See Images below and Images 15, 16, and 18-21
in Multimedia)
o

Image obtained in a 35-year-old male bouncer after blunt abdominal

injury (same patient as in Image 14 in Multimedia). Nonenhanced
axial CT scan of the abdomen demonstrates a large subcapsular
hematoma measuring more than 10 cm. The high-attenuating areas
within the lesion represent clotted blood. The injury was classified as
a grade 4 liver injury.

[ CLOSE WINDOW ]

Image obtained in a 35-year-old male bouncer after blunt abdominal

injury (same patient as in Image 14 in Multimedia). Nonenhanced
axial CT scan of the abdomen demonstrates a large subcapsular
hematoma measuring more than 10 cm. The high-attenuating areas
within the lesion represent clotted blood. The injury was classified as
a grade 4 liver injury.

Image in a 35-year-old male bouncer after blunt abdominal injury

(same patient as in Image above). Diagram of the CT scan in Image
above.

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Image in a 35-year-old male bouncer after blunt abdominal injury

(same patient as in Image above). Diagram of the CT scan in Image
above.
o

Contrast-enhanced axial CT scan in a 39-year-old man with a grade 4

liver injury shows a large parenchymal hematoma in segments 6 and
7 of the liver with evidence of an active bleed. Note the capsular
laceration and large hemoperitoneum.

[ CLOSE WINDOW ]

Contrast-enhanced axial CT scan in a 39-year-old man with a grade 4

liver injury shows a large parenchymal hematoma in segments 6 and
7 of the liver with evidence of an active bleed. Note the capsular
laceration and large hemoperitoneum.

Diagram of the CT scan in Image above in a 39-year-old man with a

grade 4 liver injury shows a large parenchymal hematoma in
segments 6 and 7 of the liver with evidence of an active bleed.

[ CLOSE WINDOW ]

Diagram of the CT scan in Image above in a 39-year-old man with a

grade 4 liver injury shows a large parenchymal hematoma in
segments 6 and 7 of the liver with evidence of an active bleed.

Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man

who was in a motor vehicle accident and underwent emergency
segmental resection of the right lobe. Note the sharply demarcated
wedge-shaped area of infarction; hence, the classification as grade 4.
 [ CLOSE WINDOW ]

Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man

who was in a motor vehicle accident and underwent emergency
segmental resection of the right lobe. Note the sharply demarcated
wedge-shaped area of infarction; hence, the classification as grade 4.

Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man

who was in a motor vehicle accident and underwent emergency
segmental resection of the right lobe. Diagram of the CT scan in
Image above.

[ CLOSE WINDOW ]

Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man

who was in a motor vehicle accident and underwent emergency
segmental resection of the right lobe. Diagram of the CT scan in
Image above.

• Grade 5 - Global destruction or devascularization of the liver (See Images below

and Images 24-27 in Multimedia)
o

Grade 5 injury in a 36-year-old man who was involved in a motor

vehicle accident demonstrates global injury to the liver. Bleeding from
the liver was controlled by using Gelfoam.

[ CLOSE WINDOW ]
 Grade 5 injury in a 36-year-old man who was involved in a motor
vehicle accident demonstrates global injury to the liver. Bleeding from
the liver was controlled by using Gelfoam.

Grade 5 injury in a 36-year-old man who was involved in a motor

vehicle accident. Diagram of the CT scan in Image above.

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Grade 5 injury in a 36-year-old man who was involved in a motor

vehicle accident. Diagram of the CT scan in Image above.

Grade 5 injury in a 36-year-old man who was involved in a motor

vehicle accident (same patient as in Images above). Axial CT scan
shows a hematoma around the right kidney and inferior vena cava
consistent with renal and inferior vena cava injury.

[ CLOSE WINDOW ]

Grade 5 injury in a 36-year-old man who was involved in a motor

vehicle accident (same patient as in Images above). Axial CT scan
shows a hematoma around the right kidney and inferior vena cava
consistent with renal and inferior vena cava injury.

o
 Grade 5 injury in a 36-year-old man who was involved in a motor
vehicle accident (same patient as in Images above). Diagram of the CT
scan in Image above.

[ CLOSE WINDOW ]

Grade 5 injury in a 36-year-old man who was involved in a motor

vehicle accident (same patient as in Images above). Diagram of the CT
scan in Image above.

• Grade 6 - Hepatic avulsion

CT scan findings include the following:

• Subcapsular hematoma
o This is usually seen in a lenticular configuration; most subcapsular
hematomas are anterolateral to the right lobe of the liver.
o Subcapsular hematomas cause direct compression and deformity of the
shape of the underlying liver.
o On nonenhanced CT scans, the liver appears hyperattenuating compared
with a subcapsular hematoma.17
o On enhanced CT scans, a subcapsular hematoma appears as a low-
attenuating, lenticular collection between the liver capsule and the
enhancing liver parenchyma.
o Unless bleeding recurs, attenuation of the subcapsular hematoma
decreases with time. Subcapsular hematomas resolve within 6-8 weeks.
• Intraparenchymal hematomas
o On contrast-enhanced CT scans, acute hematomas appear as irregular,
high-attenuation areas, which represent clotted blood, surrounded by low-
attenuating unclotted blood or bile.
o Over time, the attenuation of the hematoma is reduced, and the hematoma
eventually forms a well-defined serous fluid collection that may expand
slightly.
o A focal, intrahepatic, hyperattenuating area with attenuation of 80-350 HU
may represent an active hemorrhage or pseudoaneurysm.
o Focal or diffuse periportal low attenuation is believed to be secondary to
tracking of blood around the portal vessels, although other possibilities
include bile leaks, edema, and dilated periportal lymphatics resulting from
increased central venous pressure or injury to the lymphatics.
o A low-attenuating periportal collar is seen in children with nonhepatic
blunt abdominal trauma and also in the absence of intra-abdominal injury.
Thus, without other ancillary findings within the liver, the presence of a
low-attenuating periportal collar is not indicative of hepatic injury.
 However, the presence of this sign in documented abdominal trauma
correlates with the severity of trauma, physiologic instability, and a higher
mortality rate.
o CT scan findings in approximately 25% of children with blunt abdominal
trauma show periportal low attenuation. That only 40% of these children
have evidence of liver injury has been shown.
• Laceration
o Laceration of the liver appears as a nonenhancing linear or branching
structure, usually at the liver periphery.
o Acute lacerations have a sharp or jagged margin, but with time, lacerations
may enlarge, and the margins may develop rolled edges.
o Multiple parallel lacerations occur as result of compressive forces (bear
claw lacerations).
o Lacerations may communicate with hepatic vessels and/or biliary radicles.
• Vascular injuries
o Injuries to the major hepatic veins and the retrohepatic inferior vena cava
are uncommon after blunt abdominal trauma.
o Retrohepatic vena caval injuries are suggested on CT scans when
lacerations extend into the major hepatic veins and the inferior vena cava
or when profuse retrohepatic hemorrhage extends into the lesser sac or
near the diaphragm.
o Perihilar liver tissue may become partially devascularized by a deep
laceration or complete avulsion of the dual hepatic blood supply. These
devascularized areas of the liver appear as wedge-shaped regions
extending toward the liver periphery, and they fail to enhance after the
administration of contrast material.
o Pseudoaneurysms are better depicted by using spiral or multisection CT
scanning because of the ability to image during peak contrast
enhancement.
• Acute hemorrhage
o Acute, intrahepatic hemorrhage is seen as irregular areas of contrast agent
extravasation.
o Measurement of attenuation values is useful in differentiating extravasated
contrast from hematoma. Extravasated contrast material has an attenuation
value of 85-350 HU (mean, 132 HU), whereas hemorrhage has an
attenuation value of 40-70 HU (mean, 51 HU).
o CT scans can be useful in depicting recurrent bleeding after surgery or
radiologic intervention.
• Gallbladder injury
o Gallbladder injury is uncommon, occurring in 2-8% patients with blunt
liver trauma. Prior to the availability of CT scanning and ultrasonography,
gallbladder injuries were rarely diagnosed before surgery.18
o CT findings in gallbladder injuries include ill-defined or irregular wall
contour, pericholecystic or subserosal fluid, collapsed gallbladder, wall
thickening, intraluminal blood, free intraluminal mucosal flap, contrast
enhancement of the gallbladder wall or mucosa, free intraperitoneal fluid
 iso-attenuating with bile, mass effect on the duodenum, and displacement
of the gallbladder toward the midline.
• Biloma and bile peritonitis
• Biloma
o As a result of the slow rate of leaking, a biloma may take weeks or months
to develop after trauma; hence, it usually is diagnosed by using follow-up
scans.
o CT scan findings of a posttraumatic biloma demonstrate a cystic structure
of low attenuation in or around the liver.
o Bilomas may contain debris or septa.
o Bile peritonitis is an uncommon complication of blunt liver trauma. CT
scan findings of bile peritonitis include persistence or increasing amounts
of low-attenuating, free peritoneal fluid and thickening of a peritoneum
that shows evidence of enhancement.

Degree of Confidence

CT scanning is the mainstay of diagnosis of hepatic injuries following blunt trauma;

initial CT scan findings help in determining the type of treatment required. With the use
of high-speed, spiral CT scans, predicting the necessity of operative treatment or
angiography is possible in patients with blunt hepatic injury before deterioration of their
hemodynamic state.

A finding of pooled contrast material within the peritoneal cavity indicates active and
massive bleeding; patients with this finding may require emergency surgery.19
Intrahepatic pooling of contrast material with an intact liver capsule usually indicates a
self-limiting hemorrhage; most patients with this finding can be treated conservatively.

CT scanning has been proven to be extremely useful in helping to make therapeutic

decisions in hepatic trauma and in helping to reduce laparotomy rates in as many as 70%
patients at the time of initial evaluation.

False Positives/Negatives

False-positive errors in the diagnosis of liver injury with CT scans may occur as a result
of beam-hardening artifacts from adjacent ribs, which can mimic contusion or hematoma.
An air-contrast level within the stomach in a patient with a nasogastric tube can produce
streak artifacts throughout the left lobe of the liver; these may mimic intrahepatic
lacerations and/or hemorrhage. The nature of these artifacts can be confirmed if the
patient is scanned in a decubitus position.

False-negative findings may occur in the setting of a fatty liver only when contrast-
enhanced CT scans are obtained. On these images, the enhanced fatty liver may become
iso-attenuating relative to the laceration or hematoma. In this situation, a nonenhanced
CT scan may provide useful information regarding hepatic injury. Focal fatty infiltration
may also mimic hepatic hematoma, laceration, or infarction. Hepatic lacerations with a
branching pattern can mimic nonopacified portal or hepatic veins or dilated intrahepatic
bile ducts. Careful evaluation of all branching intrahepatic structures is important, and the
diagnosis is made with serial images to differentiate the various structures.

Small amounts of free intraperitoneal blood or fluid in the perihepatic space may mimic a
subcapsular hematoma; however, these fluid collections usually do not compress the liver
parenchyma. CT scans do not always help in predicting which patients require
laparotomy.20 Hematomas or hemorrhage within the liver can occur with a nontraumatic
etiology (see Ultrasonography).

In the evaluation of recurrent hepatic bleeding, particularly after an angiographic

intervention, nonenhanced and enhanced scans are important to distinguish extravasated
contrast material during angiography from recurrent, ongoing hemorrhage. Other hepatic
lesions that may mimic active bleeding on CT scans include calcified liver masses and
hemangiomas.

Magnetic Resonance Imaging

Findings

MRI has a limited role in the evaluation of blunt abdominal trauma, and it has no
advantage over CT scanning. Theoretically, MRI can be used in follow-up monitoring of
patients with blunt abdominal trauma, and the modality may be useful in young and
pregnant women with abdominal trauma in whom the radiation dose is a concern.21

MRCP has been used in the assessment of pancreatic duct trauma and its sequelae, and it
can be used to image biliary trauma.12 Another potential use of MRI is in patients with
renal failure and in patients who are allergic to radiographic contrast medium.

Degree of Confidence

MRI offers no significant advantage over CT scanning for routine evaluation of acute
abdominal trauma. Experience is insufficient for assessing the value of the above-
mentioned special circumstances.

False Positives/Negatives

Sufficient experience has not been gained in the use of MRI to establish false-positive
and false-negative findings.

Ultrasonography
Findings
Sonogram of the liver in a 62-year-old woman with a history of recent liver biopsy.
The scan shows a loculated anechoic collection in the liver; whether this
finding represents a biloma or a hematoma is not clear on this scan.

[ CLOSE WINDOW ]

Sonogram of the liver in a 62-year-old woman with a history of recent liver biopsy.
The scan shows a loculated anechoic collection in the liver; whether this
finding represents a biloma or a hematoma is not clear on this scan.

Abdominal sonogram in a 35-year-old male bouncer after blunt abdominal injury

shows a crescent-shaped hyperechoic collection along the right lateral
aspect of the liver consistent with subcapsular hematoma.

[ CLOSE WINDOW ]

Abdominal sonogram in a 35-year-old male bouncer after blunt abdominal injury

shows a crescent-shaped hyperechoic collection along the right lateral
aspect of the liver consistent with subcapsular hematoma.

• Ultrasonograms can demonstrate a number of traumatic lesions, such as

hematomas, contusions, bilomas, and hemoperitoneum.22
• Hepatic hematomas are grouped into 3 categories, as follows:
o Rupture into the liver and its capsule
o Separation of the capsule by a subcapsular hematoma
o Central hepatic ruptures
• A subcapsular hematoma usually appears as a curvilinear fluid collection; its
echogenicity varies with age.
o Initially, hematomas are anechoic, becoming progressively more
echogenic over the course of 24 hours.
o With the passage of time, echogenicity of the hematoma once again begins
to decrease, and within 4-5 days, the hematoma becomes hypo-echoic or
anechoic.
 o Septa and internal echoes often develop within the hemorrhagic collection
by 1-4 weeks.
• Appearances of hepatic laceration change with time. Lacerations appear slightly
echogenic, becoming hypo-echoic or cystic when scanned days after the injury.
• Similar to hematomas, contusions usually are hypo-echoic initially, becoming
transiently hyperechoic and then hypo-echoic.
• The most common ultrasonographic pattern observed with liver parenchymal
injuries is a discrete hyperechoic area; however, a diffuse hyperechoic and
occasionally a discrete hypo-echoic pattern may be observed.17,22
• An echogenic clot often is seen surrounding the liver, and hypo-echoic fluid may
be observed in other parts of the abdomen.
• Bilomas appear as rounded or ellipsoid, anechoic, loculated structures that are
fairly well defined in close proximity to the liver and bile duct.
• Diaphragmatic ruptures appear as a discontinuous line of echoes.
• A number of studies have suggested that ultrasonography can replace the invasive
procedure of peritoneal lavage in the evaluation of blunt abdominal trauma.

Degree of Confidence

Focused assessment performed by using ultrasonography in patients with liver trauma is

still investigational for evaluation of blunt and penetrating abdominal trauma.23 The
primary advantage is immediate availability in emergency departments. Some centers use
ultrasonography as the initial examination. Patients who are unstable and have a large
amount of fluid detected on ultrasonograms are immediately transported for surgery. In
addition, patients at these centers who are stable and who have a large amount of intra-
abdominal fluid also may be immediately treated with surgery.

An alternative approach is followed in other centers. If ultrasonographic findings are

positive for intra-abdominal fluid, CT scanning is the next step. If fluid is not
demonstrated on abdominal ultrasonograms, the patient is observed for 12 hours;
however, if abdominal pain persists, the patient undergoes CT scanning.

Ultrasonography is the initial examination of choice in the pediatric age group because
of the modality's nonionizing and noninvasive nature. Ultrasonography is particularly
useful in imaging neonates who are ill and in whom the clinical condition is too unstable
to allow transport to a CT scanning facility but who may have a hepatic hematoma after a
traumatic delivery or resuscitative efforts. In a neonate with a decreasing hematocrit level
and increasing abdominal distension, ultrasonography may rapidly help in confirming a
diagnosis of liver trauma. Because most children with hepatic trauma are treated
conservatively, most children can be monitored by using ultrasonography.8,24

Ultrasonography has several advantages over peritoneal lavage in the diagnosis of blunt
abdominal trauma. Ultrasonography is a noninvasive procedure that is readily available at
the patient's bedside and is less expensive to perform than is peritoneal lavage. However,
although ultrasonography may be useful in most patients with blunt abdominal trauma,
pitfalls remain.
False Positives/Negatives

Injury to the liver, especially at the dome or lateral segment of the left lobe of the liver,
can easily be missed with ultrasonography, particularly in the presence of ileus or when
pain makes the examination difficult. The sensitivity of ultrasonography in the detection
of free abdominal fluid associated with bowel or mesenteric injury has been reported as
only 44%. Blunt abdominal injury may involve organs other than the liver, and these
injuries must be detected reliably.

Ultrasonograms may not directly depict injuries to the bowel, mesentery, pancreas,
diaphragm, adrenal gland, and bone. Ultrasonography is probably limited in the detection
of many vascular injuries as well. A hepatic laceration may be initially difficult to detect,
but it may become obvious with the passage of time.

Hepatic hemorrhage may occur as a result of causes other than trauma, including sickle
cell anemia, liver tumors, coagulopathies, organ phosphate toxicity, and collagen vascular
disease. It may also occur in patients receiving long-term hemodialysis. Hepatic
hemorrhage and rupture may occur in eclampsia, pre-eclampsia during the third trimester
of pregnancy, HELLP syndrome, hepatic adenoma, and hepatocellular carcinoma.

Nuclear Imaging
Findings

A 62-year-old woman with a history of recent liver biopsy (same patient as in Image
30 in Multimedia). Technetium-99m iminodiacetic acid (IDA) scan obtained
immediately after the injection of the radioisotope shows a large filling
defect in the liver, which showed subsequent filling in the 4-hour image
consistent with biloma.

[ CLOSE WINDOW ]

A 62-year-old woman with a history of recent liver biopsy (same patient as in Image
30 in Multimedia). Technetium-99m iminodiacetic acid (IDA) scan obtained
immediately after the injection of the radioisotope shows a large filling
defect in the liver, which showed subsequent filling in the 4-hour image
consistent with biloma.
Technetium-99m iminodiacetic acid (IDA) scan in a 30-year-old man who sustained
liver injury in a motor vehicle accident. The scan was obtained 1 month
later and shows extravasation of the isotope from the biliary tract; this is
consistent with a bile leak. Note the relative photon deficiency of the right
lobe, which is due to liver contusion.

[ CLOSE WINDOW ]

Technetium-99m iminodiacetic acid (IDA) scan in a 30-year-old man who sustained

liver injury in a motor vehicle accident. The scan was obtained 1 month
later and shows extravasation of the isotope from the biliary tract; this is
consistent with a bile leak. Note the relative photon deficiency of the right
lobe, which is due to liver contusion.

Prior to the widespread availability of CT scanning,99m Tc sulfur colloid or99m Tc-labeled

denatured red blood cell studies were widely used in the evaluation of patients with blunt
hepatic and splenic trauma. The primary limitations of radionuclides are the nonspecific
findings and an inability to evaluate other intraperitoneal and retroperitoneal organs.
Despite the disadvantages, radionuclide techniques can offer an important imaging
alternative in patients in whom CT scanning cannot be performed, such as those patients
in whom the use of intravenous and oral contrast is contraindicated, those who cannot
hold their breath, and those who have metallic objects or surgical clips in the abdominal
cavity.

• Patients who have documented evidence of hepatic or splenic trauma can be

monitored noninvasively by using99m Tc sulfur colloid scanning. Most patients
with liver trauma show complete or partial resolution of the colloid defects over a
period of 3-6 months. However, defects within the spleen may persist indefinitely
and do not necessarily indicate a poor prognosis. Whether defects in the liver have
similar connotations is uncertain.
• After splenic rupture, splenic tissue can become implanted in the peritoneal or
intrathoracic cavities (splenosis). Splenosis may be difficult to differentiate from
other masses, such as lymphadenopathy, on subsequent scans obtained by using
cross-sectional imaging, particularly when scans are performed remote in time
from the injury. Uptake with99m Tc sulfur colloid or99m Tc-labeled denatured red
cells provides a tissue-specific diagnosis of ectopic splenic tissue.
• Labeled red cells may be used to detect the site of active intraperitoneal or
retroperitoneal hemorrhage, although quantitating the size of the hemorrhage is
difficult using this technique.
 • Bile duct and/or gallbladder injuries occur in 5% of patients with blunt abdominal
trauma. Moreover, biliary injuries may not be identified pre-operatively or may
remain unidentified for weeks or months after trauma.
• Although CT scanning remains the examination of choice in the evaluation of
liver trauma, the procedure of choice to evaluate bile leaks is99m Tc IDA scanning.
CT scanning and ultrasonography can help to detect intra-abdominal fluid, but
differentiation between loculated ascitic fluid and hematoma, abscess, and biloma
may not be always possible.
o Scanning for99m Tc IDA uptake usually is performed as a dynamic study
immediately after the injection of the radionuclide. The angiographic
phase can provide important information regarding vascular injuries and
associated renal injury, which may subsequently be missed on static scans.
o Following the dynamic study, a 20-min static scan of the liver is obtained
in several planes; in appropriate circumstances, scans can be obtained for
as long as 24 hours.
o Bile leaks are demonstrated as extravasated activity shortly after
administration of the radionuclide.
o Bilomas are demonstrated initially as a photon-deficient mass that shows
activity on delayed scans. In the detection of bilomas, delayed images are
essential (2-24 h); otherwise bilomas may be missed.

Degree of Confidence

In patients with blunt trauma, there is an inability to evaluate other sites of abdominal
injury and to quantitate intraperitoneal and retroperitoneal hemorrhage. However, in
patients in whom a bile leak or biloma is suspected,99m Tc IDA uptake imaging is the
examination of choice; this provides a noninvasive technique for arriving at a specific
diagnosis.

False Positives/Negatives

Focal defects identified with99m Tc sulfur colloid scanning or in the angiographic/hepatic

phase of99m Tc IDA scanning may not be related to the trauma; these defects may
instead represent simple liver cysts, granulomas, pseudotumors, abscesses, or tumors
unrelated to trauma. If delayed scans are not performed, bilomas and bile leaks may be
missed using99m Tc IDA scans. Delayed imaging not only provides time for the activity to
accumulate within the biloma but also allows clearing of the isotope from the liver,
increasing the target-to-background ratio of activity.

Angiography
Findings
Selective celiac arteriogram of a grade 1 hepatic injury in a 21-year-old man with a
stabbing injury to the right upper quadrant of the abdomen (same patient
as in Images 1-2 in Multimedia). The image shows a focal area of
hemorrhage in the right lobe of the liver (arrow) due to the stabbing injury.
The well-demarcated filling defect seen in the lateral aspect of the right lobe
of the liver is due to compression of normal liver parenchyma by the
subcapsular hematoma.

[ CLOSE WINDOW ]

Selective celiac arteriogram of a grade 1 hepatic injury in a 21-year-old man with a

stabbing injury to the right upper quadrant of the abdomen (same patient
as in Images 1-2 in Multimedia). The image shows a focal area of
hemorrhage in the right lobe of the liver (arrow) due to the stabbing injury.
The well-demarcated filling defect seen in the lateral aspect of the right lobe
of the liver is due to compression of normal liver parenchyma by the
subcapsular hematoma.

Postembolization selective arteriogram of a grade 1 hepatic injury in a 21-year-old

man with a stabbing injury to the right upper quadrant of the abdomen
(same patient as in Images 1-3 in Multimedia). The image shows cessation
of the bleeding in the right lobe of the liver.

[ CLOSE WINDOW ]

Postembolization selective arteriogram of a grade 1 hepatic injury in a 21-year-old

man with a stabbing injury to the right upper quadrant of the abdomen
(same patient as in Images 1-3 in Multimedia). The image shows cessation
of the bleeding in the right lobe of the liver.

A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver
injury after minor blunt abdominal trauma (same patient as in Images 5-8
in Multimedia). Selective celiac artery arteriogram shows multiple
 microaneurysms due to systemic lupus erythematosus. Note the
parenchymal filling defects due to contusion and medial displacement of the
right liver margin due to subcapsular hematoma.

[ CLOSE WINDOW ]

A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver
injury after minor blunt abdominal trauma (same patient as in Images 5-8
in Multimedia). Selective celiac artery arteriogram shows multiple
microaneurysms due to systemic lupus erythematosus. Note the
parenchymal filling defects due to contusion and medial displacement of the
right liver margin due to subcapsular hematoma.

Most patients with liver trauma who present to the emergency department in shock have
positive results after peritoneal lavage and require immediate laparotomy to control
hemorrhage. Angiography has no role in the evaluation of these patients. However,
patients with less severe trauma may be difficult to evaluate at clinical examination and at
laparotomy. If the patient is stable, cross-sectional imaging may provide sufficient detail
to treat the patient conservatively. A dynamic angiographic study may demonstrate the
site of active bleeding, providing an opportunity for transcatheter embolization, which
may be the only treatment required.

Angiographic findings in patients with liver trauma include the following:

• Liver contusion
o Stretching and elongation of arterial branches around an avascular mass
may be observed.
o Delay in hepatic blood flow to the involved segments may occur.
o A transient attenuation difference in uninvolved segments may be
depicted.
o Mottled accumulation of contrast material in the parenchymal phase may
be noted.
o The portal venous phase may confirm a parenchymal defect.
o Peripheral portal venous filling may be unusually well demonstrated in the
presence of contusions.
• Liver lacerations
o Arterial collaterals may bypass arterial occlusions.
o Contrast material extravasation may occur.
o Discrete lacerations may appear as linear or complex lucent defects.
o Intrahepatic hematomas may appear as poorly defined lucent defects.
o Arterioportal fistulas may be obvious.
o Contrast material may pass into the biliary tree, identifying the site of
hemobilia.
 • Subcapsular hematoma
o Subcapsular hematomas compress normal parenchyma and may appear as
sharply defined, lucent defects against the increased contrast accumulation
in the compressed parenchyma.
o Arterial displacement may be seen.
o Contrast material extravasation may occur.
• High-velocity bullet injuries
o High-velocity bullets tend to cause burst injuries with distant contusions
and parenchymal disruption.
o Occasionally, these injuries are associated with aortic and renal injuries.
o All of the angiographic findings of blunt liver trauma can be seen in this
group of patients.
• Low-velocity penetrating injury (stab wounds, liver biopsy, and biliary drainage
TIPS procedure)
o Arterial aneurysms and arterial pseudo-aneurysms
o Arteriovenous fistulas
o Hematomas

Degree of Confidence

Evaluating the extent of liver injury at surgery may be difficult; in fact, identifying the
lesion within the liver may occasionally be impossible. Emergency hepatic angiography
should be performed if at all feasible, because it not only documents the injury and helps
to evaluate complications, such as pseudo-aneurysms, subcapsular hematoma, or
hemobilia, it also provides access for transcatheter embolization.

False Positives/Negatives

Although angiography is useful in selected patients, false-positive and false-negative

results occur in patients with hepatic trauma.

Liver rupture may be spontaneous or may occur as result of liver tumors, HELLP
syndrome, simple cysts, amebic abscess, and hydatid cysts. Intrahepatic arterial
aneurysms may be congenital or may be related to vasculitides.