Abnormal abdominal ct radiology

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Abnormal abdominal CT

• Dr Pradeep Kumar

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Pancreatitis overview

• Acute pancreatitis and commonly used
  terminologies
• Revised atlanta classification
• Complications
• Outline for radiological approach
• Chronic pancreatitis
• Uncommon types of pancreatitis

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DEFINITION DIAGNOSIS OF ACUTE PANCREATITS

• The diagnosis of acute pancreatitis requires two
  of the following three features
• (1) abdominal pain consistent with acute
  pancreatitis
• (acute onset of a persistent, severe, epigastric
  pain often radiating to the back)
• (2) serum lipase activity (or amylase activity)
  at least three times greater than the upper limit
  of normal and
• (3) characteristic imaging ?ndings of acute
  pancreatitis on contrast-enhanced computed
  tomography (CECT) and less commonly magnetic
  resonance imaging (MRI) or transabdominal
  ultrasonography

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Pathophysiology

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In pathophysiologic terms .

• Acute pancreatitis into early and late phases
• Early within 1 week
• Late phase starts in 2nd week

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Course and Severity of Disease

• Over the course of the 1st week, organ failure
  either resolves or becomes more severe.
• Patients with organ failure that resolves in 48
  hours are considered to have mild pancreatitis
  without complications and have a mortality rate
  of 0
• Severe acute pancreatitis in the first phase is
  defined as organ failure that lasts more than 48
  hours or death
• A new subgroup of acute pancreatitis has recently
  been described, termed moderately severe acute
  pancreatitis, consisting of patients with local
  complications similar to those with severe acute
  pancreatitis but lower morbidity, which is
  believed to be due to more transient organ
  dysfunction lasting less than 48 hrs.

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Degrees of severity of acute pancreatitis modified from Banks et al.
Mild acute pancreatitis
lack of organ failure and local/systemic complications
Moderately severe acute pancreatitis
transient organ failure organ failure that resolves within 48 hours and/or
local or systemic complications
Severe acute pancreatitis
persistent single or multiple organ failure (gt48 hours)
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Abdominal plain film

• Findings of acute pancreatitis on abdominal plain
  film
• Duodenal ileus in 42 of Pts
• Sentinel loop sign (dilated air-filled duodenum
  or jejunum)
• Colon cutoff (paucity of gas distal to splenic
  flexure due to spasm of colon affected by spread
  of pancreatic inflammation
• Loss of left psoas shadow
• Ascites
• Gasless abdomen
• Pancreatic abscess (gas bubbles)

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Plain chest film

• 1/3 of acute pancreatitis Pts have pulmonary
  changes secondary to superior spread of
  inflammation to diaphragm and lung bases s/o
  severe acute pancreatitis
• Findings
• Pleural effusions (seen on 10 of chest films)
• Basal atelectasis
• Pulmonary infiltrates
• Elevated diaphragm
• ARDS

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Ultrasound

• Indications
• Good screening test in mild disease, suspected
  biliary pancreatitis, and thin Pts lacking fat
  planes for good CT evaluation
• Uses
• Exclude a diagnosis of gallstone
• Detection of fluid collection in peritoneum,
  retroperitoneum, and pleural spaces.
• Follow up of pseudocysts
• Doppler of cystic masses to rule out
  pseudoaneurysm
• Major limitations
• Bowel gas
• US cannot specifically reveal areas of necrosis

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CT

• According to the revised Atlanta classification,
  CECT is the primary tool for assessing the
  imaging-based criteria because it is widely
  available for these acutely ill patients and has
  a high degree of accuracy.
• Contrast-enhanced CT is especially suited for
  staging in patients with acute pancreatitis,
  helping assess complications, and monitoring of
  treatment response through follow-up studies.
• CT should be repeated when the clinical picture
  drastically changes, such as with sudden onset of
  fever, decrease in hematocrit, or sepsis.

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Other imaging modalities

• MR imaging is reserved for detection of
  choledocholithiasis not visualized on
  contrast-enhanced CT images and to further
  characterize collections for the presence of
  nonliquefied material.
• MR imaging has an important role in patients in
  whom contrast-enhanced CT is contraindicated (eg,
  due to allergy to iodinated intra-venous contrast
  agents or pregnancy).
• Endoscopic retrograde cholangiopancreatography
  has no role in this morphologic imagingbased
  classification of acute pancreatitis.

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Revised classification system

• Stratify acute pancreatitis into subcategories
• Interstitial edematous pancreatitis and
  necrotizing pancreatitis

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Interstitial edematous pancreatitis(IEP)

• Acute in?ammation of the pancreatic parenchyma
  and peripancreatic tissues, but without
  recognisable tissue necrosis
• CECT shows localized or diffuse enlargement of
  the pancreas, with normal homogenous enhancement
  or slightly heterogenous enhancement of the
  pancreatic parenchyma related to edema.
• CECT criteria
• ? Pancreatic parenchyma enhancement by
  intravenous contrast agent
• ? No ?ndings of peripancreatic necrosis

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Necrotising pancreatitis

• In?ammation associated with pancreatic
  parenchymal necrosis and/or peripancreatic
  necrosis.
• Areas of non-enhancement, especially when gt3 cm
  or gt30 of the pancreatic volume, are considered
  a reliable CT sign for necrosis.
• However, in minor necrosis (lt30 of the gland),
  CT has a false-negative rate of 21
• CECT criteria
• ? Lack of pancreatic parenchymal enhancement by
  intravenous contrast agent and/or
• ? Presence of ?ndings of peripancreatic necrosis

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APFC (acute peripancreatic ?uid collection)

• Areas of peripancreatic ?uid seen within the
  ?rst 4 weeks after onset of interstitial
  oedematous pancreatitis and without the features
  of a pseudocyst.
• Those that do not resolve may be complicated by
  infection or haemorrhage. Others may evolve to
  become pseudocysts
• CECT criteria
• ? Occurs in the setting of interstitial
  oedematous pancreatitis
• ? Homogeneous collection with ?uid density
• ? Con?ned by normal peripancreatic fascial planes
• ? No de?nable wall encapsulating the collection
• ? Adjacent to pancreas (no intrapancreatic
  extension)

Fluid collections in the pancreatic parenchyma
should be diagnosed as necrosis and not as APFCs.

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• Most APFCs are reabsorbed spontaneously within
  the 1st few wks and do not become infected.
• Intervention at this stage is to be avoided,
  because of risk of introduction of infection.
• 1st wk distinction between APFC and ANC may be
  difficult or impossible, because both collections
  may appear as areas of nonenhancement
• If non enhancing areas of variable attenuation
  seen diagnosis of peripancreatic necrosis with
  non liquefied components
• Non liquefied components hemorrhage, fat and/or
  necrotic fat.

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Pancreatic pseudocyst

• An encapsulated collection of ?uid with a well
  de?ned in?ammatory wall usually outside the
  pancreas with minimal or no necrosis.
• usually occurs more than 4 weeks after onset of
  interstitial oedematous pancreatitis to mature.
• CECT criteria
• ? Well circumscribed, usually round or oval
• ? Homogeneous ?uid density
• ? ? Well de?ned wall that is, completely
  encapsulated
• ? Maturation usually requires gt4 weeks after
  onset of acute pancreatitis occurs after
  interstitial oedematous pancreatitis

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WON (walled-off necrosis)

• A mature, encapsulated collection of pancreatic
  and/or peripancreatic necrosis that has developed
  a well de?ned in?ammatory wall.
• WON usually occurs gt4 weeks after onset of
  necrotising pancreatitis.
• CECT criteria
• ? Heterogeneous with liquid and non-liquid
  density with varying degrees of loculations (some
  may appear homogeneous)
• ? Well de?ned wall, that is, completely
  encapsulated
• ? Locationintrapancreatic and/or extrapancreatic
• ? Maturation usually requires 4 weeks after onset
  of acute necrotising pancreatitis.

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Infected necrosis

• Infected necrosis is
• Infection of necrotic pancreatic parenchyma
• And/or necrotic extrapancreatic fatty tissue
• Usually occurs in the 2nd-3rd week.
• Most severe local complication of acute
  pancreatitis
• Most common cause of death in patients with acute
  pancreatitis
• Air bubbles are seen in 20 of cases with
  infected necrosis.

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• Distinguish among infected pseudocyst, and
  infected pancreatic necrosis - Treatment and
  prognosis are very different
• Infected pseudocyst Percutaneous catheter
  drainage quick recovery
• Infected pancreatic necrosis Surgical
  debridement often repeated

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• Scores Summary
• 1.Mild Pancreatitis 0-2
• 2.Moderate Pancreatitis 4-6
• 3.Severe Pancreatitis 8-10
• Significant correlation between the severity of
  pancreatitis and development of organ failure

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What is the optimal examination for diagnosing
acute pancreatitis?

• Pancreatic imaging by contrast-enhanced CT
  provides good evidence for the presence or
  absence of pancreatitis.
• CT should be carried out 4872 h from the onset
  of the symptoms in patients with predicted severe
  pancreatitis because the evidence of necrosis
  correlates well with the risk of other local and
  systemic complications
• Patients with persisting organ failure, signs of
  sepsis, or deterioration in clinical status 610
  days after admission will require an additional
  CT scan .

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• Collections can be approached through the
  transhepatic, transgastric or transabdominal
  route, but the preferred approach is to stay in
  the retroperitoneal compartment.This approach
  has some advantages over the others
• Same abdominal compartment as the pancreas
• No contamination with intestinal flora
• Gravity
• Drain runs parallel to pancreatic bed
• This route can be used to guide surgery

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Central gland necrosis

• Central gland necrosis is a subtype of
  necrotizing pancreatitis.
• It represents necrosis between the pancreatic
  head and tail and is nearly always associated
  with disruption of the pancreatic duct. This
  leads to persistent collections as the viable
  pancreatic tail continues to secrete pancreatic
  juices.
• These collections react poorly to endoscopic or
  percutaneous drainage.
• Definitive treatment often requires distal
  pancreatectomy.

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Complications

• Pancreas Fluid collections, pseudocyst,
  necrosis, abscess
• GI Hemorrhage, infarction, obstruction, ileus
• Biliary Obstructive jaundice
• Vascular Pseudoaneurysm, porto-splenic vein
  thrombosis, hemorrhage
• Disseminated intravascular coagulation (DIC)
• Shock due to pulmonary and renal failure
• Cardiac, central nervous system, and metabolic
  complications

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• (II) Chronic Pancreatitis
• Def and type
• Etiology
• Clinical Picture
• Radiographic Findings

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Chronic Pancreatitis

• Def- Chronic pancreatitis is a progressive
  fibroinflammatory disorder characterized by
  intermittent or continuous abdominal or back pain
  (or both) due to the persistence of structural
  damage after the primary cause has been
  eliminated. This damage results in loss of
  pancreatic parenchyma, functional insufficiency
  (endocrine and exocrine), and complications such
  as biliary stricture, pseudocyst, and
  pseudoaneurysm.
• 1. Calcifying chronic pancreatitis
  characterized by acinar destruction and peri
  lobular fibrosis with acute and chronic
  inflammatory cells. It presents with recurrent
  bouts of abdominal pain and eventual development
  of intraductal calculi in a large proportion of
  cases. Causative factors include alcohol and
  tobacco use. There are hereditary, tropical,
  idiopathic, and senile forms the senile form is
  often painless.

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• 2. Obstructive chronic pancreatitis persistent
  obstruction of the pancreatic duct due to tumor
  or post inflammatory ductal stricture leads to
  atrophy of the upstream pancreas. Though often
  painless, it occasionally presents with
  clinically acute pancreatitis. Intraductal
  calculi are generally not seen.
• 3.Autoimmune pancreatitis chronic systemic
  lymphoplasmacytic inflammatory process involving
  the pancreas and other organs.Typically, chronic
  pancreatitis develops in patients with recurrent
  bouts of acute pancreatitis (e.g., alcoholic and
  hereditary forms)

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CHRONIC PANCREATITS

• Approximately 90 of calcific pancreatitides are
  caused by alcoholism
• Other 10 mostly hereditary pancreatitis
• Atrophy of gland, dilated main pancreatic duct
  (MPD), intraductal calculi
• Fibroinflammatory mass Common in pancreatic head

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Clinical Picture -Patients may present with
exacerbations (episodes of acute pancreatitis)
manifesting as epigastric pain, which may recur
over a number of years
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• Radiographic Findings
• Plain Radiography
• -Calcification
• US
• -The pancreas might appear atrophic, calcified or
  fibrotic
• -Findings that may be present on ultrasound
  include
• Hyperechogenicity (often diffuse) often
  indicates fibrotic changes
• Pseudocysts
• Pseudoaneurysms
• Presence of ascites

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• c) CT
• CT features of chronic pancreatitis include
  1-Dilatation of the main pancreatic duct
• Pancreatic calcification
• Changes in pancreatic size (i.e. atrophy),
  shape, and contour
• Pancreatic pseudocysts

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Calcification in an atrophic pancreas
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Duct dilatation
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Pancreatic calcifications
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• May have "double duct" sign (stricture of distal
  CBD and pancreatic duct) - Not pathognomonic of
  pancreatic carcinoma
• Long, smooth taper of CBD (not abrupt, as with
  carcinoma)
• MRCP Good depiction of parenchymal and ductal
  lesions
• Splenic vein thrombosis, splenomegaly, varices
  -May progress to thrombosis of portal vein
• Pseudoaneurysm of gastroduodenal or other arteries

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• Groove Pancreatitis
• -Rare form of chronic pancreatitis that may mimic
  pancreatic carcinoma
• -The term pancreaticoduodenal groove refers to
  the potential space between the head of the
  pancreas, the duodenum, and the CBD
• -Two forms of groove pancreatitis have been
  described
• Segmental Form
• -Which involves the pancreatic head with
  development of scar tissue within the groove
• Pure Form
• -Which affects the groove only, sparing the
  pancreatic head

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Groove pancreatitis with cystic dystrophy of the
duodenal wall, drawing illustrates the disease
process in groove pancreatitis, inflammation is
predominantly centered in the pancreaticoduodenal
groove, with multiple cystic lesions within the
medial wall of the duodenum (D)
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-At CT, the classic finding is soft tissue
within the pancreaticoduodenal groove this
tissue may demonstrate delayed enhancement,
small cystic lesions may be seen along the
medial wall of the duodenum
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• Sheet-like hypodense mass between pancreatic head
  and C loop of duodenum
• Thickened duodenal wall with delayed enhancement
  cysts
• MRCP- Long, smooth narrowing of intrapancreatic
  CBD and distal pancreatic duct
• Small cysts in groove or medial wall of duodenum
• Widened space between ducts and duodenal lumen

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Groove pancreatitis with cystic dystrophy of the
duodenal wall, (a) Transverse US image through
the pancreas (P) demonstrates a sheetlike
hypoechoic area in the pancreaticoduodenal
groove with areas of cystic change (arrowhead),
(b, c) Venous phase CT scans show a
hypoattenuating area in the pancreaticoduodenal
groove (arrow in b) with inflammatory stranding
within the surrounding fat and in the right
anterior pararenalparaduodenal space (arrows in
c). P pancreas
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Autoimmune pancreatitis

• Autoimmune mechanism
• Immunoglobulin G subtype 4(IgG4) systemic
  disease
• Multiple organs involvement like pancreas,
  kidney,lungs ,salivary glands and lymphnodes
• Middle aged men
• Remarkable responsive to steroids

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• AIP is classified into two types (1 and 2) with
  some overlap inclinical and histopathologic
  characteristics but also showing important
  differences. Although differentiating the two
  types of AIP could be useful to predict the
  likelihood of disease recurrence.

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• Typical Imaging findings diffuse enlargement of
  the pancreas with loss of lobulation of
  pancreatic border
• Narrowing of main pancreatic duct
• Capsule like rim

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Specific Organ Injuries

• Solid intraperitoneal organs
• Retroperitoneal organs
• Hollow organs

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FAST vs. CT
FAST
CT
Aim for
Detection of hemoperitoneum
Detection of hemoperitoneum, organ injuries
Accuracy (for hemoperitoneum)
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Nearly 100
Accuracy (for organ injuries)
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Nearly 100
Missed rate
15 of hemoperitoneum. Up to 25 of
liver/spleen, most renal/ pancreas/bowel
Benefits
Fast, bedside, no patient prep needed, no risk
of IV contrast issues
More accurate, guide non-operative management
ACR Recommendation
Done first and only if hemodynamic unstable
before going to OR
Done if hemodynamic stable
The American College of Radiology
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Liver

• Common
• Can be part of RUQ/midline package injuries
• Shearing right lobe adjacent to hepatic veins
• Compression left lobe
• Vast majority managed nonoperatively
• Surgery if severe injuries with active bleeding
  and/ or complete destruction of entire hepatic
  lobe
• Right lobe (75) gt left lobe

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Types

• Most (80) of liver injuries are minor (grades I
  to III). There is a range of injuries
• laceration (most common)
• hematoma - subcapsular or intraparenchymal
• active hemorrhage
• major hepatic vein injury
• bile duct injury
• AV fistula

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Classification

• grade I
• hematoma subcapsular, lt10 surface area
• laceration capsular tear, lt1 cm  parenchymal
  depth
• grade II
• hematoma subcapsular, 10-50 surface area
• hematoma intraparenchymal lt10 cm diameter
• laceration capsular tear 1-3 cm parenchymal
  depth, lt10 cm length
• grade III
• hematoma subcapsular, gt50 surface area of
  ruptured subcapsular or parenchymal hematoma
• hematoma intraparenchymal gt10 cm
• laceration capsular tear gt3 cm parenchymal depth
• vascular injury with active bleeding contained
  within liver parenchyma

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• grade IV
• laceration parenchymal disruption involving
  25-75 hepatic lobe or involves 1-3 Couinaud
  segments 
• vascular injury with active bleeding breaching
  the liver parenchyma into the peritoneum
• grade V
• laceration parenchymal disruption involving gt75
  of hepatic lobe
• vascular juxtahepatic venous injuries
  (retrohepatic vena cava / central major hepatic
  veins

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• Markers
• Elevated liver transaminases (ALT/AST) is 100
  specific and 93 sensitive in predicting liver
  injuries 
• CT
• CT is the investigation of choice for evaluating
  for liver trauma. It is 95 sensitive and 99
  specific for detecting liver injuries .
• lacerations appear as irregular linear/branching
  areas of hypoattenuation
• hematomas appear as a hypodensity between the
  liver and its capsule (and can be differentiated
  from intra-peritoneal hematoma as these distort
  the liver architecture) or can be
  intraparenchymal
• acute hematomas/haemorrhage are typically
  hyperdense (40-60HU) compared to normal liver
  parenchyma

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laceration
Extraperitoneal blood

• Laceration involving hepatic veins (esp. if large
  gt 10 cm focal hypoperfusion) associated with
  injuries to retrohepatic IVC

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laceration

• Liver laceration involving hilum
• Repeated CT or US, cholescintigraphy or direct
  cholangiography to detect possible biliary
  complications

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Splenic Injury

• Most frequently affected organ in blunt trauma
• Contusion, parenchymal laceration, subcapsular
  hematoma, perisplenic hematoma, fragmentation of
  parenchyma and disruption of hilar vessels
• Left lower rib fractures frequently associated

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• Types
• laceration
• hematoma subcapsular (more common) or
  intraparenchymal
• Seurat spleen
• active hemorrhage
• pseudoaneurysm or AV fistulas (in 15 of splenic
  trauma 4)
• splenic infarct (rare)

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• CT
• CT is the modality of choice for assessing
  splenic trauma
• splenic parenchyma should be assessed in portal
  venous phase as the inhomogeneous splenic
  enhancement (zebra or psychedelic spleen) seen
  on arterial phase can mimic splenic
  laceration/contusion.
• Arterial phase scanning can be useful in
  detecting vascular injuries such as
  pseudoaneurysm and AV fistula
• Lacerations appear as linear or branching
  hypodensities (geographic pattern) 
• Subcapsular hematomas can be seen as low-density
  fluid adjacent to the spleen that distorts the
  splenic architecture 
• Active haemorrhage appears as a high-density
  (80-95 HU) material due to the extravasation of
  contrast media that increases in size on delayed
  imaging 

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Classification

• grade I
• subcapsular hematoma lt10 of surface area
• parenchymal laceration lt1 cm depth
• capsular tear
• grade II
• subcapsular hematoma 10-50 of surface area
• intraparenchymal hematoma lt5 cm
• parenchymal laceration 1-3 cm in depth
• grade III
• subcapsular hematoma gt50 of surface area
• ruptured subcapsular or intraparenchymal hematoma
  5 cm
• parenchymal laceration gt3 cm in depth

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• grade IV
• any injury in the presence of a splenic vascular
  injury or active bleeding confined within
  splenic capsule
• parenchymal laceration involving segmental or
  hilar vessels producing gt25 devascularisation
• grade V
• shattered spleen
• any injury in the presence of splenic vascular
  injury with active bleeding extending beyond the
  spleen into the peritoneum

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• Contusion hypodense area within normally
  perfused splenic parenchyma

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• Laceration linear perfusion defect

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Image from Radiology.cornfield.org

• Subcapsular hematoma lenticular shape with
  compression of adjacent splenic paenchyma
• Difficult to confidently see splenic capsule
• Sometimes difficult to distinguish btw
  subcapsular and perisplenic hematoma

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Nonoperative Management of Splenic Injury

• Now accepted practice Success rate 95 in
  children, 70 in adults
• Well-recognized complication delayed splenic
  rupture
• No reliable CT finding to predict risk of delayed
  splenic rupture
• Even a normal CT cannot exclude possibility of
  delayed splenic rupture

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Pancreas

• lt2 of blunt abdominal trauma
• Up to 90 multiple organ injuries
• Contusion, superficial or partial laceration,
  complete transection or disruption
• Can be difficult to diagnose clinically
• Delayed complications recurrent pancreatitis,
  fistula, abscess, hemorrhage
• Risk of abscess/fistula high (25-50) if duct
  disruption (vs. 10 if duct not disrupted)

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Pancreas

• Predict the presence or absence of ductal
  disruption by depth of laceration and location
• Grade A, pancreatitis or superficial laceration
  (lt50 pancreatic thickness)
• Grade B, deep laceration (gt50 thickness) at
  tail
• Grade C, deep laceration at head

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Classifications

• American Association for the Surgery of Trauma
  (AAST)
• grade 1 hematoma with minor contusion/laceration
  but without duct injury
• grade 2 major contusion/laceration but without
  duct injury
• grade 3 distal laceration or parenchymal injury
  with duct injury
• grade 4 proximal (i.e. to the right of
  the superior mesenteric vein) laceration or
  parenchymal injury with an injury to bile
  duct/ampulla
• grade 5 massive disruption of the pancreatic
  head

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Focal linear non-enhancement
Focal linear non-enhancement

• Direct CT signs Pancreatic enlargement, focal
  linear non- enhancement, comminution,
  heterogeneous enhancement (subtle initially)
• Indirect CT signs Peripancreatic fat stranding,
  fluid collections, fluid separating splenic vein
  from parenchyma, hemorrhage, and thickening of
  left anterior pararenal fascia

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Bowel Injury

• 3-7 of blunt abdominal trauma
• Jejunum and ileum (near point of fixationIC
  valve and ligament of Treitz) most common
• Colon transverse, sigmoid and cecum
• Stomach-rare
• Duodenal injury 2nd/3rd part in close proximity
  to spine
• Overall CT sensitivity/specificity 85-95

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Perforation site at sigmoid colon
Colonic contrast leakage
Bullet

• Direct CT signs 1) Discontinuity of wall,
  spillage of contrast or luminal contents into
  peritoneal or retroperitoneal. 2) Extraluminal
  air (definite for blunt trauma but not for
  penetrating trauma)
• Indirect CT signs 1) Focal bowel wall
  thickening, streaky mesenteric fat, unexplained
  free fluid between mesenteric loops. 2)
  Generalized bowel wall thickening nonspecific

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Circumferential wall hematoma
Perforation site

• Duodenal perforation vs. hematoma
• Perforation ? immediate surgery
• Hematoma ? conservative
• Helpful if you can give oral contrast immediately
  before scanning to see leakage

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Kidney and Ureter

• Kidney injury most common RP injury
• Contusion, laceration, subcapsular hematoma,
  shattered kidney, renal artery occlusion
• Major renal hemorrhage with minor trauma should
  raise suspicion of underlying pathology
  (hydronephrosis, cyst, horseshoe kidney, AML,
  RCC)

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Types

• vast majority (95-98) of renal injuries are
  minor. The spectrum of renal injuries include
• contusion/hematoma
• laceration
• hemorrhage
• avulsion of the renal pedicle leading to
  devascularisation of the kidney
• pseudoaneurysm
• AV fistula
• renal artery thrombosis, transection
  or dissection 

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• Kawashima A, et al. Radiographics 2001
• Renal contusion focal zones of decreased
  enhancement, striated nephrogram because of
  temporarily impaired tubular excretion

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Delayed
Initial
Laceration Active extravasation
hematoma
hematoma

• Laceration linear or wedge-shaped hypodense area
• Fracture involving medial and lateral surface
  of kidney through hilum
• Shattered kidney laceration crossing kidney
  resulting in multiple fragments

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Delayed
Initial
Urinoma
Urinoma

• Deep laceration results in urine extravasation
• Delayed scan for confirmation

Excreted contrast in left ureter
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Classification

• grade I
• subcapsular haematoma or contusion, without
  laceration
• grade II
• superficial laceration 1 cm depth not involving
  the collecting system (no evidence of urine
  extravasation)
• perirenal haematoma confined within the perirenal
  fascia
• grade III
• laceration gt1 cm not involving the collecting
  system (no evidence of urine extravasation)
• vascular injury or active bleeding confined
  within the perirenal fascia
• grade IV
• laceration involving the collecting system with
  urinary extravasation
• laceration of the renal pelvis and/or complete
  ureteropelvic disruption
• vascular injury to segmental renal artery or vein
• segmental infarctions without associated active
  bleeding (i.e. due to vessel thrombosis)
• active bleeding extending beyond the perirenal
  fascia (i.e. into the retroperitoneum or peritoneu
  m)
• grade V
• shattered kidney
• avulsion of renal hilum or laceration of the
  main renal artery or vein devascularisation of a
  kidney due to hilar injury
• devascularised kidney with active bleeding

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• CT
• CT is the mainstay for diagnosing renal injuries
• CT multiphase protocol study for suspected renal
  trauma includes a non-contrast phase, an arterial
  phase to evaluate vascular injury, a
  nephrographic phase to evaluate renal parenchymal
  lesions and a delayed phase to evaluate bleeding
  and collecting system injuries
• an alternative protocol study is a portal venous
  phase followed by a delayed phase to assess for
  collecting system injury 
• Angiography
• CT can provide most of the information required
  regarding vascular injuries, but angiography can
  be used to further delineate the area of injury
  as well as offering the opportunity for treatment
  with angioembolisation.
• Treatment and prognosis
• Treatment depends on the specific trauma and
  complications present.
• Complications
• urinoma (most common)
• delayed bleeding (within 1-2 weeks of injury)

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• URETERIC INJURY
• Etiology
• iatrogenic
• rate of injury is 2 (range 0.5-3) for
  laparoscopic procedures 
• most commonly injured after gynecological
  procedures 
• traumatic
• uncommon represents lt1 of all urological
  trauma 
• direct trauma from penetrating injury is a more
  common cause than blunt injury 
• Classification
• Ureteric injury can be classified into three
  types according to its site
• upper-third
• upper-third and pelvico-ureteric junction (PUJ)
  most affected by blunt trauma 
• mid-third
• distal-third
• most common site
• often following iatrogenic injury
• AAST trauma grading has not been verified as
  accurate on imaging studies

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• CT
• CT with intravenous contrast and delayed scan
  with full reformatted sagittal and coronal images
  and 3D reconstruction. The delayed scan should be
  performed between 5-8 minutes after IV contrast
  to ensure a CT-IVU (a.k.a. excretory phase) set
  of images is acquired.
• Features include 
• intra-abdominal fluid collections without other
  cause shown
• contrast extravasation from renal hilum/PUJ
  (usually medially) without associated renal
  injury

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AAST Organ Injury Scale
Trauma.org
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• Most pelvic visceral injuries bladder and
  urethra
• Gynecologic injuries rare after blunt trauma
• Urinary bladder 8 of patients with pelvic fx

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Urinary Bladder
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CT Cystography

• Antegrade bladder filling by excretion of IV
  contrast is NOT enough to exclude bladder
  injuries
• Absolute indication pelvic fracture gross
  hematuria
• Technique 300-500 cc of diluted (2) contrast
  instilled through a bladder catheter using
  gravity drip, scan pelvis, drain bladder

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• THANK YOU

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IDENTIFY
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