Liver splenic and renal trauma presentation for postgraduates in radiology

Liver splenic and renal trauma

1. LIVER, SPLENIC AND RENAL TRAUMA

2. SPLEEN Most commonly injured organ in blunt abdominal trauma Approx. 25 % of all solid abdominal organ injuries Blunt abdominal trauma, penetrating injuries, iatrogenic and intraoperative accidents Clinical: Left upper quadrant tenderness Referred left shoulder pain ( Kehr’s sign) Hypotension/ Shock( 40%) Complex ligamentous attachments and spongy parenchymal consistency

3. Radiologic Findings CT- Gold standard Assessment includes: Evaluation for hematoma Extent of laceration Active contrast extravasation Vascular injuries

4. Splenic hematoma Hyperdense relative to parenchyma on unenhanced CT. Hypodense on contrast- enhanced CT. Intraparenchymal, Subcapsular or perisplenic

5. INTRASPLENIC HEMATOMA: Low density collection of blood

6. Subcapsular hematoma Crescentic fluid collections along the lateral aspect of spleen. Follow splenic contour Compress parenchyma Difficult to distinguish from perisplenic fluid. Become less dense over time, mimic free intraperitoneal fluid.

7. SUBCAPSULAR HEMATOMA: Low attenuation fluid collection located along the lateral surface of spleen causing straightening of the lateral margin. The hematoma follows the contour the spleen.

8. LARGE SUBCAPSULAR HEMATOMA: compressing the splenic parenchyma

9. Splenic lacerations Linear, low attenuation foci that may not extend completely across the spleen Single, multiple, stellate Splenic fractures : lacerations that extend completely across the parenchyma and commonly involve the splenic hilum.

10. Laceration extending to splenic hilum Associated with traumatic pseudoaneurysm with dissection

11. SPLENIC FRACTURE: Lacerations traverse splenic parenchyma

12. Shattered spleen Severe disruption of the splenic parenchyma Fragmentation of spleen Islands of enhancement identified: may represent pseudoaneurysm formation

13. Vascular pedicle injuries: significant hemorrhage and cardiovascular instability Non enhancement of caudal portion of spleen Preservation of upper pole perfusion via the short gastric arteries

14. Active hemorrhage appears as areas of irregular collection of contrast Distinguished from adjacent hematoma by its density Extravasated contrast material has higher mean attenuation than hematoma ( 132 HU vs 51 HU) Active extravasation of contrast material from the site of splenic laceration. Differentiated from the perisplenic hematoma by its higher density.

15. Splenic artery pseudoaneurysm Life threatening complication A pseudo aneurysm is formed when arterial continuity is disrupted and blood extravasates into a parenchymal hematoma with formation of a fibrous tissue capsule. Hyperdense focus within the injured parenchyma after i.v contrast administration Pseudoaneurysms have similar appearance to active hemorrhage on initial scanning but do not increase in size on delayed phases and follow the blood pool on all phases In contrast, active hemorrhage appears as a high density (80-95 Hounsfield units) material due to the extravasation of IV contrast media that increases in size on delayed imaging

16. Sentinel clot sign Presence of peri-splenic high attenuation fluid or clot Hemoperitoneum in perisplenic region Higher density clotted blood adjacent to spleen Indicates high likelihood of splenic injury even if laceration is not apparent

17. CT classification of Splenic injury( AAST)

18. USG in splenic trauma Advantages: Fast, Portable, without delaying therapeutic measures. Disadvantages: Retroperitoneal injuries, limited acoustic window In acute setting, lacerations and hematomas may appear echogenic because of the presence of clotted blood.

19. Subcapsular Hematoma

20. Laceration

21. Complications Delayed rupture Abscesses Pseudocysts Pseudoaneurysms

22. Management Conservative management in early injuries Unstable/ non responders- intervention Any contrast extravasation-angioembolization

23. LIVER Usually due to blunt trauma ( 1-8 % prevalence) Clinically: RUQ pain & tenderness falling hematocrit hypotension Delayed manifestations: jaundice( biliary trauma) Hematemesis/ Malena ( Hemobilia )

24. M.c site: posterior segment of right lobe of liver ( size and proximity to ribs and spine) Major hepatic venous injuries Right hepatic vein: greater risk due to relatively long extrahepatic segment before it enters the IVC.

25. Radiologic findings Lacerations Subcapsular hematomas Parenchymal hematomas Active hemorrhages Juxtahepatic venous injuries

26. CT classification of Liver injury( AAST)

27. Grade I

28. Grade II

29. Grade III

30. Grade IV Multiple hepatic lacerations in right hepatic lobe resulting in parenchymal disruption of about 50 % of the lobe

31. Grade V

32. Treatment Treatment is based on the hemodynamic instability When contrast extravasation-angioembolization

33. Complications Delayed hemorrhage Abscess Posttraumatic pseudoaneurysm Hemobilia Biloma ( Bile leaks into a hematoma & causes necrosis of surrounding liver tissue) Bile peritonitis

34. RENAL TRAUMA 10 % of abdominal trauma cases Blunt trauma > penetrating Clinical features: Hematuria , hypotension CT – imaging modality of choice CT Protocol: Arterial phase(20-30s)-vascular injury Nephrographic phase (70-80 s)- parenchymal lesions Late excretory phase (5-10min)- urinary contrast extravasation

35. Renal contusion Contusion results in focal interstitial edema and intraparenchymal extravasation of trace amounts of blood and urine. Ill defined hypodense area on nephrographic phase Appears slightly hyperdense on precontrast and delayed phase scans due to haemorrhage and urinary stasis

36. Subcapsular hematoma Crescent shaped hyperdense fluid collection between parenchyma and capsule Mass effect on adjacent parenchyma

37. Perirenal hematoma Poorly marginated, hyperdense fluid collection between kidney and Gerota’s fascia Spreads around the kidney, at times crossing midline No mass effect on renal contour

38. Renal Laceration Irregular, linear, or wedge shaped defects that may contain hyperattenuating blood clots in the enhanced renal parenchyma. Most severe form : shattered kidney

39. Urinary extravasation Lacerations involving renal collecting system Extravasation of opacified urine into the perirenal space on late excretory phase scan

40. Vascular extravasation Arterial active bleeding: appears in the arterial phase as linear or flame- like areas of hyperattenuating contrast material , increasing in amount on successive scans. Pseudoaneurysms: relatively well marginated, unchanged shape, isoattenuation relative to adjacent major artery in different phases.

41. During trauma, the renal artery is stretched, intimal lining may tear Leading to thrombosis/ dissection/ vessel occlusion Post contrast CT: abrupt truncation of renal artery, lack of parenchymal enhancement with preserved renal outline Segmental infarctions : well demarcated , wedge shaped, non enhancing areas of parenchyma.

42. AAST organ injury scale- Kidneys

43. I: Minor injury (75%-85%): contusions, subcapsular hematoma, small cortical infarct and lacerations that do not extend into the collecting system II: Major injury (10%): renal lacerations that extend into the collecting system and segmental renal infarct III: Catastrophic injury (5%): vascular pedicle injury and shattered kidney IV: Uretropelvic junction avulsion

44. Management Category I lesions- conservative management Category III and IV lesions - urgent surgery. Category II lesions are treated conservatively or surgically depending on severity.

45. The only absolute indication for surgical exploration –life threatening renal bleeding . Relative indications for operative management (a) extensively devitalized tissue (>50% of the renal parenchyma) (b) urinary extravasation that cannot be controlled with conservative means such as ureteral stent placement or nephrostomy (c) arterial thrombosis.

46. Thank You