Abdominal Emergency Cases. Jeff Dunkle, MD February 2011

Abdominal Emergency Cases Jeff Dunkle, MD February 2011

Case: Trauma

Dx: Shock Bowel Hypoperfusion complex Seen in patients with hypovolemic shock. Poor prognostic indicator. CT findings are generally reversible. Increased permeability. Edema Enhancement

Dx: Hypoperfusion complex Small bowel mucosal enhancement Adrenal hyperenhancement Abnormal parenchymal organ enhancement Small IVC, Aorta

Blunt Abdominal Trauma A few stats: Trauma is the leading cause of death in US for those < 44 y.o. For those age 15-34, MVA is single leading cause of death.

Blunt Abdominal Trauma Prevailing trends: MDCT is test of choice Non-operative management is favored whenever feasible.

Case: Pain.

Dx: Pneumoperitoneum.

Case: Pregnant, pain.

Dx: Ectopic Pregnancy

Case: Pregnant. Pain.

Case: cont d

Case: Trauma.

Dx: Grade II hepatic injury Grade II injury Laceration 1-3cm depth Subcapsular hematoma 10-50% surface area of liver Intraparenchymal hematoma < 10 cm.

AAST Liver Injury Grading I Hematoma: subcapsular, <10% surface area Laceration: capsular tear, <1 cm in parenchymal depth II Hematoma: subcapsular, 10% 50% surface area; intraparenchymal, <10 cm in diameter Laceration: 1 3 cm in parenchymal depth III Hematoma: subcapsular, >50% surface area or expanding or ruptured subcapsular hematoma with active bleeding; intraparenchymal, >10 cm or expanding or ruptured Laceration: >3 cm in parenchymal depth IV Hematoma: ruptured intraparenchymal hematoma with active bleeding Laceration: parenchymal disruption involving 25% 75% of a hepatic lobe or 1-3 Couinaud segments within a single lobe V Laceration: parenchymal disruption involving >75% of a hepatic lobe or >3 Couinaud segments within a single lobe Vascular: juxtahepatic venous injuries (i.e.: retrohepatic vena cava or central major hepatic veins) Advance 1 grade for multiple injuries up to Grade III

Injury grading AAST injury grading. Why? Why not? AAST grade of injury is an independent predictor of failure of non-operative management Other predictors of NOM failure: Need for multiple blood transfusions Hypotension Age

AAST injury grading Higher grade increases probability of delayed complications Delayed complications: delayed hemorrhage, pseudoaneurysm formation, AV fistula, biloma, infected hematoma, pseudocyst, urinoma Surgeons use grading system to triage management

Pitfalls of CT Grading Congenital clefts; most commonly in spleen Streak artifact simulating linear laceration Patient s arms Ribs Cardiac leads Other: focal fatty infiltration (liver) or other hypoattenuating lesions

Case: Trauma.

Dx: Grade IV liver injury Grade III Laceration >3cm in depth Large subcapsular or intraparenchymal hematoma Grade IV Laceration involving 25-75% of a lobe Ruptured intraparenchymal hematoma with active bleeding Grade V Laceration involving > 75% of a lobe Major juxta-hepatic venous injury

Case: Trauma.

Dx: Grade II splenic injury Grade II injury: Laceration 1-3cm in depth Parenchymal hematoma <5cm Subcapsular hematoma 10-50% surface area of spleen

AAST Splenic Injury Grading I Subcapsular hematoma < 10% surface area Capsular laceration < 1 cm parenchymal depth II Subcapsular hematoma, 10% 50% surface area Intraparenchymal hematoma <5 cm diameter Laceration with 1 3 cm parenchymal depth, not involving a trabecular vessel III Subcapsular hematoma >50% surface area or expanding Ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm Laceration >3 cm parenchymal depth or involving trabecular vessels IV Laceration of segmental or hilar vessels that produces major devascularization >25% of spleen V Completely shattered spleen; vascular hilar injury with devascularized spleen Advance 1 grade for multiple injuries up to Grade III

Case: Trauma.

Dx: Grade III splenic injury Grade III: Subcapsular hematoma >50% surface or expanding Ruptured subcapsular or intraparenchymal hematoma. Hematoma > 5cm Laceration > 3cm in depth

Case: Pain.

Dx: Free subdiaphragmatic air

Case: Abdominal pain.

What next?

Case: cont d

Dx: BAD things: portal venous gas, pneumatosis, bowel infarction.

Case: Trauma.

Dx: Grade IV injury

AAST Renal Injury Grading I Contusion or nonexpanding subcapsular hematoma without parenchymal laceration II Nonexpanding perirenal hematoma confined to the retroperitoneum Lacerations <1 cm depth in the renal cortex III Lacerations >1 cm depth without extension into the collecting system or urinary extravasation IV Lacerations extending through the renal cortex, medulla, and collecting system Injuries to the main renal artery or vein with contained hemorrhage V Completely shattered kidney Injuries to the renal hilum with devascularization of the kidney: traumatic renal arterial disruption, traumatic renal arterial occlusion (Advance one grade for bilateral injuries, up to Grade III)

Blunt Renal Injury: 10% of all blunt abdominal injuries involve kidneys. Mechanism: MVA Direct blow Fall Grand majority of these are minor injuries 70-85% are Grade I Contrast-enhanced MDCT is imaging modality of choice

Blunt Renal Injury: Management: Conservative management is the rule! Grade I and II: Watch Grade III and IV: Controversial. When in doubt, watch. Nephrectomy rate is higher in patients who undergo operative exploration (35%) versus those who have conservative management (12%) Intervention: Main renal artery/vein and UPJ injuries Active arterial bleeding & devascularization Urinary extravasation

Case: Trauma

Dx: Grade II renal injury: Grade I: Subcapsular hematoma Contusion Grade II: Perinephric hematoma Laceration < 1cm Grade III: Laceration > 1cm NO collecting system injury

Case: Trauma

Dx: Grade IV-V renal injury Grade IV: Laceration involving cortex, medulla, and collecting system. Segmental infarctions Main renal artery/vein injuries with contained hematoma. Grade V: Shattered kidney UPJ avulsion Main renal artery/vein avulsion with devascularization

Management?

Active Contrast Extravasation Arterial injury: Active extravasation with free spill of contrast: focal high attenuation jet (matches arteries in density) that fades into an enlarged, enhanced hematoma on delayed imaging. Pseudoaneurysm: defined collection, often round, that becomes less apparent on delayed imaging. No change in hematoma.

Active Contrast Extravasation Differentiate from: Bone fragments: unusual shapes, high attenuation on all imaging. Venous injury: initial nonvisualization, which becomes more apparent on delayed imaging. Caution.

Density of blood: Simple free fluid: 0-15 HU Unclotted blood: 20-40 HU Clotted blood / hematoma: 40-70 HU Active extravasation: matches origin vessel Usually within 10 HU

Case: Pain.

Dx: Free subdiaphragmatic air

Dx: Acute cholecystitis.

Case: RUQ pain

Additional imaging

Additional imaging:

Dx: Normal Gallbladder

Case: Abdominal pain. Case 18: abdominal pain

Case: later that day

Dx: Acute Cholecystitis

Case: Trauma

Dx: Grade III pancreatic injury

AAST Pancreatic Injury Grading I II III IV V Minor contusion without ductal injury Superficial laceration without ductal injury Major contusion without ductal injury Major laceration without ductal injury Distal transection or parenchymal injury with ductal laceration Proximal transection or parenchymal injury involving the ampulla Massive disruption of the pancreatic head *proximal: to the right of the SMV

Blunt pancreatic injury: Rare (<2% of abdominal injuries) Mechanism: MVA Direct blow Rare isolated injury Usually multiple concomitant intra-abdominal injuries. Associated with relatively high morbidity and mortality Usually from non-pancreatic causes

Blunt pancreatic injury: Late or missed diagnosis can result in significant morbidity (or death) Mortality if diagnosed early (<24hrs): 11% Mortality if diagnosed late (>24hrs): 40% Complications: Pancreatitis Pseudocyst Fistula formation Abscess Sepsis

Detection of Pancreatic Injury Overall CT sensitivity in detecting all grades of pancreatic injury is approx. 80% Accuracy of detecting ductal injury may be as low as 40% CT may be normal in the first 12 hrs. after injury in 20-40% of patients Serum amylase levels drawn within 3 hrs. of injury are unreliable

Management of Pancreatic Injury Grade I and II injuries best treated with hemostasis +/- external drainage Grade III injuries treated with distal pancreatectomy Grade IV and V injuries treated with surgery (Whipple)

Case: Trauma

Dx: Grade III pancreatic injury Grade I: superficial laceration Duct intact Grade II: major laceration Duct intact Grade III: distal transection Duct injury Grade IV: Proximal transection Involves ampulla or bile duct Grade V: Massive disruption of pancreatic head.

Post-therapy follow-up:

The End.