Contrasted CT scan is the preferred method to emergently evaluate patients with suspected liver injury. Liver lacerations are graded per the American Association for the Surgery of Trauma criteria according to their severity based on radiographic features. Grade I liver lacerations feature subcapsular hematomas measuring no greater than 1 cm at their greatest thickness, capsular avulsion, superficial parenchymal lacerations less than 1 cm deep, and isolated periportal blood tracking. Grade II injuries are characterized by parenchymal laceration 1–3 cm deep and parenchymal or subcapsular hematomas 1–3 cm thick. Those injuries demonstrating parenchymal laceration more than 3 cm deep, or subcapsular hematomas more than 3 cm in diameter are considered Grade III lacerations. Grade IV injuries are recognized by parenchymal or subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization of the liver, while Grade V injuries demonstrate global destruction of the liver parenchyma. Complete hepatic avulsions (Grade VI) may also occur.
Subcapsular hematomas are generally identified between the liver capsule and the enhancing liver parenchyma on contrasted CT, and are most commonly located anterolateral to the right hepatic lobe. Liver parenchymal lacerations are seen as nonenhancing linear or jagged lesions typically observed in the periphery of the organ and may enlarge over time. Acute liver hemorrhage features areas of contrast extravasation on contrasted CT scan, while devascularized areas of the liver appear as unenhanced wedge-shaped regions extending toward the liver periphery.
The liver is quite vulnerable to blunt trauma and significant hepatic injuries may rapidly cause severe hemorrhagic shock and death. Contrasted CT scan may be very helpful in guiding therapy for patients who have sustained hepatic injury, both in identifying severe injury or active hemorrhage in need of immediate intervention as well as identifying those patients in whom nonoperative management may be appropriate. Hemodynamic stability is the most important factor when considering operative versus nonoperative management regardless of the radiographic features of the injury. Most liver lacerations in stable patients will resolve spontaneously without operative intervention. However, higher-grade liver injuries are associated with a greater incidence of significant vascular injuries and need immediate surgical consultation.
Contrasted CT scan is the preferred method to emergently evaluate patients with suspected splenic injury. Splenic lacerations are seen as nonenhancing linear or jagged hypodense lesions typically observed in the periphery of the organ. Accompanying subcapsular hematomas are identified as crescent-shaped hypoattenuating fluid collections at the margin of the spleen. Splenic clefts may be confused for lacerations, but generally appear more sharply marginated than true lacerations and may have associated rounded splenic surface contours at the site of the cleft. Intraparenchymal hematomas may also form, and are seen as hypoattenuating areas with mass effect and organ enlargement. Acute splenic hemorrhage is seen as a “blush” of contrast extravasation on contrasted CT scan. Hemoperitoneum is present in a vast majority of splenic injuries.
Splenic lacerations are graded per the American Association for the Surgery of Trauma criteria according to their severity based on radiographic features. Grade I splenic lacerations feature subcapsular hematoma measuring less than 10% of the organ surface area or capsular tear of less than 1 cm depth. Those injuries with subcapsular hematoma comprising 10-50% of the organ surface area, intraparenchymal hematoma of less than 5 cm in diameter, or laceration of 1-3 cm in depth without involvement of trabecular vessels are considered Grade II. Grade III lacerations are differentiated from Grade II by the presence of subcapsular hematoma greater than 50% of the organ surface area, expanding subcapsular or parenchymal hematoma, intraparenchymal hematoma of greater than 5 cm, or laceration of greater than 3 cm in depth or involving trabecular vessels. Grade IV injuries feature lacerations involving segmental or hilar vessels with devascularization of greater than 25% of the spleen, while Grade V injuries involve shattered splenic parenchyma or hilar vascular injury.
The spleen is quite vulnerable to trauma and is the most commonly injured abdominal organ by blunt mechanism. The spleen is a highly vascular organ and when significantly injured hemodynamic instability may rapidly develop. Hemodynamic stability is the most important factor when considering operative versus nonoperative management regardless of the radiographic features of the injury. However, higher-grade splenic injuries are associated with a greater incidence of significant vascular injuries, failure of nonsurgical management, remote complications, and the potential for hemodynamic collapse.
Hemodynamic stability or lack thereof, not the grade of splenic injury, is the primary compass used to guide the initial management of splenic lacerations.
Distinguish normal parenchymal clefts from peripheral lacerations by the lack of surrounding pericapsular hematoma, and rounded or “infolded” surface contours at the site of cleft. Lacerations tend to be more indistinct or jagged in their appearance.
Figure 6.7 ▪ Splenic Laceration.
A, B: Extensive hemoperitoneum accompanies the splenic rupture in this case. The spleen is devascularized (Grade V). Intravascular volume loss is present with a slit-like Inferior Vena Cava (arrow). Enhancing loops of small bowel in the lower quadrants are seen consistent with “shock bowel.”
Contrasted CT scan is the preferred method to emergently evaluate patients with suspected pancreatic injury unless penetrating trauma mandates an immediate operative intervention and direct exploration. When indications of pancreatic injury are present, they are generally divided into direct and indirect signs of injury. Direct signs of pancreatic injury include detection of parenchymal injury or laceration, pancreatic enlargement or hematoma, fluid separating the splenic vein and pancreas, increased peripancreatic fat attenuation, and active hemorrhage from the pancreas. Indirect signs of injury may include retroperitoneal hematoma, extraperitoneal or intraperitoneal fluid, and peripancreatic fluid. Pancreatic injuries are further graded by AAST classification according to severity. Grade I pancreatic injuries are characterized by superficial contusion with or superficial laceration with no ductal injury. Grade II injuries feature major contusion or laceration of the pancreas without ductal injury. Those injuries where the distal pancreas sustains parenchymal damage or transecting trauma including ductal injury are considered Grade III, while Grade IV injuries are parenchymal injuries or transecting lesions of the proximal pancreas involving the ampulla. Grade V injuries feature massive disruption of the pancreatic head.
The pancreas is relatively well protected anatomically and thus blunt pancreatic injuries are less common than other intra-abdominal injuries. Isolated pancreatic injuries are rare. Subtle nonspecific or delayed presentations and the lack of sensitivity of CT scan for injury make this diagnosis difficult. Penetrating injuries to the pancreas are somewhat more common and may arise from wounds from anterior or posterior approach. Contrasted CT scan is often helpful in guiding therapy for patients who have sustained pancreatic injury, both in identifying severity of injury and any active hemorrhage in need of immediate intervention. CT also helps distinguish those patients with less severe injuries in whom nonoperative management may be appropriate. CT scanning is limited however in its ability to identify pancreatic ductal injuries. Due to the prognostic importance of ductal injury, dedicated evaluation with endoscopic retrograde pancreatography (ERP, the gold standard for evaluating pancreatic ductal integrity), or magnetic resonance cholaniopancreatography is often required.
An IV contrast CT scan is the preferred method when evaluating a patient with possible hollow viscus injury. In the past, oral and IV contrast was frequently given, but the use of oral contrast has been found to be unnecessary in the majority of cases and adds the potential for aspiration. Intestinal injuries may be either intraperitoneal, retroperitoneal, or both. Radiographic findings may include free air in the abdomen or extravasation of intestinal contents if there is a perforation of the viscus. If there is a transmural injury or a vascular injury with disruption of arterial or venous blood flow to the intestine, bowel wall thickening may be seen. Vascular injuries may also present as mesenteric infiltration or stranding. Hemoperitoneum is a common finding in abdominal trauma from either solid organ or intestinal origin. Therefore, if no solid organ injury is identified, a bowel or mesenteric source of the bleeding should be considered. Unlike intraperitoneal bleeding, the sources of retroperitoneal hematomas are easier to identify since the hematoma typically resides near the area of injury. For example, a retroperitoneal hematoma identified near the duodenum is usually indicative of a duodenal injury.
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