DOI:10.2214/AJR.08.2163
AJR 2009; 192:1179-1189
© American Roentgen Ray Society
Imaging Children with Abdominal Trauma
Carlos J. Sivit1
1 Department of Radiology, Division of Pediatric Radiology, Rainbow Babies and
Children's Hospital, 11100 Euclid Ave., Cleveland, OH 44106-5056.
Received November 24, 2008;
accepted after revision November 25, 2008.
Address correspondence to C. J. Sivit
(Carlos.Sivit{at}UHhospitals.org).
CME
This article is available for CME credit. See
www.arrs.org
for more information.
Abstract
OBJECTIVE. Trauma is a leading cause of morbidity and mortality in
children. The abdomen is the second most common site of injury. This article
discusses abdominal trauma in children.
CONCLUSION. The clinical evaluation of children with potential blunt
abdominal injury presents a challenging task. Therefore, imaging plays an
essential role in the evaluation of such children.
Keywords: abdominal injury • abdominal trauma • emergency radiology • pediatric imaging • trauma
Introduction
Trauma is a leading cause of morbidity and mortality in childhood,
resulting in more than 1.5 million injuries, 500,000 hospital admissions, and
20,000 deaths per year [1].
Approximately 80% of injuries are due to blunt force trauma. The abdomen is
the second most common site of injury. The most common reported mechanism for
abdominal injury is motor vehicle crashes, followed by
automobile-versus-pedestrian injuries and falls
[2]. Other frequently
associated mechanisms of injury include handlebar injuries from bicycles,
all-terrain vehicle crashes, and sports. In young children, injuries may also
result from intentional trauma.
There are important physiologic differences between children and adults
after blunt abdominal trauma. Children have smaller blood vessels with
enhanced vasoconstrictive response. Thus bleeding associated with solid viscus
injury usually stops spontaneously regardless of injury grade. As a result,
most solid viscus injury in children can be successfully managed
nonoperatively. In a study of 122 children with isolated hepatic or splenic
injury over a 10-year period, only 3% of hepatic and 2% of splenic injuries
required laparotomy [3]. More
recently in a multicenter study of 316 children with isolated grade I–IV
hepatic or splenic injury, only 1% required laparotomy
[4].
The clinical evaluation of children with potential blunt abdominal injury
presents a difficult and challenging task. There is much concern about the
reliability of the abdominal examination in preverbal children. In addition,
multisystem injuries are often present that can divert attention from the
abdomen, making diagnosis and triage more difficult and complex. Therefore,
diagnostic imaging plays an important role in the evaluation of injured
children.
Diagnostic Imaging
The indications for imaging after blunt trauma are physical examination or
laboratory findings suggestive of abdominal injury including hematuria,
abdominal bruising or ecchymosis, abdominal distention, abdominal pain,
absence of bowel sounds, vomiting, decreased hematocrit, and blood from the
rectum or nasopharyngeal tube aspirate. The most common indication for
abdominal imaging after trauma in children is hematuria
[5]. Several points to be noted
regarding hematuria and abdominal injury include, first, most children with
hematuria do not have urinary tract injury; second, non–urinary tract
injury is observed more frequently than urinary tract injury in children with
hematuria; and, third, asymptomatic hematuria is a low-risk indicator for
abdominal injury [5,
6].
If clinical examination could accurately predict which children have
abdominal injuries, there would be no need for diagnostic tests. However,
certain clinical variables have been associated with a higher risk of
abdominal injury including gross hematuria, abdominal tenderness, ecchymoses,
and a low trauma score [2,
7,
8]. Lap-belt ecchymoses
represent an important high-risk marker for injury
[9]. These linear ecchymoses
across the lower abdomen or flank are seen in belted passengers involved in
motor vehicle crashes. The ecchymoses show the pattern of the lap belt. They
are associated with a complex of injury to the lumbar spine, bowel, and
bladder accounting for most injuries to belted motor vehicle passengers
[9].
Two clinical indications that have a low diagnostic yield in predicting
injury are asymptomatic hematuria and neurologic impairment in the absence of
abdominal signs and symptoms
[5,
10]. Abdominal injuries in
both of these groups have been shown to be uncommon and minor in
significance.
CT
CT is the imaging method of choice in the evaluation of abdominal and
pelvic injuries after blunt trauma in hemodynamically stable children.
Unstable patients need to be stabilized before CT or to proceed directly to
surgery. If they require rapid imaging, hemodynamically unstable children can
be examined at the bedside with sonography. Evaluation with CT allows accurate
detection and quantification of injury to solid and hollow viscera. CT also
identifies and quantifies intraperitoneal and extraperitoneal fluid and blood
and active hemorrhage. CT can help prioritize optimal management by diagnosing
the major or most life-threatening site of hemorrhage or injury. In addition,
CT shows associated bone injury to the ribs, spine, and pelvis. An important
issue that should not be overlooked when evaluating the impact of CT as the
primary screening technique for children after abdominal trauma relates to the
value of a normal examination: A normal CT examination may prevent unnecessary
surgical exploration owing to its ability to provide a comprehensive
evaluation of the abdomen and pelvis.
CT scans are obtained from the lower chest to the symphysis pubis.
Monitoring devices and metallic leads should be moved from the scanning plane
because they will yield streak artifacts. Gastric distention should be
relieved because artifacts may arise from air–fluid interfaces. Sedation
is rarely required before CT because advances in CT technology have greatly
reduced scanning times. However, excessive patient motion will result in image
degradation. Therefore, in select instances, a short-acting sedative may be
necessary to obtain diagnostic images.
The use of IV contrast material by rapid bolus injection is essential to
maximize opacification of solid viscera and ensure adequate injury detection.
We administer 2 mL/kg with a maximum amount of 120 mL. IV contrast material is
necessary because solid viscus laceration or hematoma may be relatively
isodense to unenhanced or poorly enhanced solid viscera. In addition, the use
of IV contrast material allows the detection of active hemorrhage. Scanning of
the pelvis should be delayed by several minutes after IV contrast injection to
optimize bladder distention by IV contrast material. If a renal parenchymal
injury is noted at initial scanning, delayed scanning through the kidneys is
also helpful in the detection of renal collecting system injury.
There is controversy regarding the use of oral contrast material after
blunt trauma [11,
12]. Potential advantages to
the use of oral contrast material include, first, enhanced detection of small
intramural or mesenteric hematomas; second, improved delineation of the
pancreas from surrounding bowel; and, third, detection of oral contrast
extravasation as a sign of bowel rupture. Potential disadvantages include time
constraints and decreased bowel motility in injured children, which limits the
ability to opacify much beyond the proximal small bowel; creation of artifacts
from air–contrast interfaces in the stomach; and the possibility of
vomiting with resultant aspiration. If oral contrast material is used, dilute
(2%) water-soluble contrast material should be administered at least 30
minutes before scanning.
Sonography
Sonography has limited utility in the assessment of pediatric abdominal
trauma. It has been primarily used in the detection of hemoperitoneum in
trauma patients. However, the presence of hemoperitoneum in the
hemodynamically stable child typically has limited impact on management
decisions. In addition, sonography has been shown to have variable sensitivity
and specificity in the detection of hemoperitoneum
[13–16].
A meta-analysis of abdominal sonography in pediatric trauma patients showed a
sensitivity of 80% (95% CI, 76–84%) and specificity of 96% (95% CI,
95–97%) [17]. Sonography
has other important limitations in the evaluation of the abdomen in injured
children. First, it does not provide any diagnostic information regarding
injury to the pelvis or lumbar spine. Moreover, sonography cannot be used in
the diagnosis of hollow viscus injury. Finally, sonography has been shown to
miss approximately one fourth to one third of solid viscus injuries
[18,
19]. Nevertheless, sonography
has an important role in the assessment of the hemodynamically unstable
patient because it can be rapidly performed at the bedside before taking the
patient to the operating room. In this role, it can serve as a fast,
noninvasive replacement of diagnostic peritoneal lavage.
The primary sonographic technique used for the evaluation of blunt
abdominal trauma has been described as focused abdominal sonography for trauma
(FAST). The focus of this technique is to evaluate the right upper quadrant,
left upper quadrant, and pelvis for free peritoneal fluid. If possible, the
pelvis should be examined when the bladder is full or nearly full. However,
there is no uniform approach to the sonographic technique and some examiners
also perform a more comprehensive assessment of the pleural and pericardial
spaces and solid organs including the liver, spleen, pancreas, and
kidneys.
Abdominal Injury
Hepatic Injury
The liver is frequently injured viscus after blunt trauma. In various
series it is either the most commonly injured or second most commonly injured
solid viscera after blunt trauma. Associated abdominal visceral injuries are
seen frequently. Splenic injuries occur in nearly one third of patients with
hepatic injury. Most hepatic injury occurs in the posterior segment of the
right lobe [20]. The effects
of blunt force are maximized in this location because the posterior right lobe
is fixed by the coronary ligaments, which limits its movement while the rest
of the liver is free to move. This results in shearing forces centered in the
posterior segment of the right lobe.
The principal types of liver injury are laceration, hematoma, and vascular
injuries. Lacerations appear as linear or branching low-attenuation areas
(Fig. 1). Lacerations are often
associated with hematomas. Hepatic hematomas may be parenchymal, subcapsular,
or parenchymal and subcapsular. Subcapsular hematomas cause direct compression
of underlying liver parenchyma, which allows differentiation from peritoneal
fluid surrounding the liver (Figs.
2A and
2B). Vascular hepatic injury is
rare in children. Partial hepatic devascularization can result from injury
affecting the dual blood supply of the liver. At CT, devascularized segments
appear as low-attenuation areas that may be wedged shaped and may fail to show
contrast enhancement (Fig.
3).
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Fig. 2A —12-year-old boy with subcapsular hematoma of liver.
Contrast-enhanced CT scan through upper abdomen shows laceration extending to
periphery of liver with associated subcapsular hematoma.
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Fig. 3 —5-year-old boy with vascular injury in posterior segment of
right hepatic lobe. Contrast-enhanced CT scan through upper abdomen shows
absence of contrast enhancement in posterior segment of right hepatic
lobe.
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The liver is surrounded by a thin capsule that, in turn, is covered by
peritoneal reflection of thin connective tissue. The presence of
hemoperitoneum associated with hepatic injury principally relates to whether a
laceration extends to the liver surface and whether the liver capsule remains
intact at the site of injury. Hepatic injury is associated with hemoperitoneum
in approximately two thirds of cases
[21,
22]. Associated hemoperitoneum
may be seen throughout the greater peritoneal cavity. Often the largest fluid
pockets are located in the pelvis.
Hepatic injury may not be associated with intraperitoneal hemorrhage if the
injury does not extend to the surface of the liver, if the hepatic capsule is
not disrupted, or if there is extension to the liver surface in the bare area
of the liver, which is devoid of peritoneal reflection
[23]. The bare area is the
site of insertion of the coronary ligaments. The bare area of the liver is in
continuity with the retroperitoneum. Injury extending to the bare area may
lead to associated retroperitoneal hemorrhage, with blood often surrounding
the right adrenal gland or extending into the anterior pararenal space
(Fig. 4).
Circumferential zones of periportal low attenuation may be seen in the
liver after trauma [24,
25]
(Fig. 5). They have also been
reported in several nontraumatic conditions. The presence of these
low-attenuation zones does not indicate hepatic injury. They are likely due to
elevated central venous pressures and resultant intravascular third-space
fluid losses after vigorous fluid resuscitation
[25]. The fluid extends to the
periportal lymphatics, which are located within the portal triad. Thus, the
periportal zones of low attenuation likely result from distention of these
lymphatics.
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Fig. 5 —8-year-old girl with periportal low-attenuation zones.
Contrast-enhanced CT scan through liver shows circumferential periportal
low-attenuation zones surrounding main portal vein. Note there is right-sided
periadrenal hematoma. Also note small amount of free peritoneal air anterior
to liver.
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A number of grading scales to quantify the severity of hepatic injury have
been proposed. The scales emphasize the anatomic extent of the injury
including capsular integrity, the extent of subcapsular collection, the extent
of parenchymal disruption, and the state of the vascular pedicle. The most
widely used grading scale was developed by the American Association for the
Surgery of Trauma (AAST) [26].
In children, these scales are not predictive of a need for operative
management because most hepatic injuries can be successfully managed
nonoperatively regardless of the severity because bleeding typically stops
spontaneously. In various reports, between 1% and 3% of children with hepatic
injury required surgical hemostasis
[4,
27]. The most common cause for
failed nonoperative management is ongoing bleeding. However, the injury
grading scales are often used in patient management decisions including the
duration and intensity of hospitalization and activity restriction.
Splenic Injury
Splenic injury is common after blunt trauma. It is also frequently
associated with other organ injuries. Splenic lacerations have a variable
appearance ranging from linear to a branching pattern. Because the spleen is
much smaller than the liver, complex injury results in shattering or
fragmentation of the organ (Figs.
6A and
6B). Associated
intraparenchymal or subcapsular hematoma may be present
(Fig. 7). As with hepatic
injury, associated intraperitoneal hemorrhage is not always present. If the
splenic capsule remains intact, there is no associated hemoperitoneum. The
absence of hemoperitoneum is observed in approximately 25% of splenic injuries
[21,
22]. Blood can also track into
the retroperitoneum after splenic injury
[28]. This typically occurs
with injury extending to the splenic hilum. In these instances, blood extends
along the splenorenal ligament into the anterior pararenal space surrounding
the pancreas (Fig. 8).
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Fig. 7 —12-year-old boy with splenic laceration and associated
intraparenchymal hematoma. Contrast-enhanced CT scan through upper abdomen
shows splenic laceration and associated intraparenchymal hematoma.
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Fig. 8 —15-year-old boy with splenic injury and retroperitoneal
extension of hemorrhage. Contrast-enhanced CT scan through upper abdomen shows
splenic laceration associated with blood in anterior pararenal space
surrounding pancreas.
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Various injury grading scales have been reported for quantifying injury to
the spleen. The most widely used grading scale was developed by the AAST
[26]. As is true for hepatic
injury, these scales are not measures of required surgical treatment because
bleeding typically stops spontaneously and nonoperative management is
successful in most splenic injuries. The injury grade is often used for
nonoperative management decisions similar to its use in hepatic injury.
Pitfalls that may result in the false-positive diagnosis of splenic injury
include heterogeneous enhancement early during the bolus and splenic clefts.
Splenic clefts can be differentiated from lacerations: Clefts have a smooth
contour, whereas lacerations have irregular contours and are often associated
with hematoma or fluid around the spleen.
Renal Injury
The kidney is the third most frequently injured abdominal viscera in
children. Renal parenchyma injury typically results from direct impact,
whereas vascular and collecting system injuries usually result from
deceleration. The most common renal injury is the parenchymal contusion, which
is manifested on CT by a focal or diffuse region of delayed contrast
enhancement (Fig. 9). The
contusion represents an organ bruise characterized by microscopic areas of
hemorrhage and surrounding edema. The involved kidney may also appear larger
than the uninvolved kidney on CT as a result of the associated edema. Renal
lacerations appear as linear low-attenuation areas in the parenchyma. Deep
lacerations may involve the renal collecting system.
Renal injury may be complicated by perirenal hematoma, which may be
subcapsular or perinephric. These two types of hematoma can be differentiated
on the basis of CT features: A subcapsular hematoma is limited in its
extension by the renal capsule and will therefore exert greater mass effect on
renal parenchyma (Fig. 10),
whereas a perinephric hematoma is distributed throughout the perirenal space
and typically shows less mass effect on renal parenchyma
[29]
(Fig. 11).
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Fig. 11 —10-year-old girl with perinephric hematoma. Sagittal
reformation of contrast-enhanced CT scan through mid abdomen shows renal
laceration associated with perinephric hematoma distributed through perirenal
space.
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Renal collecting system injury results in urinary extravasation of IV
contrast medium [30]. Delayed
scanning 10–15 minutes after IV contrast administration may be useful in
detecting such extravasation
[30] (Figs.
12A and
12B). Urine leakage typically
remains encapsulated in the perirenal space and is referred to as a
"urinoma." Occasionally, hemorrhage or urinary extravasation may
extend into the pelvis owing to direct communication between the perirenal
space in the abdomen and the prevesical extraperitoneal space in the pelvis in
some individuals [31]. Renal
collecting system injury is typically managed nonoperatively, particularly if
the leak is confined to the perirenal space. Occasionally, urinary tract
obstruction requiring surgical repair may result
[29].
Renal infarction occurs after laceration of a main or segmental renal
arterial branch. Injury to a segmental renal artery produces a segmental renal
infarct. The appearance at CT is that of a peripheral wedged-shaped area of
nonenhancing parenchyma [29,
32]
(Fig. 13). Renal infarction is
typically managed nonoperatively and results in a focal area of renal
scarring. Injury to the main renal artery results in devascularization of the
entire kidney (Fig. 14). This
is the most severe form of renal injury. This injury must be treated promptly
because permanent, progressive loss of renal function begins 2 hours after
injury [33].
Pancreatic Injury
Pancreatic injury is relatively uncommon in children. Isolated injuries are
rare. Most pancreatic injuries are seen in association with hepatic, splenic,
or duodenal injury. Injury to the body of the pancreas typically results from
direct compression of the gland against the vertebral column, whereas injury
to the head or tail of the pancreas results from a blow to the flank. Direct
signs of injury may be difficult to identify owing to the small size of the
gland, the paucity of surrounding fat, and the minimal separation of fracture
fragments. Pancreatic laceration appears as linear low-attenuation parenchymal
areas. Transection results in complete separation of pancreatic fragments
(Fig. 15). Unless the two
edges of a fracture are separated by low-attenuation fluid or hematoma, the
diagnosis may be difficult to recognize at CT. The best indicator of
pancreatic injury at CT is unexplained peripancreatic fluid—that is,
fluid in the anterior pararenal space or lesser sac
[34,
35]
(Fig. 16). This finding may be
seen more often than the actual laceration. When fluid collects in the
anterior pararenal space, it may also dissect between the pancreas and the
splenic vein [35,
36]
(Fig. 16). Pancreatic injury
is only one cause of fluid in the anterior pararenal space. Other causes
include third-space intravascular fluid loss, blood extending from injury to
the spleen or a bare area of the liver, blood or bowel contents from a
duodenal injury, and blood or urine dissecting from a renal injury after
disruption of the renal fascia
[28,
37,
38].
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Fig. 16 —10-year-old girl with pancreatic injury and associated
peripancreatic fluid. Contrast-enhanced CT scan through upper abdomen shows
fluid is in anterior pararenal space surrounding pancreas. Also note fluid
dissecting between splenic vein and pancreas.
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Additional CT signs of pancreatic injury include focal or diffuse gland
enlargement, stranding of peripancreatic or mesenteric fat, thickening of the
anterior renal fascia, and free peritoneal fluid
(Fig. 17). These findings are
typically due to a secondary pancreatitis that develops after injury. Trauma
is the leading cause of pancreatitis in children.
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Fig. 17 —12-year-old boy with acute pancreatitis after pancreatic
trauma. Contrast-enhanced CT scan through upper abdomen shows stranding of
peripancreatic fat and ill-definition of pancreatic borders.
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Pancreatic injury can be complicated by peripancreatic fluid collections,
which may evolve into pancreatic pseudocysts. Approximately one half of focal
fluid collections that develop after pancreatic injury evolve into
pseudocysts, whereas the remaining one half spontaneously resolve
[37]. The most common location
for pseudocyst formation in either intrapancreatic or peripancreatic in the
anterior pararenal space or lesser sac (Figs.
18A and
18B). However, pseudocysts may
develop anywhere in the abdomen or pelvis. Approximately one half of
pseudocysts resolve spontaneously, and the remaining require percutaneous or
surgical drainage.
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Fig. 18B —11-year-old boy with pancreatic pseudocyst. Follow-up CT scan
obtained 5 weeks after A shows focal fluid collection representing
pancreatic pseudocyst is in head of pancreas and is extending into anterior
pararenal space.
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Identification of possible pancreatic duct disruption may impact
management, although there are currently divergent opinions regarding the
management of ductal injury. Nonoperative management of most pancreatic
injury—even when there is involvement of the pancreatic duct—has
been proven successful by some
[39,
40]. Others believe that a
distal pancreatectomy for transection to the left of the spine is the
treatment of choice because it is definitive with an acceptable morbidity
[41]. CT may show pancreatic
duct injury directly. Injury to the duct can also be predicted at CT by
evaluating the depth of laceration.
Further assessment of the pancreatic duct can also be performed with MR
cholangiopancreatography (MRCP) and ERCP. MRCP has the advantage of being
noninvasive and faster than ERCP. In addition, MRCP is helpful in further
defining pancreatic injury and associated fluid collections
[42]. MR pancreatograms are
acquired using heavily T2-weighted sequences
[43]. Pancreatic parenchyma is
best assessed using T1- and T2-weighted sequences with fat suppression
[43].
Active Hemorrhage
Children are typically excluded from CT if ongoing bleeding is clinically
evident. Occasionally, CT may show active hemorrhage in children who appear
hemodynamically stable. The amount of hemoperitoneum noted on CT is not a
measure of ongoing hemorrhage
[21]. Rather, it reflects the
cumulative amount of bleeding occurring between the time of injury and the
time that CT was performed.
The only sign of active hemorrhage at CT is a contrast "blush,"
which is defined as high-attenuation areas (> 90 HU) after IV contrast
enhancement [44,
45]. However, a contrast blush
alone is insufficient to diagnose active hemorrhage because it can also be
seen with a contained vascular injury or pseudoaneurysm. Active hemorrhage
will appear as a high-attenuation jet of extravasated IV contrast material
(Fig. 19) or as
high-attenuation fluid in the peritoneum or retroperitoneum
(Fig. 20). A pseudoaneurysm
will appear as a contained high-attenuation collection
(Fig. 21). If the blush is
surrounded by solid organ parenchyma, it may be difficult to differentiate a
contained from a noncontained collection. In this instance, delayed scanning
is useful. A contained vascular injury will wash out on delayed imaging,
whereas active hemorrhage will not wash out. The rate of active bleeding
required for detection at CT is unclear. CT is useful in these cases not only
in identifying the active bleeding but also in localizing the site of
hemorrhage.
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Fig. 19 —8-year-old boy with active hemorrhage. Contrast-enhanced CT
scan through mid abdomen shows linear high-attenuation collection representing
IV contrast extravasation from splenic arterial tear.
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Fig. 20 —11-year-old boy with active hemorrhage. Contrast-enhanced CT
scan through pelvis shows high-attenuation fluid representing active
hemorrhage. At surgery tear of right iliac vein was noted.
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Fig. 21 —12-year-old boy with hepatic pseudoaneurysm.
Contrast-enhanced CT scan through upper abdomen shows focal, rounded,
enhancing lesion in posterior segment of right hepatic lobe. Also note large
hepatic subcapsular hematoma.
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Fig. 22A —12-year-old girl with active hepatic hemorrhage that did not
require laparotomy. Contrast-enhanced CT scan through upper abdomen shows
hepatic laceration with focal area of increased attenuation representing
active hemorrhage. Patient was managed nonoperatively.
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Most children with active hemorrhage detected at CT do not require
operative intervention, particularly when the active hemorrhage is within a
solid viscus and is surrounded by organ parenchyma (Figs.
22A and
22B). In various reports, 20%
or less of children with hepatic or splenic injury and active hemorrhage
required operative hemostasis
[46–48].
Bowel Injury
Bowel injury is uncommon after blunt trauma in children. Injury can result
in a partial-thickness injury that results in intramural hematoma or a
full-thickness injury that results in bowel rupture. Associated mesenteric
injury is often present. Most injuries are noted in children who have been
involved in motor vehicle crashes and who display lap-belt ecchymoses
[9]. The injuries can be seen
in children who are wearing three-point restraints. The clinical diagnosis of
bowel injury may be challenging. Clinical signs and symptoms may be absent,
minimal, or delayed. Therefore, CT plays an important role in the
diagnosis.
Intramural hematoma results from hemorrhage into the bowel wall after a
partial-thickness tear. The most common location is the duodenum. The injury
can usually be managed nonoperatively. Patients are usually placed at bowel
rest for 1 week or more. Large hematomas can result in a proximal small-bowel
obstruction. The CT appearance is of focal bowel wall thickening that is often
eccentric (Fig. 23). Large
duodenal hematomas may appear dumbbell shaped. Neither extraluminal air nor
extravasated contrast material should be present.
Bowel rupture most commonly occurs in the mid to distal small intestine.
The most common site is the jejunum. Extraluminal air is noted on CT in only
approximately one third to one half of cases
[49–51].
Review of the examination at a wide window setting is helpful in the detection
of small amounts of extraluminal air (Fig.
24). Extravasation of oral contrast material is rarely seen
[50]
(Fig. 25). The most frequent
CT finding associated with bowel rupture is "unexplained"
peritoneal fluid—that is, moderate to large amounts of fluid in the
absence of solid viscus injury or pelvic fracture
[49] (Figs.
26A and
26B). Approximately one half
of children with moderate to large amounts of peritoneal fluid as the only
finding on CT after blunt trauma have a bowel injury
[21]. Additional CT findings
associated with bowel rupture include abnormally intense bowel wall
enhancement, focal bowel wall discontinuity, bowel dilatation, bowel wall
thickening, and streaky infiltration of mesenteric fat
[49–51]
(Fig. 27). The latter finding
may result from either associated mesenteric injury or chemical irritation of
the mesentery from spilled intestinal contents.
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Fig. 25 —9-year-old boy with bowel rupture associated with oral
contrast extravasation. CT scan through upper abdomen shows extravasated
high-attenuation oral contrast material in peritoneal cavity.
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Fig. 26A —12-year-old boy with bowel rupture associated with large
amount of "unexplained" peritoneal fluid. Contrast-enhanced CT
scan through upper abdomen shows large amount of peritoneal fluid in
perihepatic and perisplenic spaces.
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Fig. 26B —12-year-old boy with bowel rupture associated with large
amount of "unexplained" peritoneal fluid. CT scan through mid
abdomen shows large amount of fluid in right and left paracolic spaces.
Patient did not have any other abnormalities at CT. At surgery, jejunal
rupture was noted.
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Fig. 27 —9-year-old boy with bowel rupture associated with bowel wall
discontinuity. Contrast-enhanced CT scan through upper abdomen shows
discontinuity in wall of duodenum indicative of bowel wall rupture.
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Fig. 28 —15-year-old girl with intraperitoneal bladder rupture.
Contrast-enhanced CT scan through upper pelvis shows high-attenuation fluid in
lateral pelvic recess secondary to intraperitoneal bladder rupture.
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Bladder Injury
Bladder injury is also uncommon in children. Bladder rupture can be
intraperitoneal or extraperitoneal. Combined injuries may occur.
Extraperitoneal bladder rupture occurs more frequently than intraperitoneal
rupture in children. Intraperitoneal rupture typically results from shearing
of the distended bladder by a lap belt, whereas extraperitoneal rupture often
results from laceration by a bone spicule from a pelvic fracture
[52]. The most common pelvic
injuries associated with extraperitoneal bladder rupture are obturator ring
fractures, pubic symphysis diastasis, sacral fractures, and sacroiliac joint
diastasis.
Bladder distention is essential in the detection of bladder injury at CT to
show extravasation of IV contrast material. This is best achieved by
performing CT cystography
[53–55].
CT cystography is performed by administering dilute iodinated contrast
material into the bladder in a retrograde fashion until the flow stops
followed by clamping of the Foley catheter
[53,
54]. Adequate bladder
distention is critical. Images are then obtained from the bladder dome through
the ischial tuberosities. Reformations should be performed in the coronal and
sagittal planes.
The location of extravasated IV contrast material on CT is useful in
differentiating intraperitoneal from extraperitoneal bladder rupture. This
distinction is important because an extraperitoneal bladder rupture is
typically managed nonsurgically, whereas an intraperitoneal rupture requires
immediate surgical repair. Intraperitoneal fluid in the pelvis will be located
in the lateral perivesical spaces superior to the bladder and anterior to the
rectosigmoid colon (Fig. 28).
Extraperitoneal pelvic fluid will be localized in the perivesical space that
surrounds the bladder superiorly and anteriorly to the umbilicus and
posteriorly behind the rectum (Fig.
29). Thus, if pelvic fluid is noted lateral to the bladder or
behind the rectum, it is extraperitoneal in location. Fluid superior and
anterior to the bladder may be intraperitoneal or extraperitoneal. If fluid
superior to the bladder is extraperitoneal, it will extend superiorly and
anteriorly to the level of the umbilicus. If fluid superior to the bladder is
intraperitoneal, it will be in a more lateral location and will typically be
contiguous with fluid in the lateral pericolic spaces.
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Fig. 29 —12-year-old girl with extraperitoneal bladder rupture.
Contrast-enhanced CT scan through pelvis shows high-attenuation fluid adjacent
to right pelvic side wall and low-attenuation fluid posterior to rectum. These
fluid collections are extraperitoneal in location, consistent with
extraperitoneal bladder rupture.
|
|
Hypoperfusion Complex
A characteristic complex of findings on CT associated with hypovolemic
shock in severely injured children has been characterized as the
"hypoperfusion complex"
[38,
56]. Most children with
hypovolemic shock have arterial hypotension on admission
[56]. The hypotension may be
transiently corrected, and it may be believed that the child is
hemodynamically stable enough to undergo CT, but many children subsequently
develop rapid hemodynamic decompensation. The transition from a compensated
state to noncompensated shock is usually abrupt.
CT findings in all children with the hypoperfusion complex include diffuse
intestinal dilatation with fluid; abnormally intense contrast enhancement of
the bowel wall, mesentery, kidneys, aorta, and inferior vena cava; and
diminished caliber of the aorta and inferior vena cava
[56] (Figs.
30A and
30B). Variable findings
include periportal low-attenuation zones; intense adrenal, pancreatic, and
mesenteric enhancement; decreased pancreatic and splenic enhancement
(Fig. 31); peritoneal and
retroperitoneal fluid; and bowel wall thickening
[38,
57]
(Fig. 32). Familiarity with
the variable CT findings that are part of the hypoperfusion complex is
important to avoid unnecessary laparotomy for the mistaken suspicion of
abdominal visceral injury.
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Fig. 30A —2-year-old girl with hypoperfusion complex. Contrast-enhanced
CT scans through upper (A) and mid (B) abdomen show diffuse
intestinal dilatation with fluid, intense contrast enhancement of bowel wall,
and diminished caliber of great vessels indicative of systemic
hypoperfusion.
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Fig. 30B —2-year-old girl with hypoperfusion complex. Contrast-enhanced
CT scans through upper (A) and mid (B) abdomen show diffuse
intestinal dilatation with fluid, intense contrast enhancement of bowel wall,
and diminished caliber of great vessels indicative of systemic
hypoperfusion.
|
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Fig. 31 —3-year-old boy with hypoperfusion complex and absence of
pancreatic enhancement. Contrast-enhanced CT scan through upper abdomen shows
absence of pancreatic enhancement. Pancreas appeared normal at surgery.
Findings were thought to be secondary to systemic hypoperfusion.
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Fig. 32 —2-year-old boy with hypoperfusion complex associated with
free peritoneal fluid. Contrast-enhanced CT scan through mid abdomen shows
diffuse intestinal dilatation with fluid, intense contrast enhancement of
bowel wall, and diminished caliber of great vessels indicative of systemic
hypoperfusion. Also note free peritoneal fluid in both paracolic spaces.
|
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The hypoperfusion complex is a marker for a tenuous hemodynamic state and
is a predictor of a poor outcome. The reported mortality rate in children with
this constellation of findings at CT is more than 80%
[56]. Many of these children
have severe associated multisystem injury.
Impact of CT on Clinical Decision Making
The role of CT in the evaluation of injured children includes establishing
the presence or absence of visceral and bone injury, identifying injury
requiring close monitoring and operative intervention, detecting active
hemorrhage, and estimating associated blood loss. The use of CT as the primary
screening technique in the assessment of injured children, along with
improvements in supportive care, has played a critical role in the success of
nonoperative management of solid viscus injuries. The rapid evaluation of
injured children with CT has also resulted in improved triage and has
contributed to reduced morbidity and mortality.
The decision for operative intervention in the small percentage of children
who require surgical hemostasis is primarily made based on clinical criteria
and not on CT findings. In a study of 1,500 consecutive children examined with
CT, only 7% of children with solid viscus injury underwent laparotomy
[27]. The decision for
operative intervention in this small subset of children was based on clinical
criteria in 15 (75%) and CT findings in five (25%)
[27]. Therefore, CT primarily
guides nonoperative decisions such as the duration of hospitalization,
intensity of care, and length of activity restriction. The American Pediatric
Surgical Association Trauma Committee has defined consensus guidelines for
resource utilization in hemodynamically stable children with isolated hepatic
or splenic injury based on CT grading
[4]. These guidelines include
ICU stay, length of hospital stay, and physical activity restriction
[4]. A study of 138 consecutive
children studied by CT after blunt trauma showed that CT findings changed the
diagnoses after initial clinical assessment in 84% and management plans in
44%, decreasing the intensity of care in 38% and increasing the intensity of
care in 6% [58].
Solid viscus injury grading at CT has been shown to be useful for
estimating the time course of healing
[59–63].
However, follow-up imaging of solid viscus injury is probably not necessary in
asymptomatic children for several reasons. First, no injury progression or
complication is noted in most solid viscus injuries. Second, clinical
management is rarely altered on the basis of followup imaging.
A negative CT also serves an important function in excluding an
intraabdominal or pelvic source of blood loss, thus enabling an early
discharge of the child from the hospital without further observation
[64]. The high negative
predictive value of CT indicates that hospital admission or observation is not
necessary for patients with suspected blunt abdominal injury and a negative
abdominal CT [64].
CT Dose Reduction Strategies
It is evident that CT is useful in the evaluation and management of
children with blunt abdominal trauma. The concern is that CT also provides the
largest single source of radiation exposure in diagnostic imaging. In
addition, the use of CT in children has increased dramatically in recent years
[65]. It is estimated that
more than 4 million CT examinations are currently performed on children in the
United States per year [66].
CT accounts for approximately 5–10% of the total imaging procedures and
40–70% of the imaging dose
[67]. Children are at greater
risk than adults from a given dose of radiation; they are inherently more
radiosensitive and they have more remaining years of life during which a
radiation-induced cancer could develop. Therefore, we must consider all
possible means by which to reduce the administered CT dose.
The most important dose reduction strategy is to reduce utilization. This
can be achieved by, first, eliminating unnecessary examinations; second,
ensuring availability of outside examinations; and, third, decreasing or
eliminating follow-up CT examinations. When CT is deemed necessary, the ALARA
(as low as reasonably achievable) principles should be followed rigorously.
These principles include limiting the use of multiphase examinations,
collimating the examination to the area of interest, and adjusting the
technique for the patient size. The use of automatic exposure control
available on the latest generation of CT scanners is helpful in optimizing
dose reduction [68]. The
judicious use of CT and adherence to ALARA principles are therefore essential
to minimize the population risk.
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Abstract
Introduction
