PERANAN

PENCITRAAN PADA
TRAUMA ABDOMEN
DEWASA DAN ANAK
Oleh:
dr. HANS MARPAUNG, SpB, FICS

There are two basic categories

of abdominal trauma:
Penetrating Trauma

Shotgun wounds

Non Penetrating
Trauma
-

Compression

- Gunshot wound
- Crush
- Stabbing
- Seat belt
- Acceleration/Deceleration

Abdominal Injuries

Blunt Trauma
Aortic rupture
Splenic rupture
Liver rupture or
laceration
Diaphragmatic tear
Pelvic fracture
Intestinal tear
Bladder rupture

Penetrating Trauma
Splenic rupture
Liver rupture or
laceration
Kidney laceration
Intestinal
lacerations
Bladder rupture
Laceration of
blood vessels

Regions of the
abdomen
The abdomen can be arbitrarily divided into
4 areas:
intrathoracic abdomen
pelvic abdomen
retroperitoneal abdomen
true abdomen
THIS TO SHOW YOU
HOW RADIOLOGY IS
BADLY NEEDED

The Intrathoracic abdomen, which is

the portion of the upper abdomen that lies beneath

Its contents include the

diaphragm, liver, spleen, and stomach. The
rib cage makes this area inaccessible for
palpation and complete examination.
the rib cage

You need
RADIOLOGY

The Pelvic abdomen, which is defined

by the bony pelvis. Its contents include
the urinary bladder, urethra, rectum, small
intestine, and, in females, the ovaries,

Injury to
these structures may be
extraperitoneal in nature and
therefore difficult to diagnose.
fallopian tubes, and uterus.

You also need RADIOLOGY

The retroperitoneal abdomen,

which contains the kidneys, ureters,
pancreas, aorta, and vena cava. Injuries to

these structures are very difficult to

diagnose based on physical
examination findings. Evaluation of the
structures in this region may require a
CT scan, angiography, and an
intravenous pyelogram.
You also need RADIOLOGY
Evaluation of the structures in
this region may require a CT scan,
angiography, and an intravenous pyelogram.

The true abdomen, which contains the small

and large intestines, the uterus (if gravid), and the
bladder (when distended). Perforation of these organs is
associated with significant physical findings and usually
manifests with pain and tenderness from peritonitis.
Plain x-ray films are helpful if free air is present.
Additionally, DPL is a useful adjunct

The abdomen is the

Box

Black

i.e., it is impossible to know what specific

- Internal bleeding ?
injuries have occurred at initial evaluation:

- Organ injurie ?

Penetrating Abdominal Trauma

Visible wounds may not reflect

severity of underlying injury
Significant internal bleeding likely
Bowel injury likely
Patient may be in shock

You need
RADIOLOGY

One of the big challenges facing

the emergency room medical
team

is
How to establish non-invasively
the presence and extent of internal injury in a patient
presenting with abdominal trauma. Such patients are
often in severe pain and may sometimes be
unconscious.

You need RADIOLOGY

Modern medical Radiological imaging

facilities

have rendered erstwhile surgical procedures like

the
four quadrant tap for haemoperitoneum,

as a first line clinical diagnostic measure,

unnecessary and obsolete..

Radiologic step
1.

Plain radiography

2.

FAST:

Focused Assessment with Sono

graphy for Trauma

3.

C T Scan

4.

Angiography

5.

MRI

THE PLAIN RADIOGRAPH

is useful to diagnose

fractures in the lower ribs and this is important

because a rib fracture may draw attention to the
possibility of co-existing solid organ injury in the
spleen, liver or kidneys.
The chest radiograph may aid in the diagnosis of
abdominal injuries such as ruptured hemidiaphragm
or pneumoperitoneum.

PNEUMOPERITONEUM

Radiologic step
Abdominal ultrasound is
the first imaging modality
of choice
(FAST = Focused
assessment with
sonography for trauma)

FAST

A POSITIVE FAST

A NEGATIVE FAST does not exclude

indicates peritoneal
penetration, but is poor at discriminating for
injuries requiring intervention
significant abdominal injury.
It is therefore impossible to recommend FAST
as the only investigation for the assessment
of penetrating intra-abdominal injury. It MAY
have a role in combination with other
investigations

FASTFocused Assessment
with Sonography for Trauma

is currently the diagnostic

modality of choice when
evaluating the UNSTABLE patient
with BLUNT ABDOMINAL TRAUMA.
Sensitifity 92% Specifity 95%

The minimum threshold for detecting hemoperitoneum is

unknown and remains a subject of interest. Kawaguchi and colleagues
found that 70 mL of blood could be detected, while Tiling et al found
that 30 mL is the minimum requirement for detection with ultrasound.

Anechoic stripe in the Morison pouch

represents approximately 250 mL of
fluid
while 0.5-cm and 1-cm stripes
represent
approximately 500 mL and 1 L of free
fluid, respectively

COMPUTED TOMOGRAPHY (CT)

CT has become the mainstay of radiological

diagnosis of splenic, hepatic and renal injuries
especially when doubt exists after an ultrasound scan.

Contrast enhanced CT is excellent in defining the

contour and parenchymal density of these organs
making it easier to identify and locate an injury after
trauma.

CT is important to determine the location, type and

volume of both intra and extraperitoneal fluid .
It can detect the presence of haemoperitoneum

Spiral CT has gone a step further

with its ability to produce three dimensional

(3-D) images of blood vessels making
demonstration of vascular injuries easier.

Recent advances in CT imaging now

make it possible to identify bleeding
vessels using this modality

MAGNETIC RESONANCE IMAGING

(MRI)

MRI has better soft tissue discrimination over CT.

Magnetic resonance angiography can demonstrate
damage to an injured vessel even without use of a
contrast medium. This is an advantage over CTA and
DSA which both employ iodine-based contrast media
and x-rays.

In the unconscious patient, MRI is capable of producing

axial, sagittal and coronal images without change in
patient position which is an added advantage over CT.

Newer generation MRI scanners are also capable of

helps to determine the presence and site of a

bleeding vessel .
Angiography

- Demonstrate the vessel in cases of arterial

extravasations.
- Arterial embolisation of the splenic, hepatic and renal

FAST examination has virtually replaced

DPL
as the procedure of choice in the evaluation of
hemodynamically unstable trauma patients.

DPL
FAST
RSNA, 2003
Radiology 2003;227:95103

A standard Diagnostic Peritoneal Lavage

(DPL) catheter is secured in place following
an open DPL. An aspirating syringe is
attached to the catheter via extension tubing
as the initial step in the evaluation for

Focused Assessment with Sonography for Trauma

(FAST) is a limited ultrasound examination directed
solely at identifying the presence of free intraperitoneal
or pericardial fluid. In the context of traumatic injury,
free fluid is usually due to haemorrhage and contributes
to the assessment of the circulation

THE TRAUMA PATIENT

IS HE/ SHE

Hemodynamically unstable
OR
Hemodynamically stable

Hemodynamically unstable patients

The abdomen is evaluated by
Physical examination,

FAST Ultrasound,

DPL or

Celiotomy.

Selected patients (cardiovascular stability) may be

evaluated by the CT scan.

FAST examination is
NEGATIVE in hemodynamically unstable
When the

trauma patients.

are a diagnostic
challenge to the
treating physician.
Options include

DPL, exploratory

Laparotomy,
and, possibly, a CT
scan after aggressive
resuscitation.

Hemodynamically unstable patients

FAST
POSTIVE

perform
exploratory
laparotomy

NEGATIVE

rapidly identify other

source

Hemodynamically stable patients

with positive FAST results

may require a CT scan to better define the nature

and extent of their injuries.

Taking every patient with a positive

FAST result to the operating room
may result in an unacceptably high
laparotomy rate.

Hemodynamically stable patients

with negative FAST results
require
1. Close observation,
2 Serial abdominal examinations,
3. A follow-up FAST examination repeat FAST in 6
hours, if no other indications there is no need for a CT
scan.

ULTRASONOGRAPHY

quick,
noninvasive,
inexpensive,
and
transportable
tool

The sensitivity of sonography for

hemoperitoneum is usually considered
high, comparable with computed
tomography (CT), but sensitivity for
direct demonstration of organ injury is
lower.

Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound
in detecting free intraperitoneal fluid. J Trauma 1995; 39:375380.[Medline

Images in an 18-year-old woman after a motor vehicle

accident, with normal screening US findings. abdominal
CT scan obtained at 31 hours after a to evaluate
increasing abdominal pain shows small liver laceration
(arrow) with no hemoperitoneum.

Images in a 21-year-old woman admitted to the hospital with diffuse

abdominal pain after trauma. (a) Transverse image obtained at
admission US shows a hyperechoic area (arrowheads) in the right
lobe of the liver. (b) Subsequently obtained transverse CT scan of
the abdomen reveals a grade III liver laceration (arrowhead). The
admission US examination was considered to have yielded a true-

Splenic injury from an assault in a 15-year-old boy.

A, Intercostal sonogram of the spleen showing heterogeneous
parenchyma including small hypoechoic areas.
B, Computed tomographic scan showing splenic lacerations
(arrows) with hemoperitoneum (arrowheads). The patient was

A
Type IIIa renal injury from a traffic accident in a 6-year-old
boy.
A, Longitudinal sonogram of the right kidney showing a
poorly defined echogenic area with an irregular anechoic
area in the midpole of the kidney (arrows).
B, Computed tomographic scan showing a lowattenuation area in the renal parenchyma (arrow) with
perirenal hematoma (arrowhead), representing a deep

COLOUR DOPPLER
ULTRASOUND
Trauma may result in vascular damage with associated
disruption of blood supply to any of the abdominal

Colour Doppler
ultrasound
organs.

is
useful for mapping out the colour flow in the
spleen, liver or kidneys to confirm suspected
damage of vessels.

ABDOMINAL TRAUMA
IMAGING

GASTRO-INTESTINAL STUDIES

Although it is a rare occurrence, gastro-intestinal tract

(GIT) perforation can be associated with blunt
abdominal trauma especially following falls and motor
vehicle accidents; the site that most frequently
perforates is the jejunum followed by the ileum 14.

When the GIT is perforated it is advisable to use water

soluble gastrograffin contrast medium for upper and
lower GIT studies.

Bowel Rupture

The diagnosis of bowel rupture is made by finding

free air on abdominal x-ray.

Use a decubitus or cross-table view for the patient

who cannot stand for an upright view.
Duodenal or sigmoid colon injury may result in
retroperitoneal air only.

Pneumoperitoneum
Imaging findings
There is a large quantity of
free air in this patient's
abdomen.
The image is obtained with the
patient supine, yet there are
crescents of air seen beneath
each hemidiaphragm (white
arrows), and both sides of the
bowel wall are visible (blue
arrow).
There is a lucency overlying

LIVER TRAUMA Grade 1 hepatic injury in a 21-year-old

man with a stabbing injury to the right upper quadrant of
the abdomen

Axial contrast-enhanced CT scan demonstrates a small

crescent- shaped subcapsular and parenchymal
hematoma less than 1 cm thick.

Selective celiac arteriogram (same

patient as in Images 1-2). The image
shows a focal area of hemorrhage in the
right lobe of the liver (arrow) due to the
stabbing injury. The well-demarcated
filling defect seen in the lateral aspect of
the right lobe of the liver is due to
compression of normal liver parenchyma
by the subcapsular hematoma.

Postembolization selective
arteriogram The image
shows cessation of the
bleeding in the right lobe of
the liver.

Active splenic vascular contrast material

extravasation in a 77-year-old patient with
blunt trauma. (a, b) Transverse contrastenhanced spiral CT images show a grade III
splenic injury, with subcapsular (straight
arrow in a), intraparenchymal (arrowheads),
and intraperitoneal (open arrow in b)
vascular contrast material extravasation.
Some free intraperitoneal fluid (curved
arrow) is seen adjacent to the liver. (c)
Anteroposterior celiac-axis arteriogram
shows active bleeding (arrow). Transcatheter

ABDOMINAL TRAUMA IMAGING

CONCLUSION
Medical imaging has an invaluable role to play in the
management of the patient with blunt abdominal
trauma using various modalities that are currently
available in the radiological amarmentarium.
Choice and employment of any particular radiological
investigation would depend on the equipment available
at a particular facility and the urgency of the demand
especially in life threatening situations. In terms of
cost-effectiveness it is better to start with less
sophisticated and cheaper options like US for detection
of solid viscera injury especially when the patients
condition is stable. If there is doubt and in the face of
deteriorating condition of the patient without a clear-cut
diagnosis, then sophisticated CT examinations should

Thank You