Abnormal abdominal CT is best powerpoint presentation for radiologist, radiology resident and gastroenterologist, this include pancreatitis, all abdominal trauma grading with systemic manner. Thanks

1. Abnormal abdominal CT
Dr Pradeep Kumar

2. Pancreatitis overview
• Acute pancreatitis and commonly used terminologies
• Revised atlanta classification
• Complications
• Outline for radiological approach
• Chronic pancreatitis
• Uncommon types of pancreatitis

3. DEFINITION & DIAGNOSIS OF ACUTE PANCREATITS
• The diagnosis of acute pancreatitis requires two of the following
three features:
• (1) abdominal pain consistent with acute pancreatitis
• (acute onset of a persistent, severe, epigastric pain often radiating
to the back);
• (2) serum lipase activity (or amylase activity) at least three times
greater than the upper limit of normal; and
• (3) characteristic imaging findings of acute pancreatitis on contrast-
enhanced computed tomography (CECT) and less commonly
magnetic resonance imaging (MRI) or transabdominal
ultrasonography
*

5. Pathophysiology
*

7. In pathophysiologic terms ….
Acute pancreatitis into early and late phases
• Early within 1 week
• Late phase starts in 2nd week

8. Course and Severity of Disease
• Over the course of the 1st week, organ failure either resolves or becomes more severe.
• Patients with organ failure that resolves in 48 hours are considered to have mild
pancreatitis without complications and have a mortality rate of 0%
• Severe acute pancreatitis in the first phase is defined as organ failure that lasts
more than 48 hours or death
• A new subgroup of acute pancreatitis has recently been described, termed
“moderately severe acute pancreatitis,” consisting of patients with local complications
similar to those with severe acute pancreatitis but lower morbidity, which is believed to
be due to more transient organ dysfunction lasting less than 48 hrs.

9. Degrees of severity of acute pancreatitis; modified from Banks et al.
Mild acute pancreatitis
lack of organ failure and local/systemic complications
Moderately severe acute pancreatitis
transient organ failure – organ failure that resolves within 48 hours and/or
local or systemic complications
Severe acute pancreatitis
persistent single or multiple organ failure (>48 hours)

10. * 5

11. Abdominal plain film
Findings of acute pancreatitis on abdominal
plain film
•Duodenal ileus in 42% of Pts
•Sentinel loop sign (dilated air-filled
duodenum or jejunum)
•Colon cutoff (paucity of gas distal to
splenic flexure due to spasm of colon
affected by spread of pancreatic
inflammation
•Loss of left psoas shadow
•Ascites
•Gasless abdomen
•Pancreatic abscess (gas bubbles)

12. 12
Plain chest film
• 1/3 of acute pancreatitis Pts have pulmonary changes secondary to
superior spread of inflammation to diaphragm and lung bases – s/o
severe acute pancreatitis
• Findings:
• Pleural effusions (seen on 10% of chest films)
• Basal atelectasis
• Pulmonary infiltrates
• Elevated diaphragm
• ARDS

13. Ultrasound
• Indications
• Good screening test in mild disease, suspected biliary pancreatitis,
and thin Pts lacking fat planes for good CT evaluation
• Uses
• Exclude a diagnosis of gallstone
• Detection of fluid collection in peritoneum, retroperitoneum, and
pleural spaces.
• Follow up of pseudocysts
• Doppler of cystic masses to rule out pseudoaneurysm
• Major limitations
• Bowel gas
• US cannot specifically reveal areas of necrosis

14. CT
• According to the revised Atlanta classification, CECT is the primary tool for
assessing the imaging-based criteria because it is widely available for these
acutely ill patients and has a high degree of accuracy.
• Contrast-enhanced CT is especially suited for staging in patients with acute
pancreatitis, helping assess complications, and monitoring of treatment
response through follow-up studies.
• CT should be repeated when the clinical picture drastically changes, such as
with sudden onset of fever, decrease in hematocrit, or sepsis.

15. Other imaging modalities
• MR imaging is reserved for detection of choledocholithiasis not
visualized on contrast-enhanced CT images and to further characterize
collections for the presence of nonliquefied material.
• MR imaging has an important role in patients in whom contrast-
enhanced CT is contraindicated (eg, due to allergy to iodinated intra-
venous contrast agents or pregnancy).
• Endoscopic retrograde cholangiopancreatography has no role in this
morphologic imaging–based classification of acute pancreatitis.

16. Revised classification system…
• Stratify acute pancreatitis into subcategories
• Interstitial edematous pancreatitis and necrotizing pancreatitis

20. Interstitial edematous pancreatitis(IEP)
•Acute inflammation of the pancreatic parenchyma and peripancreatic
tissues, but without recognisable tissue necrosis
•CECT shows localized or diffuse enlargement of the pancreas, with
normal homogenous enhancement or slightly heterogenous
enhancement of the pancreatic parenchyma related to edema.
•CECT criteria
•▸ Pancreatic parenchyma enhancement by intravenous contrast agent
•▸ No findings of peripancreatic necrosis

22. Necrotising pancreatitis
•Inflammation associated with pancreatic parenchymal necrosis and/or
peripancreatic necrosis.
• Areas of non-enhancement, especially when >3 cm or >30% of the
pancreatic volume, are considered a reliable CT sign for necrosis.
• However, in minor necrosis (<30% of the gland), CT has a false-negative
rate of 21%
•CECT criteria
•▸ Lack of pancreatic parenchymal enhancement by intravenous contrast
agent and/or
•▸ Presence of findings of peripancreatic necrosis
*

24. APFC (acute peripancreatic fluid collection)
• Areas of peripancreatic fluid seen within the first 4 weeks after onset of
interstitial oedematous pancreatitis and without the features of a
pseudocyst.
• Those that do not resolve may be complicated by infection or
haemorrhage. Others may evolve to become pseudocysts
CECT criteria
•▸ Occurs in the setting of interstitial oedematous pancreatitis
•▸ Homogeneous collection with fluid density
•▸ Confined by normal peripancreatic fascial planes
•▸ No definable wall encapsulating the collection
•▸ Adjacent to pancreas (no intrapancreatic extension)
* 8
Fluid collections in the pancreatic parenchyma should be
diagnosed as necrosis and not as APFCs.

25. • Most APFCs are reabsorbed spontaneously within the 1st few wks and
do not become infected.
• Intervention at this stage is to be avoided, because of risk of
introduction of infection.
• 1st wk – distinction between APFC and ANC may be difficult or
impossible, because both collections may appear as areas of
nonenhancement
• If non enhancing areas of variable attenuation seen – diagnosis of
peripancreatic necrosis with non liquefied components
•Non liquefied components – hemorrhage, fat and/or necrotic
fat.

26. Pancreatic pseudocyst
•An encapsulated collection of fluid with a well
defined inflammatory wall usually outside the
pancreas with minimal or no necrosis.
• usually occurs more than 4 weeks after onset
of interstitial oedematous pancreatitis to
mature.
•CECT criteria
▸ Well circumscribed, usually round or oval
▸ Homogeneous fluid density
▸ ▸ Well defined wall; that is, completely
encapsulated
▸ Maturation usually requires >4 weeks after
onset of acute pancreatitis; occurs after interstitial
oedematous pancreatitis
*

27. WON (walled-off necrosis)
•A mature, encapsulated collection of pancreatic and/or
peripancreatic necrosis that has developed a well defined
inflammatory wall.
•WON usually occurs >4 weeks after onset of necrotising pancreatitis.
•CECT criteria
•▸ Heterogeneous with liquid and non-liquid density with varying
degrees of loculations (some may appear homogeneous)
•▸ Well defined wall, that is, completely encapsulated
•▸ Location—intrapancreatic and/or extrapancreatic
•▸ Maturation usually requires 4 weeks after onset of acute
necrotising pancreatitis.
*

28. *

29. 29

30. Infected necrosis
• Infected necrosis is:
– Infection of necrotic pancreatic parenchyma
– And/or necrotic extrapancreatic fatty tissue
• Usually occurs in the 2nd-3rd week.
• Most severe local complication of acute pancreatitis
• Most common cause of death in patients with acute
pancreatitis
• Air bubbles are seen in 20% of cases with infected
necrosis.
*

31. • Distinguish among infected pseudocyst, and
infected pancreatic necrosis - Treatment and
prognosis are very different
– Infected pseudocyst: Percutaneous catheter
drainage; quick recovery
– Infected pancreatic necrosis: Surgical debridement;
often repeated
*

32. *

34. • Scores Summary
1.Mild Pancreatitis 0-2
2.Moderate Pancreatitis 4-6
3.Severe Pancreatitis 8-10
Significant correlation between the severity of
pancreatitis and development of organ failure

35. What is the optimal examination for diagnosing
acute pancreatitis?
• Pancreatic imaging by contrast-enhanced CT provides
good evidence for the presence or absence of pancreatitis.
• CT should be carried out 48–72 h from the onset of the
symptoms in patients with predicted severe pancreatitis
because the evidence of necrosis correlates well with the
risk of other local and systemic complications ;
• Patients with persisting organ failure, signs of sepsis, or
deterioration in clinical status 6–10 days after admission
will require an additional CT scan .
*

36. *

37. *

38. • Collections can be approached through the transhepatic,
transgastric or transabdominal route, but the preferred
approach is to stay in the retroperitoneal compartment.
This approach has some advantages over the others:
• Same abdominal compartment as the pancreas
• No contamination with intestinal flora
• Gravity
• Drain runs parallel to pancreatic bed
• This route can be used to guide surgery
*

39. *

41. Central gland necrosis
• Central gland necrosis is a subtype of necrotizing pancreatitis.
• It represents necrosis between the pancreatic head and tail
and is nearly always associated with disruption of the
pancreatic duct. This leads to persistent collections as the
viable pancreatic tail continues to secrete pancreatic juices.
• These collections react poorly to endoscopic or percutaneous
drainage.
• Definitive treatment often requires distal pancreatectomy.
*

42. Complications
• Pancreas: Fluid collections, pseudocyst, necrosis,
abscess
• GI: Hemorrhage, infarction, obstruction, ileus
• Biliary: Obstructive jaundice
• Vascular: Pseudoaneurysm, porto-splenic vein
thrombosis, hemorrhage
• Disseminated intravascular coagulation (DIC)
• Shock due to pulmonary and renal failure
• Cardiac, central nervous system, and metabolic
complications
*

43. *

44. (II) Chronic Pancreatitis :
1. Def and type
2. Etiology
3. Clinical Picture
4. Radiographic Findings

45. Chronic Pancreatitis
Def:- Chronic pancreatitis is a progressive fibroinflammatory disorder
characterized by intermittent or continuous abdominal or back pain (or both)
due to the persistence of structural damage after the primary cause has been
eliminated. This damage results in loss of pancreatic parenchyma, functional
insufficiency (endocrine and exocrine), and complications such as biliary
stricture, pseudocyst, and pseudoaneurysm.
1. Calcifying chronic pancreatitis: characterized by acinar destruction and
peri lobular fibrosis with acute and chronic inflammatory cells. It presents with
recurrent bouts of abdominal pain and eventual development of intraductal
calculi in a large proportion of cases. Causative factors include alcohol and
tobacco use. There are hereditary, tropical, idiopathic, and senile forms; the
senile form is often painless.

46. 2. Obstructive chronic pancreatitis: persistent obstruction of the
pancreatic duct due to tumor or post inflammatory ductal stricture
leads to atrophy of the upstream pancreas. Though often painless,
it occasionally presents with clinically acute pancreatitis.
Intraductal calculi are generally not seen.
3.Autoimmune pancreatitis: chronic systemic lymphoplasmacytic
inflammatory process involving the pancreas and other organs.
Typically, chronic pancreatitis develops in patients with recurrent
bouts of acute pancreatitis (e.g., alcoholic and hereditary forms)

47. CHRONIC PANCREATITS
• Approximately 90% of calcific
pancreatitides are caused by
alcoholism
• Other 10% = mostly hereditary
pancreatitis
• Atrophy of gland, dilated main
pancreatic duct (MPD), intraductal
calculi
• Fibroinflammatory mass: Common in
pancreatic head
* 34

48. Clinical Picture :
-Patients may present with exacerbations
(episodes of acute pancreatitis)
manifesting as epigastric pain, which may
recur over a number of years

49. Radiographic Findings :
a) Plain Radiography :
-Calcification
b) US :
-The pancreas might appear atrophic, calcified or
fibrotic
-Findings that may be present on ultrasound
include :
*Hyperechogenicity (often diffuse) often indicates
fibrotic changes
*Pseudocysts
*Pseudoaneurysms
*Presence of ascites

52. c) CT :
CT features of chronic pancreatitis include :
1-Dilatation of the main pancreatic duct
2 Pancreatic calcification
3 Changes in pancreatic size (i.e. atrophy),
shape, and contour
4 Pancreatic pseudocysts

53. Calcification in an atrophic pancreas

54. Duct dilatation

55. Pancreatic calcifications

57. • May have "double duct" sign (stricture of distal CBD
and pancreatic duct) - Not pathognomonic of
pancreatic carcinoma
• Long, smooth taper of CBD (not abrupt, as with
carcinoma)
• MRCP: Good depiction of parenchymal and ductal
lesions
• Splenic vein thrombosis, splenomegaly, varices -May
progress to thrombosis of portal vein
• Pseudoaneurysm of gastroduodenal or other arteries
* 35

58. * 37

59. Groove Pancreatitis :
-Rare form of chronic pancreatitis that may mimic
pancreatic carcinoma
-The term pancreaticoduodenal groove refers to
the potential space between the head of the
pancreas, the duodenum, and the CBD
-Two forms of groove pancreatitis have been
described :
a) Segmental Form :
-Which involves the pancreatic head with
development of scar tissue within the groove
b) Pure Form :
-Which affects the groove only, sparing the
pancreatic head

60. Groove pancreatitis with cystic dystrophy of the duodenal wall, drawing
illustrates the disease process in groove pancreatitis, inflammation is
predominantly centered in the pancreaticoduodenal groove, with multiple
cystic lesions within the medial wall of the duodenum (D)

62. -At CT, the classic finding is soft tissue
within the pancreaticoduodenal groove;
this tissue may demonstrate delayed
enhancement, small cystic lesions may be
seen along the medial wall of the
duodenum

63. •Sheet-like hypodense mass between pancreatic head and C
loop of duodenum
•Thickened duodenal wall with delayed enhancement ±
cysts
•MRCP- Long, smooth narrowing of intrapancreatic CBD and
distal pancreatic duct
•Small cysts in groove or medial wall of duodenum
•Widened space between ducts and duodenal lumen

64. Groove pancreatitis with cystic dystrophy of the duodenal wall, (a) Transverse
US image through the pancreas (P) demonstrates a sheetlike hypoechoic
area in the pancreaticoduodenal groove with areas of cystic change
(arrowhead), (b, c) Venous phase CT scans show a hypoattenuating area in
the pancreaticoduodenal groove (arrow in b) with inflammatory stranding
within the surrounding fat and in the right anterior pararenalparaduodenal
space (arrows in c). P = pancreas

66. Autoimmune pancreatitis
• Autoimmune mechanism
• Immunoglobulin G subtype 4(IgG4) systemic disease
• Multiple organs involvement like pancreas,
kidney,lungs ,salivary glands and lymphnodes
• Middle aged men
• Remarkable responsive to steroids

67. • AIP is classified into two types (1 and 2) with some overlap in
clinical and histopathologic characteristics but also showing
important differences. Although differentiating the two types of AIP
could be useful to predict the likelihood of disease recurrence.

70. • Typical Imaging findings diffuse enlargement of the
pancreas with loss of lobulation of pancreatic border
• Narrowing of main pancreatic duct
• Capsule like rim

75. Specific Organ Injuries
• Solid intraperitoneal organs
• Retroperitoneal organs
• Hollow organs

76. FAST vs. CT
FAST CT
Aim for Detection of hemoperitoneum Detection of
hemoperitoneum, organ
injuries
Accuracy (for
hemoperitoneum)
88% Nearly 100%
Accuracy (for
organ injuries)
74% Nearly 100%
Missed rate 15% of hemoperitoneum. Up to
25% of liver/spleen, most renal/
pancreas/bowel
Benefits Fast, bedside, no patient prep
needed, no risk of IV contrast
issues
More accurate, guide
non-operative
management
ACR*
Recommendation
Done first and only if
hemodynamic unstable before
going to OR
Done if hemodynamic
stable
*The American College of Radiology

77. Liver
• Common
• Can be part of RUQ/midline “package injuries”
– Shearing right lobe adjacent to hepatic veins
– Compression left lobe
• Vast majority managed nonoperatively
– Surgery if severe injuries with active bleeding and/ or
complete destruction of entire hepatic lobe
• Right lobe (75%) > left lobe

78. Types
• Most (~80%) of liver injuries are minor (grades I to III). There is a
range of injuries:
• laceration (most common)
• hematoma - subcapsular or intraparenchymal
• active hemorrhage
• major hepatic vein injury
• bile duct injury
• AV fistula

79. Classification
• grade I
• hematoma: subcapsular, <10% surface area
• laceration: capsular tear, <1 cm parenchymal depth
• grade II
• hematoma: subcapsular, 10-50% surface area
• hematoma: intraparenchymal <10 cm diameter
• laceration: capsular tear 1-3 cm parenchymal depth, <10 cm length
• grade III
• hematoma: subcapsular, >50% surface area of ruptured subcapsular or parenchymal
hematoma
• hematoma: intraparenchymal >10 cm
• laceration: capsular tear >3 cm parenchymal depth
• vascular injury with active bleeding contained within liver parenchyma

80. • grade IV
• laceration: parenchymal disruption involving 25-75% hepatic lobe or involves
1-3 Couinaud segments
• vascular injury with active bleeding breaching the liver parenchyma into the
peritoneum
• grade V
• laceration: parenchymal disruption involving >75% of hepatic lobe
• vascular: juxtahepatic venous injuries (retrohepatic vena cava / central major
hepatic veins

82. Markers
• Elevated liver transaminases (ALT/AST) is 100% specific and ~93%
sensitive in predicting liver injuries
CT
• CT is the investigation of choice for evaluating for liver trauma. It is ~95%
sensitive and 99% specific for detecting liver injuries .
• lacerations appear as irregular linear/branching areas of hypoattenuation
• hematomas appear as a hypodensity between the liver and its capsule
(and can be differentiated from intra-peritoneal hematoma as these
distort the liver architecture) or can be intraparenchymal
• acute hematomas/haemorrhage are typically hyperdense (40-60HU)
compared to normal liver parenchyma

83. • Laceration involving hepatic veins (esp. if large >
10 cm focal hypoperfusion) associated with
injuries to retrohepatic IVC
laceration
Extraperitoneal blood

84. • Liver laceration involving hilum
– Repeated CT or US, cholescintigraphy or direct
cholangiography to detect possible biliary
complications
laceration

85. Splenic Injury
• Most frequently affected organ in blunt trauma
• Contusion, parenchymal laceration, subcapsular
hematoma, perisplenic hematoma, fragmentation of
parenchyma and disruption of hilar vessels
• Left lower rib fractures frequently associated

86. • Types
• laceration
• hematoma: subcapsular (more common) or intraparenchymal
• Seurat spleen
• active hemorrhage
• pseudoaneurysm or AV fistulas (in ~15% of splenic trauma 4)
• splenic infarct (rare)

87. CT
• CT is the modality of choice for assessing splenic trauma:
• splenic parenchyma should be assessed in portal venous phase as
the inhomogeneous splenic enhancement (zebra or psychedelic spleen) seen
on arterial phase can mimic splenic laceration/contusion.
• Arterial phase scanning can be useful in detecting vascular injuries such as
pseudoaneurysm and AV fistula
• Lacerations appear as linear or branching hypodensities (geographic pattern)
• Subcapsular hematomas can be seen as low-density fluid adjacent to the spleen
that distorts the splenic architecture
• Active haemorrhage appears as a high-density (80-95 HU) material due to the
extravasation of contrast media that increases in size on delayed imaging

88. Classification
• grade I
• subcapsular hematoma <10% of surface area
• parenchymal laceration <1 cm depth
• capsular tear
• grade II
• subcapsular hematoma 10-50% of surface area
• intraparenchymal hematoma <5 cm
• parenchymal laceration 1-3 cm in depth
• grade III
• subcapsular hematoma >50% of surface area
• ruptured subcapsular or intraparenchymal hematoma ≥5 cm
• parenchymal laceration >3 cm in depth

89. • grade IV
• any injury in the presence of a splenic vascular injury* or active bleeding
confined within splenic capsule
• parenchymal laceration involving segmental or hilar vessels producing >25%
devascularisation
• grade V
• shattered spleen
• any injury in the presence of splenic vascular injury* with active bleeding
extending beyond the spleen into the peritoneum

91. • Contusion = hypodense area within normally
perfused splenic parenchyma

92. • Laceration = linear perfusion defect

93. • Subcapsular hematoma = lenticular shape with
compression of adjacent splenic paenchyma
– Difficult to confidently see splenic capsule
– Sometimes difficult to distinguish btw subcapsular and
perisplenic hematoma
Image from Radiology.cornfield.org

94. Nonoperative Management of Splenic
Injury
• Now accepted practice: Success rate 95% in
children, 70% in adults
• Well-recognized complication = delayed splenic
rupture
– No reliable CT finding to predict risk of delayed
splenic rupture
– Even a normal CT cannot exclude possibility of
delayed splenic rupture

95. Pancreas
• <2% of blunt abdominal trauma
• Up to 90% multiple organ injuries
• Contusion, superficial or partial laceration,
complete transection or disruption
• Can be difficult to diagnose clinically
– Delayed complications: recurrent pancreatitis,
fistula, abscess, hemorrhage
– Risk of abscess/fistula high (25-50%) if duct
disruption (vs. 10% if duct not disrupted)

96. Pancreas
• Predict the presence or absence of ductal
disruption by depth of laceration and
location
– Grade A, pancreatitis or superficial laceration
(<50% pancreatic thickness)
– Grade B, deep laceration (>50% thickness) at
tail
– Grade C, deep laceration at head

97. Classifications
American Association for the Surgery of Trauma (AAST)
• grade 1: hematoma with minor contusion/laceration but without
duct injury
• grade 2: major contusion/laceration but without duct injury
• grade 3: distal laceration or parenchymal injury with duct injury
• grade 4: proximal (i.e. to the right of the superior mesenteric
vein) laceration or parenchymal injury with an injury to bile
duct/ampulla
• grade 5: massive disruption of the pancreatic head

99. • Direct CT signs: Pancreatic enlargement, focal linear non-
enhancement, comminution, heterogeneous enhancement (subtle
initially)
• Indirect CT signs: Peripancreatic fat stranding, fluid collections, fluid
separating splenic vein from parenchyma, hemorrhage, and
thickening of left anterior pararenal fascia
Focal linear non-enhancement
Focal linear non-enhancement

100. Bowel Injury
• 3-7% of blunt abdominal trauma
• Jejunum and ileum (near point of fixation—IC
valve and ligament of Treitz) most common
• Colon: transverse, sigmoid and cecum
• Stomach-rare
• Duodenal injury: 2nd/3rd part in close proximity
to spine
• Overall CT sensitivity/specificity 85-95%

101. • Direct CT signs: 1) Discontinuity of wall, spillage of contrast or
luminal contents into peritoneal or retroperitoneal. 2) Extraluminal
air (definite for blunt trauma but not for penetrating trauma)
• Indirect CT signs: 1) Focal bowel wall thickening, streaky
mesenteric fat, unexplained free fluid between mesenteric loops. 2)
Generalized bowel wall thickening nonspecific
Colonic contrast leakage
Perforation site at sigmoid colon
Bullet

102. • Duodenal perforation vs. hematoma
– Perforation  immediate surgery
– Hematoma  conservative
• Helpful if you can give oral contrast immediately before
scanning to see leakage
Perforation site
Circumferential wall hematoma

103. Kidney and Ureter
• Kidney injury = most common RP injury
• Contusion, laceration, subcapsular hematoma, shattered kidney,
renal artery occlusion
• Major renal hemorrhage with minor trauma should raise suspicion of
underlying pathology (hydronephrosis, cyst, horseshoe kidney, AML,
RCC)

104. Types
vast majority (95-98%) of renal injuries are minor. The spectrum of renal
injuries include:
• contusion/hematoma
• laceration
• hemorrhage
• avulsion of the renal pedicle leading to devascularisation of the kidney
• pseudoaneurysm
• AV fistula
• renal artery thrombosis, transection or dissection

105. Kawashima A, et al. Radiographics 2001
• Renal contusion: focal zones of decreased
enhancement, striated nephrogram because of
temporarily impaired tubular excretion

106. • Laceration: linear or wedge-shaped hypodense area
– Fracture = involving medial and lateral surface of kidney through hilum
– Shattered kidney = laceration crossing kidney resulting in multiple fragments
Initial Delayed
Laceration
Active extravasation
hematoma
hematoma

107. • Deep laceration results in
urine extravasation
• Delayed scan for
confirmation
Initial Delayed
Excreted contrast in left ureter
Urinoma
Urinoma

108. Classification
• grade I
• subcapsular haematoma or contusion, without laceration
• grade II
• superficial laceration ≤1 cm depth not involving the collecting system (no evidence of urine extravasation)
• perirenal haematoma confined within the perirenal fascia
• grade III
• laceration >1 cm not involving the collecting system (no evidence of urine extravasation)
• vascular injury or active bleeding confined within the perirenal fascia
• grade IV
• laceration involving the collecting system with urinary extravasation
• laceration of the renal pelvis and/or complete ureteropelvic disruption
• vascular injury to segmental renal artery or vein
• segmental infarctions without associated active bleeding (i.e. due to vessel thrombosis)
• active bleeding extending beyond the perirenal fascia (i.e. into the retroperitoneum or peritoneum)
• grade V
• shattered kidney
• avulsion of renal hilum or laceration of the main renal artery or vein: devascularisation of a kidney due to hilar
injury
• devascularised kidney with active bleeding

111. CT
• CT is the mainstay for diagnosing renal injuries:
• CT multiphase protocol study for suspected renal trauma includes a non-contrast phase, an
arterial phase to evaluate vascular injury, a nephrographic phase to evaluate renal parenchymal
lesions and a delayed phase to evaluate bleeding and collecting system injuries
• an alternative protocol study is a portal venous phase followed by a delayed phase to assess for
collecting system injury
Angiography
• CT can provide most of the information required regarding vascular injuries, but angiography
can be used to further delineate the area of injury as well as offering the opportunity for
treatment with angioembolisation.
Treatment and prognosis
• Treatment depends on the specific trauma and complications present.
Complications
• urinoma (most common)
• delayed bleeding (within 1-2 weeks of injury)

112. URETERIC INJURY
Etiology:
• iatrogenic
• rate of injury is ~2% (range 0.5-3%) for laparoscopic procedures
• most commonly injured after gynecological procedures
• traumatic
• uncommon; represents <1% of all urological trauma
• direct trauma from penetrating injury is a more common cause than blunt injury
Classification
• Ureteric injury can be classified into three types according to its site:
• upper-third
• upper-third and pelvico-ureteric junction (PUJ) most affected by blunt trauma
• mid-third
• distal-third
• most common site
• often following iatrogenic injury
• AAST trauma grading has not been verified as accurate on imaging studies

113. CT
• CT with intravenous contrast and delayed scan with full reformatted
sagittal and coronal images and 3D reconstruction. The delayed scan
should be performed between 5-8 minutes after IV contrast to ensure
a CT-IVU (a.k.a. excretory phase) set of images is acquired.
Features include :
• intra-abdominal fluid collections without other cause shown
• contrast extravasation from renal hilum/PUJ (usually medially)
without associated renal injury

114. AAST Organ Injury Scale
Trauma.org

115. • Most pelvic visceral injuries = bladder and
urethra
• Gynecologic injuries rare after blunt trauma
• Urinary bladder 8% of patients with pelvic fx

116. Urinary Bladder

118. CT Cystography
• Antegrade bladder filling by excretion of IV
contrast is NOT enough to exclude bladder
injuries
• Absolute indication: pelvic fracture + gross
hematuria
• Technique: 300-500 cc of diluted (2%) contrast
instilled through a bladder catheter using gravity
drip, scan pelvis, drain bladder

119. THANK YOU

120. IDENTIFY