Pencitraan trauma abdomen pada anak

1. Oleh :
Argadia Y.
IMAGING CHILDREN WITH
ABDOMINAL TRAUMA
Pembimbing :
Prof. Dr. dr. Suyono, Sp.Rad(K)
1
Carlos J. Sivit

2. Latar Belakang
 Salah satu penyebab mortalitas dan
morbiditas pada anak
TRAUMA ABDOMEN
PADA ANAK
 Penyebab :
 Perbedaan anatomi dan fungsi
Anak vs Dewasa
TIDAK SEMUA TRAUMA ABDOMEN PADA ANAK
MEMERLUKAN TINDAKAN OPERASI
 PENCITRAAN  Trauma Abdomen
• Diagnosis
• Evaluasi
2

3. ANATOMI ABDOMEN
3

4. ANATOMI ABDOMEN
4

5. ANATOMI ABDOMEN
5

6. PRINSIP TRAUMA ABDOMEN PADA ANAK
 KLINISlebih penting
Anamnesis dan Pemeriksaan Fisik  Pemeriksaan Penunjang
(laboratorium, radiologi)
Anamnesis
• Keluhan Utama
• Nyeri Perut
• Hematuria
• Riwayat Penyakit Sekarang
• Riwayat Penyakit Dahulu
6

7. PRINSIP
 Pemeriksaan Fisik TANDA VITAL
• Tekanan Darah
• Laju Nadi
• Laju Nafas
• Suhu tubuh
• Saturasi SiO2
7
Utamakan untuk
mengatasi
kegawatan terlebih
dahulu

8. PRINSIP
Higher risk of abdominal
injury
• gross hematuria,
• abdominal tenderness,
• ecchymoses,
• a low trauma score
Low risk of abdominal
injury
• Asymptomatic
hematuria
• Neurologic impairment
in the absence of
abdominal signs and
symptoms
 Pemeriksaan Fisik
(Taylor GA, dkk., 1994; Cotton BA, 2003)
8

9. PRINSIP TRAUMA ABDOMEN PADA ANAK
Suara usus berkurang Vomitus
Hematemeis/Melena
Hematuria
• Indikator cedera renal
 Pemeriksaan Fisik
9

10. PRINSIP
10
Hematuria,
Abdominal bruising /
ecchymosis,
Abdominal distention, Abdominal pain,
Suara usus berkurang, vomiting, Penurunan hematokrit,
Darah dari rektum
(hematosezia/melena)
atau dari NGT
(perdarahan saluran
cerna atas)
INDIKASI PEMERIKSAAN RADIOLOGI
Ditemukan pemeriksaan fisik dan laboratorium yang menunjukkan
kecurigaan ke arah injuri abomen, seperti :

11. Computed Tomography (CT)
 Lebih akurat dalam mendeteksi dan kuantifikasi cedera organ
abdomen baik pada organ solid maupun berongga
 Dapat mengidentifikasi cairan-darah intraperitoneal atau
extraperitoneal serta perdarahan aktif
 Dapat memperlihatkan lesi trauma pada tulang rusuk,
vetebrata, dan pelvis
Pemeriksaan pilihan untuk trauma abdomen
11

12. Computed Tomography (CT)
 Injeksi Kontras I.V dapat digunakan untuk memperjelas
pencitraan
 Kontras peroral  masih kontroversi
Pemeriksaan
KONTRA INDIKASI PENGGUNAAN CT PADA TRAUMA
ABDOMEN :
Hemodinamika pasien tidak stabil
12

13. SONOGRAFI
13
MANFAAT
 Deteksi ada tidaknya hemoperitoneum
 Pilihan utama pada pasien trauma dengan hemodinamika tidak
stabil (mobile)
 focused abdominal sonography for trauma (FAST)
Sonografi punya keterbatasan
KEKURANGAN
 Sonografi tidak dapat meilhat cedera pelvis dan spinal
 Tidak dapat menilai organ berongga
 25-30% kesalahan menilai cedera organ solid

14. CEDERA HEPAR
Pencitraan Trauma Abdomen Pada Anak
14

15. CEDERA HEPAR
15
Anatomi liver

16. CEDERA HEPAR
ANATOMI LIVER
• Segmen Hepar
Fungsional :
• Lobus Kiri
– Segment I - IV
• Lobus Kanan
– Segmen V – VIII
• Masing-masing
segmen disuplai oleh
arteri dan vena yang
berbeda
16

17. CEDERA HEPAR
17
 Most commonly injured or second most commonly injured solid
viscera after blunt trauma
 Most hepatic injury occurs in the posterior segment of the right
lobe
Liver
Injury
laceration
hematoma
Cedera
vascular

18. CEDERA HEPAR
18
AAST liver injury grading system
Grade Type of Injury Description of injury
I
Haematoma • Sub capsular, < 10% surface area
Laceration • Capsular tear, < 1cm depth
II
Haematoma • Sub capsular, 10 - 50% surface area
• Intraparenchymal < 10cm diameter
Laceration Capsular tear, 1 - 3cm depth, < 10cm length
III
Haematoma • Sub capsular, > 50% surface area, or ruptured with active bleeding
• intraparenchymal > 10 cm diameter
Laceration Capsular tear, > 3 cm depth
IV
Haematoma Ruptured intraparenchymal with active bleeding
Laceration • Parenchymal distruption involving 25 - 75% hepatic lobes or
• involves 1-3 Couinaud segments (within one lobe)
V
Laceration • Parenchymal distruption involving >75% helpatic lobe or
• Involves > 3 Couinaud segments (within one lobe)
Vascular Juxtahepatic venous injuries (IVC, major hepatic vein)
VI Vascular Hepatic avulsion

19. CEDERA HEPAR
19
Liver Laceration
Grade
1
•Less than ½ inch (1 cm).
Grade
2
•½ -1 inch deep (1 to 3 cm). It is
less than 4 inches long (10 cm).
Grade
3
•more than 1 inch deep (3 cm).
Grades
4 and
5:
•These lacerations are very deep.
They affect a large part of the
liver

20. CEDERA HEPAR
Liver Laceration
• 8-year-old boy with
hepatic laceration.
Coronal reformation
of contrast-enhanced
CT scan through upper
abdomen shows
complex hepatic
laceration.
20

21. CEDERA HEPAR
Liver Laceration
• Grade 2 - Parenchymal
laceration 1-3 cm
deep and
parenchymal/subcaps
ular hematomas 1-3
cm thick
21
http://uvmrads.org/clinical-resources/bodyct/86-liver-lacerations-aast-
criteria-and-examples.html?showall=1&limitstart=

22. CEDERA HEPAR
Liver Laceration
• Grade 3 - Parenchymal
laceration more than 3
cm deep and
parenchymal or
subcapsular
hematoma more than
3 cm in diameter
22
http://uvmrads.org/clinical-resources/bodyct/86-liver-lacerations-aast-
criteria-and-examples.html?showall=1&limitstart=

23. CEDERA HEPAR
Liver Laceration
• Grade 4 -
Parenchymal/subcaps
ular hematoma more
than 10 cm in
diameter, lobar
destruction, or
devascularization
23
http://uvmrads.org/clinical-resources/bodyct/86-liver-lacerations-aast-
criteria-and-examples.html?showall=1&limitstart=

24. CEDERA HEPAR
Liver Subcapsular Hematoma • 12-year-old boy with
subcapsular
hematoma of liver
– A, Contrast-enhanced
CT scan through upper
abdomen shows
laceration extending to
periphery of liver with
associated subcapsular
hematoma.
– B, CT scan obtained 2
cm below A shows
inferior extension of
subcapsular
hematoma. Note
compression of
underlying hepatic
parenchyma
24

25. CEDERA HEPAR
Liver Vascular Injury
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.
25

26. CEDERA LIMFA / SPLEEN
Pencitraan Trauma Abdomen Pada Anak
26

27. CEDERA LIMFA
27
 Organ Solid
 Berukuran lebih kecil daripada
hepar
 Pecah & terfragmen
 Nyeri perut kiri atas, fraktur iga kiri bawah, kontusio pada
abdomen regio kiri atas
 LESI : Contusion, parenchymal laceration, subcapsular
hematoma, perisplenic hematoma, fragmentation of parenchyma
and disruption of hilar vessels
 Tidak selalu terjadi hemoperitonium
TRAUMA

28. CEDERA LIMFA
28
AAST SPLENIC INJURY SCALE
Grade Keterangan
I
Subcapsular hematoma of less than 10% of surface area or capsular tear of
less than 1 cm in depth
II
Subcapsular hematoma of 10%–50% of surface area, intraparenchymal
hematoma of less than 5 cm in diameter, or laceration of 1–3 cm in depth
and not involving trabecular vessels
III
Subcapsular hematoma of more than 50% of surface area or expanding and
ruptured subcapsular or parenchymal hematoma, intraparenchymal
hematoma of more than 5 cm or expanding, or laceration of more than 3 cm
in depth or involving trabecular vessels
IV
Laceration involving segmental or hilar vessels with devascularization of
more than 25% of the spleen
V Shattred spleen or hilar vascular injury

29. Cedera Limfa
Kontusio
• Contusion =
hypodense area within
normally perfused
splenic parenchyma
29
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30. CEDERA LIMFA
• 14-year-old boy with
shattered spleen.
• A and B, Contrast-
enhanced CT scans
through upper
abdomen (A) and 2 cm
lower (B) show shat
tered spleen
30

31. Cedera Limfa
Laceration
• Laceration = linear
perfusion defect
31
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32. CEDERA LIMFA
Laceration
• 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
32

33. CEDERA LIMFA
Subcapsular hematom
• Subcapsular
hematoma = lenticular
shape with
compression of
adjacent splenic
paenchyma
– Difficult to confidently
see splenic capsule
– Sometimes difficult to
distinguish between
subcapsular and
perisplenic hematoma
33
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34. CEDERA LIMFA
• 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.
34

35. CEDERA RENAL
Pencitraan Trauma Abdomen Pada Anak
35

36. CEDERA RENAL
36
 Cedera organ solid abdomen tersering ketiga setelah trauma
tumpul
 Terutama trauma pada punggung
 Pemeriksaan CT jika :
 Nyeri pinggang + Riw Trauma + Hematuria
 Hematuria Makroskopis + Pasien stabil + Tidak ada cedera
urethral
 JENIS LESI :
Contusion, laceration, subcapsular hematoma, shattered kidney,
renal artery occlusion

37. CEDERA RENAL
RENAL CONTUSION
• Renal contusion: focal
zones of decreased
enhancement, striated
nephrogram because
of temporarily
impaired tubular
excretion
37
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38. CEDERA RENAL
RENAL CONTUSION
• 10-year-old girl with
renal contusion.
• Contrast-enhanced CT
scan through mid
abdomen shows
rounded focus of low
at tenuation in
midpole of left kidney
indicative of contusion
38

39. CEDERA RENAL
RENAL LACERATION
• 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
39
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40. CEDERA RENAL
RENAL LACERATION • 14-year-old boy with
renal collecting system
injury.
• A, Contrast-enhanced CT
scan through mid
abdomen shows left
renal laceration with
surrounding perinephric
hematoma.
• B, Delayed image
obtained 5 minutes af
ter A shows
extravasation of IV
contrast material into
perirenal space
40

41. CEDERA RENAL
Laceration + Extravasation
• Deep laceration
results in urine
extravasation
• Delayed scan for
comfirmation
41
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42. CEDERA RENAL
RENAL HEMATOMA • KIRI : 12-year-old boy with
subcapsular renal
hematoma.
• Contrast-enhanced CT scan
through mid abdomen
shows large lef t-sided
subcapsular hematoma
compressing renal
parenchyma
• Kanan : 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
42
Renal
hematom
Subcapsular Perinephric

43. CEDERA RENAL
Occlusion
• Occlusion of main
renal artery
• Cortical enhancement
du to patent capsular
arteries originating
proximal to occlusion
should always raise
suspicion of injury to
main renal artery
43
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44. CEDERAL RENAL
VASCULAR INJURY
15-year-old boy with
vascular injury of left
kidney.
• Contrast-enhanced CT
scan through mid
abdomen shows
devascularization of
left kidney after left
renal artery avulsion
44

45. CEDERA PANKREAS
Pencitraan Trauma Abdomen Pada Anak
45

46. CEDERA PANKREAS
46
 Frekuensi lebih jarang (< 2%)
 Menyertai pada cedera organ multiple
 MEKANISME
 Cedera pada badan pankreas : Kompresi dengan
tulang vetebrate
 Kepala / Ekor : Pecah:
 KLINIS :
 Sering tidak bergejala  karena berukuran kecil
dan dikelilingi oleh lemak

47. CEDERA PANKREAS
47
 Komplikasi : Pankreatitis berulang, fistula, abses,
perdarahan
 Resiko terjadinya abses & fistula
• Disrupsi duktus (25-50%)
• Tanpa Disrupsi duktus (10%)
 LESI : Contusio, Laserasi superfisial atau parsial,
transeksi komplit atau disrupsi

48. CEDERA PANKREAS
48
 Memprediksi ada tidaknya disrupsi duktus dengan
mengetahui kedalaman dan lokasi laserasi ;
GRADE A
• Pancreatitis atau
laserasi superfisial
• <50% ketebalan
pankreas
GRADE B
• Laserasi dalam
(>50% ketebalan)
pada ekor
GRADE C
• Laserasi dalam
pada kepala

49. CEDERA PANKREAS
TRANSEKSI
11-year-old boy with
pancreatic transection.
• Contrast-enhanced CT
scan through upper
abdomen shows
pancreatic transection
at junction of head
and body.
49

50. CEDERA PANKREAS
Peripancreatic Fluid 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
50

51. CEDERA PANKREAS
51
 Pancreatitis
focal or diffuse gland enlargement, stranding of
peripancreatic or mesenteric fat, thickening of the
anterior renal fascia, and free peritoneal fluid
 peripancreatic fluid collections  Pseudocyst
KOMPLIKASI

52. CEDERA PANKREAS
Pancreatic enlargement Direct CT signs:
• Pancreatic enlargement,
focal linear
nonenhancement,
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
52

53. CEDERA PANKREAS
Pancreatitis
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
pancreaticborders
53

54. CEDERA PANKREAS
Pancreatic Pseudocyst 11-year-old boy with
pancreatic pseudocyst.
• A, Contrast-enhanced CT
scan through upper
abdomen shows
laceration through head
of pancreas.
• B, Follow-up CT scan
obtained 5 weeks af ter
A shows focal fluid
collection representing
pancreatic pseudocyst is
in head of pancreas and
is extending into
anterior pararenal
space.
54

55. PERDARAHAN AKTIF
Pencitraan Trauma Abdomen Pada Anak
55

56. PERDARAHAN AKTIF
56
 Sign  a contrast “blush,” which is defined as
highattenuation Areas (> 90 HU) after IV contras
 Hemoperitonium
 Tidak menggambarkan perdarahan aktif
Perdarahan Aktif
Hemodinamika
Tidak stabil
Hemodinamika
stabil
Pemeriksaan CT
KONTRAINDIKASI
CT

57. PERDARAHAN AKTIF
Linear high-attenuation
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
57

58. PERDARAHAN AKTIF
high-attenuation fluid
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
58

59. PERDARAHAN AKTIF
Pseudoaneurysm
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
59

60. PERDARAHAN AKTIF
12-year-old girl with active
hepatic hemorrhage that
did not require
laparotomy.
• A, Contrast-enhanced CT
scan through upper
abdomen shows hepatic
laceration with focal
area of increased
attenuation
representing active
hemorrhage. Patient
was managed
nonoperatively.
• B, Follow-up CT scan
obtained 2 weeks af ter
A shows resolving low-
attenuation hematoma
within liver
60

61. CEDERA USUS
Pencitraan Trauma Abdomen Pada Anak
61

62. CEDERA USUS
62
 Jarang terjadi (3-7% trauma tumpul abdominal)
 Tanda dan gejala : kadang tidak bergejala, minimal, atau
delayed
 Lesi :
 Intramural hematom :
• tersering duodenum
• Gambaran penebalan dinding tanpa adanya
extravasasi kontras
 Ruptur usus :
• Tersering jejenum

63. CEDERA USUS
• Duodenal perforation
vs hematoma
– Perforation 
Immediate surgery
– Hematoma 
Conservative
• Jika memungkinkan
dapat diberika kontras
peroral sebelum
dilakukan CT
63
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64. CEDERA USUS
Duodenal Hematom (intramural hematom)
8-year-old boy with
duodenal hematoma.
• Contrast-enhanced CT
scan through upper
abdomen shows
rounded duodenal
hematoma to left of
midline
64

65. CEDERA USUS
65
Tanda Radiologi
 Udara Extraluminal  1/3 kasus
 Ekstravasasi kontras  jarang terlihat
 “unexplained” peritoneal fluid (tanpa cedera organ solid dan
fraktur pelvis)  50% kasus
 Lain-lain :
• Abnormally intense bowel wall enhancement,
• focal bowel wall discontinuity,
• bowel dilatation,
• Bowel wall thickening,
• streaky infiltration of mesenteric fat
• Associated mesenteric injury or
• chemical irritation of the mesentery from spilled intestinal contents
Ruptur Usus

66. CEDERA USUS
bowel rupture
10-year-old girl with
bowel rupture associated
with extraluminal air.
• Contrast-enhanced CT
scan through upper
abdomen shows
extraluminal air.
66

67. CEDERA USUS
bowel rupture
9-year-old boy with
bowel rupture
associated with oral
contrast extravasation.
• CT scan through upper
abdomen shows
extravasated high-at
tenuation oral
contrast material in
peritoneal cavity.
67

68. CEDERA USUS
“unexplained” peritoneal fluid 12-year-old boy with bowel
rupture associated with large
amount of “unexplained”
peritoneal fluid.
• A, Contrast-enhanced CT
scan through upper
abdomen shows large
amount of peritoneal fluid
in perihepatic and
perisplenic spaces.
• B, 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.
68

69. CEDERA USUS
bowel wall discontinuity
9-year-old boy with
bowel rupture
associated with bowel
wall discontinuity.
• Contrastenhanced
• CT scan through upper
abdomen shows
discontinuity in wall of
Duodenum indicative
of bowel wall rupture
69

70. CEDERA USUS
• 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
70
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71. CEDERA KANDUNG KEMIH
Pencitraan Trauma Abdomen Pada Anak
71

72. CEDERA KANDUNG KEMIH
72
 Jarang terjadi
 Ekstravasasi ruptur
 Intraperitonial
• Trauma kandung kemih yang penuh
• Perlu tindakan operasi segera
 Ekstraperitonial
• Lebih sering
• Laserasi karena fraktur tulang pelvis
(obturator ring fractures, pubic symphysis diastasis,
sacral fractures, and sacroiliac joint diastasis)
• Tidak memerlukan tindakan operasi
segera
 CT cystography  retrogard

73. CEDERA KANDUNG KEMIH
73
Penentuan lokasi ekstravasi  PENTING
INTRAPERITONIAL EKSTRAPERITONIAL
Lateral peravesical spaces superior to the
bladder and anterior to the rectosigmoid
Colon
• the peravesical space that surrounds the
bladder superiorly and anteriorly to the
umbilicus and posteriorly behind the
rectum
• pelvic fluid is noted lateral to the bladder
or behind the rectum,
Fluid superior and anterior to the bladder
more lateral location and will typically be
contiguous with fluid in the lateral pericolic
spaces
Fluid extend superiorly and anteriorly to the
level of the umbilicus

74. CEDERA KANDUNG KEMIH
Intraperitoneal rupture
• More frequently
caused by direct
perforation of bone
fragment (> rupture of
distended bladder)
• Plugged by omentum
or bowel loops making
it difficult to detect
• Surgical Rx
75
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75. CEDERA KANDUNG KEMIH
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 ruptur
76

76. CEDERA KANDUNG KEMIH
Extraperitoneal rupture
• Direct perforation by
bony fragment,
rupture of pubovesical
ligament near bladder
neck after symphysis
injury or contusion of
distended UB Often
involves anterior
bladder wall near neck
• Conservative Rx
77
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77. CEDERA KANDUNG KEMIH
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
78

78. KOMPLEK HIPOPERFUSI
Pencitraan Trauma Abdomen Pada Anak
79

79. KOMPLEK HIPOPERFUSI
80
Pasien Stabil Syok Hipovolemik
CT :
komplek hipoperfusi

80. KOMPLEK HIPOPERFUSI
81
Komplek Hipoperfusi
 Tanda awal syok hipovolemik
 Komponen :

81. KOMPLEK HIPOPERFUSI
Komponen Vaskular
Flatening IVC
• Reduced venous
return secondary to
systemic hypotension
• Radigraph Definition :
– AP diameter < 9 mm
– Measured at 3 level
(Intrahepatic IVC, Renal
artery, 2 cm below
renal artery
82
NORMAL IVC NARROWED IVC

82. KOMPLEK HIPOPERFUSI
Komponen Vaskular
• Flat IVC, small aorta,
hyperenhanced
kidneys,
hyperenhanced GI
mucosa, and
peripancreatic edema
caused by
hypoperfusion state
from left pelvic ring
injury
83
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83. KOMPLEK HIPOPERFUSI
Komponen Vaskular
HALO SIGN
• Circumferential zone
of low attenuation
(<20HU) around a
collapsed intrahepatic
IVC
• Extracellular fluid
• Common Location :
Superior segment of
the liver
84

84. KOMPLEK HIPOPERFUSI
Komponen Vaskular
SMALL CALIBRE AORTA
• Sering ditemukan
• Define as calibre
<13mm at a level 2 cm
below and above the
origin of renal aorta
• Not spesific
85
NORMAL IVC Small Calibre Aorta

85. Komplek Hipoperfusi
Komponen Viseral
Splenic Hypoperfusion
• Arterial flow to the
spleen lacks
autoregulatory
mechnisms
• Highly sensitive to
sympathetic
stimulation 
vasocontriction in the
situation of
hypoperfusion
86
Normal Perfusion Spleen Hypoperfusion Spleen

86. KOMPLEK HIPOPERFUSI
Komponen Visceral 2-year-old girl with
hypoperfusion complex.
• A and B, 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.
87

87. KOMPLEK HIPOPERFUSI
3-year-old boy with
hypoperfusion complexand
absence of pancreatic
enhancement.
• Contras tenhanced CT
scan through upper
abdomen shows
absence of pancreatic
enhancement Pancreas
appeared normal at
surgery.
• Findings were thought
to be secondary to
systemic hypoperfusion.
88

88. Komplek Hipoperfusi
Komponen Viseral
Increased adrenal gland
enhancement
• Attenuation value
equal or greater than
thos of IVC
• Usually symmetrical
• May be due to a
protentive
sympathetic respone
to preserve the vital
organ
89
Normal adrenal
enhancement

89. Komplek Hipoperfusi
Komponen Viseral
Intense renal
parenchymal
enhancement
• ↓ systolic presure 
vasocontriction of
glomerular arteriolar
 increased
resorption of salt and
water
• A prolonge,
abnormally intense
nephogram
90
Normal Kidney

90. Komplek Hipoperfusi
Komponen Viseral
SHOCK BOWEL
• Increased mucosal
enhancement (HU >
Poas muscle)
• Mural Thickening >
3mm
• MIRIP : Bowel
perforation (+free
fluid)
91
Normal bowel
Increased bowel wall
thickness
Increased Enhancement

91. KOMPLEK HIPOPERFUSI
2-year-old boy with
hypoperfusion complex
associated with free
peritoneal fluid.
• Contrastenhanced CT
scan through mid
abdomenshows 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.
92

92. CLINICAL DECISION
Pencitraan Trauma Abdomen Pada Anak
93

93. 94
Pasien Datang
Pasien trauma
Pasien lain
tersangka trauma
Anamnesis &
Px Fisik HEMATURIA
Hemodinamika
Tidak Stabil
Hemodinamika
Stabil
“FAST”
Sonography
CT
Hemodinamika