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Penetrating Torso Trauma: Triple-Contrast Helical CT in Peritoneal Violation and Organ Injury—A Prospective Study in 200 Patients¹

¹ From the Department of Diagnostic Radiology (K.S., S.E.M., K.L.K., G.J.F.H.) and Maryland Shock-Trauma Center (K.S., S.E.M., W.C.C., T.M.S.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201. From the 2002 RSNA scientific assembly. Received February 6, 2003; revision requested April 2; final revision received August 4; accepted September 29. Address correspondence to K.S. (e-mail: kshanmuganathan@umm.edu).

View larger version (149K): [in a new window]   Figure 1a. Transverse CT scans show peritoneal violation in a 37-year-old woman stabbed multiple times in the chest and abdomen. (a) Large liver laceration (straight arrow) with active bleeding (curved arrow). Free intraperitoneal fluid (black arrowheads) is seen anterior to the liver. Air bubbles (white arrowheads) are seen along the knife track. (b, c) Linear laceration (arrow in b) in pancreatic body with free fluid in lesser sac (arrowheads). Gastric contrast material extravasation (arrow in c) is also seen in the lesser sac. Injuries to the liver, stomach, and pancreas were confirmed surgically. (Adapted and reprinted, with permission, from reference 27.)

View larger version (164K): [in a new window]   Figure 1b. Transverse CT scans show peritoneal violation in a 37-year-old woman stabbed multiple times in the chest and abdomen. (a) Large liver laceration (straight arrow) with active bleeding (curved arrow). Free intraperitoneal fluid (black arrowheads) is seen anterior to the liver. Air bubbles (white arrowheads) are seen along the knife track. (b, c) Linear laceration (arrow in b) in pancreatic body with free fluid in lesser sac (arrowheads). Gastric contrast material extravasation (arrow in c) is also seen in the lesser sac. Injuries to the liver, stomach, and pancreas were confirmed surgically. (Adapted and reprinted, with permission, from reference 27.)

View larger version (168K): [in a new window]   Figure 1c. Transverse CT scans show peritoneal violation in a 37-year-old woman stabbed multiple times in the chest and abdomen. (a) Large liver laceration (straight arrow) with active bleeding (curved arrow). Free intraperitoneal fluid (black arrowheads) is seen anterior to the liver. Air bubbles (white arrowheads) are seen along the knife track. (b, c) Linear laceration (arrow in b) in pancreatic body with free fluid in lesser sac (arrowheads). Gastric contrast material extravasation (arrow in c) is also seen in the lesser sac. Injuries to the liver, stomach, and pancreas were confirmed surgically. (Adapted and reprinted, with permission, from reference 27.)

View larger version (151K): [in a new window]   Figure 2. Transverse CT scan in a man from a mental institution who was admitted after impaling himself with a metallic wire. The wire (arrow) is superficial within the anterior abdominal wall, without peritoneal violation.

View larger version (117K): [in a new window]   Figure 3. Transverse CT scan in a 23-year-old man shot multiple times in the back shows major vascular injury in the retroperitoneum. Note retroperitoneal hematoma (curved white arrows) within and along the right psoas muscle. A defect (black arrow) is seen in the posterior wall of the inferior vena cava. Air bubbles are present within the spinal canal (arrowhead) and left psoas muscle (straight arrows) along bullet tracks.

View larger version (145K): [in a new window]   Figure 4a. CT findings false-negative for peritoneal violation in a 25-year-old man stabbed in the left thoracoabdominal region. (a) Transverse CT scan obtained at admission shows an air bubble (white arrowhead) in the left thoracoabdominal region at the entry site. Localized thickening (arrows) is seen in the left side of the diaphragm adjacent to the wound site. A small hemothorax (black arrowheads) is seen in the lower chest. (b) Follow-up CT scan obtained because of abdominal pain during observation shows active bleeding (curved arrows) within a large mesenteric hematoma (white arrowheads) and free intraperitoneal blood (black arrowheads) around the liver. (c) Follow-up CT scan shows a subtle defect (arrowheads) in the left side of the diaphragm. (Adapted and reprinted, with permission, from reference 27.)

View larger version (152K): [in a new window]   Figure 4b. CT findings false-negative for peritoneal violation in a 25-year-old man stabbed in the left thoracoabdominal region. (a) Transverse CT scan obtained at admission shows an air bubble (white arrowhead) in the left thoracoabdominal region at the entry site. Localized thickening (arrows) is seen in the left side of the diaphragm adjacent to the wound site. A small hemothorax (black arrowheads) is seen in the lower chest. (b) Follow-up CT scan obtained because of abdominal pain during observation shows active bleeding (curved arrows) within a large mesenteric hematoma (white arrowheads) and free intraperitoneal blood (black arrowheads) around the liver. (c) Follow-up CT scan shows a subtle defect (arrowheads) in the left side of the diaphragm. (Adapted and reprinted, with permission, from reference 27.)

View larger version (122K): [in a new window]   Figure 4c. CT findings false-negative for peritoneal violation in a 25-year-old man stabbed in the left thoracoabdominal region. (a) Transverse CT scan obtained at admission shows an air bubble (white arrowhead) in the left thoracoabdominal region at the entry site. Localized thickening (arrows) is seen in the left side of the diaphragm adjacent to the wound site. A small hemothorax (black arrowheads) is seen in the lower chest. (b) Follow-up CT scan obtained because of abdominal pain during observation shows active bleeding (curved arrows) within a large mesenteric hematoma (white arrowheads) and free intraperitoneal blood (black arrowheads) around the liver. (c) Follow-up CT scan shows a subtle defect (arrowheads) in the left side of the diaphragm. (Adapted and reprinted, with permission, from reference 27.)

View larger version (114K): [in a new window]   Figure 5. Transverse CT scan shows a wound track that extends to the bowel in a 33-year-old man shot in the right hemipelvis. Note bullet and bone fragments (black arrowheads) outlining the wound track that extends to a loop of small bowel. Free intraperitoneal air (white arrowheads) and fluid (arrows) are seen from peritoneal violation. An injury to the ileum was confirmed surgically.

View larger version (144K): [in a new window]   Figure 6a. Transverse CT scans show gastrointestinal contrast material extravasation in a 29-year-old man shot in the left thoracoabdominal region. (a) Scan shows focal thickening of the splenic flexure of the colon (curved black arrow) and rectally administered contrast material (black arrowhead) within the chest wall. Free intraperitoneal air (white arrowhead) is seen from peritoneal violation. Peritoneal fat (curved white arrow) herniates through a defect (straight arrows) in the left side of the diaphragm. (b) Scan obtained in the middle of the abdomen shows rectally administered contrast material extravasation (curved arrow) from the descending colon (straight arrow) and free intraperitoneal air (arrowhead). Colon and diaphragm injuries were repaired surgically.

View larger version (148K): [in a new window]   Figure 6b. Transverse CT scans show gastrointestinal contrast material extravasation in a 29-year-old man shot in the left thoracoabdominal region. (a) Scan shows focal thickening of the splenic flexure of the colon (curved black arrow) and rectally administered contrast material (black arrowhead) within the chest wall. Free intraperitoneal air (white arrowhead) is seen from peritoneal violation. Peritoneal fat (curved white arrow) herniates through a defect (straight arrows) in the left side of the diaphragm. (b) Scan obtained in the middle of the abdomen shows rectally administered contrast material extravasation (curved arrow) from the descending colon (straight arrow) and free intraperitoneal air (arrowhead). Colon and diaphragm injuries were repaired surgically.

View larger version (159K): [in a new window]   Figure 7. Transverse CT scan shows findings false-positive for duodenal injury in a 21-year-old man shot in the right flank. Note the pellet (arrowhead) between the pancreatic head (curved arrow) and the second part of the duodenum (straight arrow). At surgery, no bowel injury was found.

View larger version (113K): [in a new window]   Figure 8a. Transverse CT scans show right-sided diaphragm injury and biliary-pleural fistula in a 16-year-old adolescent shot in the right side of the back. (a) CT scan obtained at admission shows a posterior right-lobe liver laceration (arrow) and air bubbles (white arrowheads) within the liver. A bullet track (black arrowheads) is seen in the back. (b) CT scan obtained in the lower chest shows extensive lung contusion (arrows) along the bullet track, indicating contiguous organ injury on either side of the diaphragm. Anteroposterior radiograph (not shown) obtained 5 days after admission showed a right lung cavity with an air-fluid level. (c) CT scan obtained after chest radiography shows a cavity (straight arrow) with an air-fluid level (curved arrow) in the posterior right lower lobe. Bile was aspirated from this cavity with CT guidance.

View larger version (88K): [in a new window]   Figure 8b. Transverse CT scans show right-sided diaphragm injury and biliary-pleural fistula in a 16-year-old adolescent shot in the right side of the back. (a) CT scan obtained at admission shows a posterior right-lobe liver laceration (arrow) and air bubbles (white arrowheads) within the liver. A bullet track (black arrowheads) is seen in the back. (b) CT scan obtained in the lower chest shows extensive lung contusion (arrows) along the bullet track, indicating contiguous organ injury on either side of the diaphragm. Anteroposterior radiograph (not shown) obtained 5 days after admission showed a right lung cavity with an air-fluid level. (c) CT scan obtained after chest radiography shows a cavity (straight arrow) with an air-fluid level (curved arrow) in the posterior right lower lobe. Bile was aspirated from this cavity with CT guidance.

View larger version (115K): [in a new window]   Figure 8c. Transverse CT scans show right-sided diaphragm injury and biliary-pleural fistula in a 16-year-old adolescent shot in the right side of the back. (a) CT scan obtained at admission shows a posterior right-lobe liver laceration (arrow) and air bubbles (white arrowheads) within the liver. A bullet track (black arrowheads) is seen in the back. (b) CT scan obtained in the lower chest shows extensive lung contusion (arrows) along the bullet track, indicating contiguous organ injury on either side of the diaphragm. Anteroposterior radiograph (not shown) obtained 5 days after admission showed a right lung cavity with an air-fluid level. (c) CT scan obtained after chest radiography shows a cavity (straight arrow) with an air-fluid level (curved arrow) in the posterior right lower lobe. Bile was aspirated from this cavity with CT guidance.

View larger version (121K): [in a new window]   Figure 9a. Active bleeding spleen in a 33-year-old man stabbed in the left thoracoabdominal region. (a) CT scans obtained in the portal venous phase show active bleeding (arrowheads) from a splenic laceration (straight arrow). Perisplenic blood (curved arrows) is also seen. (b) Delayed CT scan obtained in the same region shows an increase in the amount of active bleeding (curved arrows) seen within the perisplenic hematoma (straight arrows). (c) Splenic arteriogram confirms bleeding (arrow) from a splenic artery branch. Hemorrhage was stopped by using transcatheter embolization (not shown).

View larger version (116K): [in a new window]   Figure 9b. Active bleeding spleen in a 33-year-old man stabbed in the left thoracoabdominal region. (a) CT scans obtained in the portal venous phase show active bleeding (arrowheads) from a splenic laceration (straight arrow). Perisplenic blood (curved arrows) is also seen. (b) Delayed CT scan obtained in the same region shows an increase in the amount of active bleeding (curved arrows) seen within the perisplenic hematoma (straight arrows). (c) Splenic arteriogram confirms bleeding (arrow) from a splenic artery branch. Hemorrhage was stopped by using transcatheter embolization (not shown).

View larger version (183K): [in a new window]   Figure 9c. Active bleeding spleen in a 33-year-old man stabbed in the left thoracoabdominal region. (a) CT scans obtained in the portal venous phase show active bleeding (arrowheads) from a splenic laceration (straight arrow). Perisplenic blood (curved arrows) is also seen. (b) Delayed CT scan obtained in the same region shows an increase in the amount of active bleeding (curved arrows) seen within the perisplenic hematoma (straight arrows). (c) Splenic arteriogram confirms bleeding (arrow) from a splenic artery branch. Hemorrhage was stopped by using transcatheter embolization (not shown).

View larger version (30K): [in a new window]   Figure 10. Schematic shows imaging algorithm for hemodynamically stable patients with penetrating torso trauma.