Radiography
Findings
The use of radiography for blunt abdominal trauma is nearly nonexistent, despite being an important tool in the primary evaluation of chest and skeletal trauma. In general, abdominal radiography has been replaced by CT because of its widespread accessibility and, to some degree, ultrasonography. However, radiography still plays a role in the assessment of penetrating trauma to the abdomen.
Intravenous urography
The traditional tools for assessing genitourinary injury have been IVU, standard cystography, and retrograde urethrography. The role of IVU, however, has become more limited as CT has become more available. IVU may still be used if CT is not readily available, for unstable patients going to surgery or for urologic imaging of a patient in the operating room. These studies are typically performed as a one-shot IVU, which consists of the acquisition of a scout radiograph, a radiograph taken immediately after the injection of contrast material, and a third radiograph obtained approximately 10 minutes after the injection (see Images 1-2). Additional delayed radiographs may be necessary to assess delayed excretion of contrast material if present and to detect the presence of urinary contrast extravasation.
Findings that may be revealed by IVU include the loss of the renal outline or psoas shadow if there is perinephric hemorrhage, diminished or absent excretion (see Image 3 and Image 34), or contrast extravasation. The ureters should also be visualized to evaluate for ureteral injury or displacement, and the presence of a contralateral functioning kidney should be confirmed in the event that significant unilateral renal injury warrants nephrectomy (Santucci, 2001; Morey, 1999). However, the findings on IVU may not always accurately specify the cause or extent of renal involvement, while minor vascular injury or urinary extravasation may be missed. A nonvisualized kidney (nephrogram/pyelogram) does not necessarily represent significant renal trauma.
Retrograde pyelography
Retrograde pyelography is primarily useful when there is a suggestion of ureteral, UPJ, or renal pelvic injury and delayed images were not made or were not sufficient to exclude these injuries on CT or IVU. However, this is not routinely needed; drawbacks to retrograde pyelography include its impracticality in the emergent evaluation of a severely injured patient and the fact that it does not characterize renal parenchymal injuries.
Degree of Confidence
Compared with CT, IVU has lower sensitivity for detecting renal injury and a lower sensitivity for detecting urinary contrast extravasation. In addition, it lacks the ability to detect nonurologic injuries; therefore, with the high availability of CT, IVU has taken a more limited role (McAninch, 1982; Federle, 1981).
Previously reported signs of hemoperitoneum on radiography are not sensitive or specific enough to be useful.
False Positives/Negatives
Minor extravasation from the UPJ or the ureter is difficult to diagnose on limited IVU and may result in a false-negative finding. Similarly, grade 1 or 2 renal injuries are not easy to detect on the IVU.
Computed Tomography
Findings
Across all imaging modalities, CT is the most comprehensive diagnostic tool for assessing patients with blunt abdominal trauma. CT can be used to evaluate a large breadth of intra-abdominal injuries with accuracy, and hence, it has a primary role in evaluating the trauma patient. Further, the success of CT in staging abdominal injuries has contributed to the growing trend toward nonoperative management of traumatic abdominal injuries. As such, the CT scanner should be as close to the trauma bay as possible to minimize patient transport time.
CT technique
To best evaluate blunt abdominal trauma, the technique with which a CT is obtained must first be optimized. Conventional axial CT scanners can provide sufficient scans; however, helical CT scanners offer a considerable gain in speed and quality. Multidetector-row CT (MDCT) scanners are even more powerful than single-slice helical CT scanners because their thin-section, high-quality images can be obtained more quickly. As a result of shorter scanning times, less opportunity is available for motion or breathing artifact to appear. Furthermore, MDCT is advantageous because of its improved ability to depict injuries such as active arterial extravasation. Apart from faster scanning time that MDCT provides, it also utilizes the tube-heat capacity in a more efficient manner. This allows multiple, successive CT examinations to be carried out without the need to wait for the CT tube to cool.
Intravenous and oral contrast material
Intravenous contrast enhancement is essential for abdominal CT. Without intravenous contrast enhancement, solid-organ injuries such as renal lacerations can often be imperceptible. In addition, active arterial extravasation is only detectable with intravenous contrast material. Its usage with helical CT and MDCT scanners has further increased the frequency with which active arterial extravasation is seen. For adults, the typical contrast dose is 100-150 mL, whereas for children, the dose is 1.5-2 mL/kg. The desirable injection rate is at least 2 mL/s; however, rates of 3-4 mL/s allow for optimal enhancement of the vasculature and parenchyma. A low-osmolarity, non-ionic contrast agent is standard at our institution.
Contrast material, when given orally, also has clinical utility in aiding in the detection of bowel injuries. Fortunately, oral contrast material is safe, even for children (Federle, 1997; Lim-Dunham, 1997). As soon as an abdominal CT scanning is requested, 400-600 mL of a dilute solution, for example, 4% diatrizoate meglumine in tap water, is given by mouth or by nasogastric tube. Images of trauma patients are then obtained without delay. Thus, the stomach, duodenum, and proximal jejunum are typically the only structures opacified; fortunately, these are the most common sites of bowel injury. Finally, some authors suggest withdrawing the nasogastric tube into the distal esophagus during the scan in an attempt to reduce upper abdominal streak artifact.
For CT, an image thickness of 5 mm or less prevents major volume-averaging artifacts, and a scanner pitch of 1.5:1 for single-slice helical scanners optimizes speed while preventing excessive section-profile broadening. For an MDCT scanner, a pitch greater than 1 but less than 2 hastens image acquisition yet usually results in excellent image quality. Further, by scanning at speeds less than the maximum table speed or with a detector configuration narrower than the image thickness usually produced, thinner sections can be retrospectively reconstructed. This is sometimes needed to evaluate subtle injuries or associated spine or bony pelvic injuries.
As an example, the authors use HS mode on a GE four-slice scanner with 5-mm images and a table speed of 15 mm per rotation and 0.8-second scanning. With this protocol, 2.5-mm sections can be obtained with retrospective reconstruction when needed. Depending on the scanning mode and the patient's size, 100-300 mA is typically used at a KVp of 140. The image acquisition start time begins 45 seconds after the injection of contrast material for the chest and 75 seconds for the abdomen. If a CT cystogram is being obtained, a pause of 180 seconds prior to pelvic scanning permits the bladder to opacify.
Some institutions regularly scan through the kidneys a second time during the urographic phase of enhancement to aid in detection of subtle injuries of the parenchyma and collecting system. At the author's institution, images of trauma patients are regularly evaluated as they are obtained while the patient is still in the CT scanner. If noteworthy perinephric or periureteral fluid is found, urinary contrast extravasation is investigated by taking images delayed at 5-15 minutes.
If clinical findings, such as gross hematuria or pelvic ring fracture are present, and if bladder injury is a concern, cystography or CT cystography should be performed. Standard CT with intravenous contrast enhancement has a lower sensitivity for these injuries. CT cystography offers a few advantages over conventional cystography. First, the patient can be evaluated by CT cystography after the initial scan without the need to move to another location. CT cystography can also distinguish intraperitoneal, extraperitoneal, or combined bladder rupture (Morgan, 2000).
When CT cystography is performed, the urinary bladder is first drained by Foley catheter following the abdominal CT scan. The CT cystogram is done with either standard scans or scout imaging. The cystogram should be performed before intravenous injection of contrast media. In the adult, a minimum of 300 mL of dilute contrast media is necessary. If this is normal, drainage and wash out (bladder flushed with sterile fluid) may be performed but is not routinely needed.
CT interpretation
CT scans for blunt abdominal trauma must be meticulously reviewed for proper interpretation. On evaluation, urgent life-threatening injuries, such as a large hemoperitoneum, a large or tension pneumothorax, pneumoperitoneum, signs of hypovolemic shock, or active arterial extravasation, should be sought out first. This should be followed by a thorough interrogation for injury of the abdomen and pelvis: liver and right paracolic gutter; spleen and left paracolic gutter; upper abdominal organs, including the stomach, duodenum, pancreas, gallbladder and biliary tree; retroperitoneum, including the adrenals, kidneys, inferior vena cava, and aorta; small bowel, colon, and mesentery; pelvis, including the urinary bladder; muscles, including the abdominal wall, psoas, iliacus, and gluteals; bones, including the spine and pelvis; and thighs.
To perform a complete evaluation, the entire scan must be scrutinized with 3 different window/level settings: soft tissue, lung, and bone. The entire systemic review has been called the "every-organ-on-every-slice" approach (West, 2000). The authors believe that, with the modern Picture Archiving and Communication System (PACs) workstation, image review is best accomplished by rapidly paging through the images multiple times, with special attention to one organ at a time; hence, "every slice of every organ." With this method, renal injuries can be readily identified and classified for proper treatment.
Grade 1 injuries
AAST grade 1 renal injuries include hematuria with normal imaging, contusions, and nonexpanding subcapsular hematomas; overall, this grade accounts for 80% of renal injuries. In CT images, contusions are perceived as ill-defined or sometimes sharply marginated areas of reduced enhancement and excretion (see Image 10). A segmental infarction, which is an AAST grade 4 renal injury, is differentiated from contusions by a lack of enhancement altogether (see Images 20-21).
Subcapsular hematomas usually appear as a hyperattenuating fluid collection between the renal parenchyma and the renal capsule, at times deforming the underlying kidney. These hematomas are less common than perinephric hematomas in blunt abdominal trauma. Small, subcapsular hematomas often take on a crescent shape, whereas larger hematomas may appear elliptical and compress the renal parenchyma (see Images 11-13). On rare occasions, the hematoma may progressively enlarge and compress the kidney enough to lower renal perfusion. This may result in reactive hypertension (Page kidney).
Grade 2 and 3 injuries
Renal injuries that are classified as grade 2 include nonexpanding perinephric hematomas contained by the retroperitoneum and superficial cortical lacerations less than 1 cm in depth without injury to the collecting system.
On CT, a perinephric hematoma often appears as an ill-defined, hyperattenuating fluid collection located between the Gerota fascia and the renal parenchyma (see Images 13-16). More often than not, such a hematoma is associated with underlying injury, though they can occur in isolation. Thus, when a perinephric hematoma is discovered, a thorough investigation of the kidney should be undertaken to look for associated renal injury. Unlike a subcapsular hematoma, even a large perinephric hematoma does not traditionally deform the kidney.
Renal lacerations are seen on CT as jagged or linear parenchymal disruptions that can contain fresh or clotted blood (see Image 2 and Images 15-19). The laceration may thus show attenuation higher than that of water, but this would occur without the contrast enhancement present in the renal parenchyma. By definition, grade 2 renal lacerations are less than 1 cm in depth, while grade 3 lacerations are greater than 1 cm in depth. Both grade 2 and grade 3 renal lacerations, however, do not involve the collecting system. As such, there would be no evidence of urinary contrast extravasation on delayed CT.
The treatment of most grade 1, 2, or 3 renal injuries is usually conservative, except when a vigorous active hemorrhage is present (Knudson, 1999; Brandes, 1999). In such cases, the active hemorrhage may be treated successfully with selective catheter embolization in an otherwise stable patient (Corr, 1991; Dinkel, 2002). Occasionally, continued bleeding or extravasation can lead to complications and higher morbidity if not identified and managed appropriately. Follow-up CT is useful for restaging the renal trauma and helps in identifying the patients with progressive worsening on conservative management. Appropriate intervention in these patients can help prevent complications.
Grade 4 injuries
Grade 4 renal injuries include renal lacerations that extend into the collecting system, injuries to the main renal artery or vein with contained hemorrhage, and segmental infarctions without associated lacerations. The first of these, renal lacerations with collecting system involvement, frequently produce extravasation of urine or contrast agent. Extravasation such as this should be thoroughly sought any time a laceration extends through the kidney or substantial perinephric fluid is seen on CT, especially if that fluid is around the renal hilum. Delayed images allow contrast material to filter into the collecting system, providing adequate views of any urinary extravasation (see Images 22-23).
Under many circumstances, the healing of even large urinary extravasations can occur with conservative treatment; however, stenting is sometimes necessary to facilitate the process. Surgical debridement or repair is usually necessary only when the laceration is accompanied by significant devitalized renal tissue, particularly when concomitant intraperitoneal injuries are also present. The main purpose of such a procedure is to prevent the development of urinoma, infection, or abscess. In the absence of such repair, a nephrectomy may be needed later to prevent sepsis (Moudouni, 2001).
On CT, renal segmental infarctions appear as well-delineated, linear or wedge-shaped, often multifocal and nonenhancing areas that extend through the parenchyma in a radial or segmental orientation (see Images 20-21). Thrombosis, dissection, and laceration of segmental renal arteries are primary causes of segmental infarctions, and such infarctions are frequently associated with other renal injuries. These injuries are treated conservatively, as they often resolve spontaneously or result in relatively minor renal scaring (Carroll, 1990; Cass, 1987). In 6-20% of patients, hypertension may develop as a delayed complication; however, this often resolves or can be medically managed (Bertini, 1986; Bruce, 2001).
Grade 5 injuries
Grade 5 renal injuries include a shattered or devascularized kidney, UPJ avulsions, and complete laceration or thrombosis of the main renal artery or vein. The first of these, a shattered kidney, essentially describes the extreme of multiple renal lacerations, often with devitalized areas due to infarction, and urinary extravasation resulting from injuries to the collecting system (see Images 22-24 and Images 30-35).
A different type of grade 5 renal injury, the UPJ injury, characteristically involves a medial or circumrenal urinoma on CT (see Images 25-29 ) (Harris, 2001; Kawashima, 1997; Kenney, 1987). Such injuries are caused by a shearing force on the renal pelvis. Complete avulsion or partial tear of the UPJ occurs when rapid deceleration of the kidney pulls on the relatively fixed ureter and renal blood supply. Imaging can distinguish a partial tear from a complete avulsion by the presence of contrast agent in the distal ureter (Kawashima, 1997). In many cases, hematuria is absent or minimal (Kawashima, 1997; Campbell, 1992). Treatment for complete UPJ tears is surgical repair, but some partial tears can be managed with stenting and/or observation. When a UPJ injury is undiagnosed and when the proximal collecting system is not drained, an urinoma can develop. This may lead eventually to a nephrectomy.
With CT imaging, a devascularized kidney appears nonenhancing (see Images 3-6 and Images 36-37). Often, little hematoma or other sign of injury is depicted. In some cases, CT angiography shows a blind-ending renal artery. Retrograde opacification of the renal vein from IV contrast indicates an acute injury indicating the need for immediate emergency surgery to reestablish blood flow. In late evaluation, the renal vein is thrombosed, and this reverse flow is not seen. The cortical rim sign may be apparent, but not early (Kamel, 1996). This usually indicates a dead kidney with rare recovery of renal function (if it ever occurs). In the absence of other associated injuries, hematuria is many times nonexistent (Haas, 1998).
The most common cause of a devascularized kidney is an incomplete renal artery tear with thrombosis; a complete tear of the renal artery with an extensive hematoma or active bleeding is less common. When they occur, these injuries are often present with other renal injuries. This association contributes to the poor renal outcome after attempted repair; therefore, the care of stable patients is usually expectant. For patients with active bleeding or major parenchymal disruption, treatment is usually nephrectomy except in the case where there is injury to or absence of the contralateral kidney (Haas, 1998; Knudson, 2000). A potential complication of these injuries is hypertension; it can develop weeks to months after the initial injury in as many as 40-50% of patients. This often resolves or can be medically managed, but nephrectomy is sometimes necessary (Haas, 1998; Knudson, 2000).
Another less frequent form of vascular pedicle injury is damage to the main renal vein. One type of such an injury is laceration of the renal vein. On CT, this usually presents with medial or circumrenal subcapsular or perinephric hematoma. Thrombosis is a second type of renal vein injury that is depicted on CT as a filling defect or as nonenhancement of the vein (see Images 34-35). A delayed or persistent nephrogram may be present when thrombosis results in complete occlusion (Harris, 2001; Blankenship, 1997). This may be lethal in the adult.
Vascular extravasation of contrast material
Contained or active hemorrhage is indicated by bright enhancement with attenuation similar to that of nearby arteries within a laceration or around an injured kidney during the early phases of CT scanning. Active hemorrhage appears as an ill-defined, flame-shaped, or waterfall-shaped area on CT, with an associated fresh hematoma (see Images 38-43). The hematoma often demonstrates circumferential or dependent layering of older and fresher hemorrhage. On the contrary, contained hemorrhage or pseudoaneurysm is somewhat bound and contained within the renal parenchyma or laceration. If active extravasation of arterial contrast material from the main renal artery or lacerated kidney appears present, immediate transcatheter embolization or surgery may be needed to prevent exsanguination (Federle, 2000; Jeffrey, 1991; Lane, 1998; Shanmuganathan, 1993; Willmann, 2002).
Delayed bleeding or rare cases of hypertension occasionally result from persistent pseudoaneurysms. Renal lacerations from blunt or penetrating trauma can also produce arteriovenous fistulas. Initially, these may be difficult to detect, but they can enlarge over time. The results of this may be delayed bleeding, hypertension, or high-output cardiac failure.
Degree of Confidence
CT is highly accurate in identifying different types of renal injuries.
False Positives/Negatives
CT is sensitive for most renal injuries and generally specific. It may be difficult to distinguish small contusions from lacerations or infarctions, but major injuries are easily distinguished from normal kidneys or minor injuries. Delayed scanning is needed to sufficiently evaluate urinary extravasation.
Standard CT with intravenous contrast enhancement can yield false-negative rates of 40% for bladder injury. A CT cystogram gives a higher accuracy rate, which equals or surpasses that of standard cystogram as long as appropriate distention of the bladder is obtained.
Magnetic Resonance Imaging
Findings
For stable patients with a strong contraindication for iodinated contrast material, MRI with a gadolinium-based contrast agent can be helpful in assessing a renal injury; however, for the acutely injured patient, MRI is usually not practical because of motion artifacts and the examination time.
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.
As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving ors traightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Degree of Confidence
Specificities and sensitivities of MRI for renal injuries are unknown.
False Positives/Negatives
Specific data for false-positive or false-negative findings are not available.
Ultrasonography
Findings
The use of abdominal ultrasonography for trauma patients remains controversial, particularly for detecting renal and urologic injuries. Despite this, in the United States, ultrasonography has achieved moderate acceptance for evaluating a patient with blunt abdominal trauma.
In the trauma setting, sonography is usually performed as a FAST scan for the primary purpose of identifying free fluid in the unstable patient. In most circumstances, FAST scans can be executed in the few minutes during patient resuscitation in a trauma bay. The examination includes probing six locations for the existence of free fluid: the right upper quadrant with the hepatorenal recess, the left upper quadrant with the splenorenal recess, both paracolic gutters, the pelvis and its various peritoneal cavity recesses, and the pericardial space (McKenney, 1998). If the examination demonstrates the presence of fluid, surgeons will generally perform an exploratory laparotomy.
In situations in which sonography has been used to screen blunt abdominal trauma as part of a management algorithm, there is some variability in the training of the individual performing the examination. In some institutions, radiologists or sonologists perform the study, but in many centers, the trauma surgeon or emergency physician do so. These specialists may have little training in clinical sonography and virtually no training in its technical aspects. Therefore, their ability to execute high-quality examinations has been seriously questioned. However, if the radiology staff is to perform trauma sonography, the service must be readily available at all times.
Degree of Confidence
Although sonography can depict free fluid in the abdomen and pelvis, it cannot be used to make the clinically important distinction between extravasated urine, blood, or other types of fluid. Moreover, ultrasonography cannot depict the source of the bleeding. A variety of groups also have proposed the use of ultrasound to search for solid-organ injury, but sufficient sensitivities and specificities have not been demonstrated to date (Bode, 1993; Rothlin, 1993; Tso, 1992).
Ultrasonography may demonstrate renal laceration, a change in echogenicity of an injured kidney, or a decrease in the usual perinephric echogenicity if perinephric fluid or hemorrhage is present. However, if sonograms are negative and if noteworthy hematuria is present, or if the sonogram is positive, CT is still indicated for evaluation of the injury if the patient is stable. For this reason, the use of sonography is probably best reserved for the rapid evaluation for intraperitoneal fluid in the unstable patient who may require urgent surgery.
False Positives/Negatives
In at least 1 study, ultrasonography depicted only 22% of solid organ injuries (McGahan, 1999; McGahan, 1997). Although significant renal injuries are often associated with other abdominal injuries, associated peritoneal fluid is not present in as many as 65% of isolated renal injuries; this possibility increases the risk for missing a renal injury (McGahan, 1999). In addition, ultrasonography is insensitive for retroperitoneal blood and injury to a hollow organ (Miller, 2003).
Nuclear Imaging
Findings
Nuclear scintigraphy may be used to evaluate renal function after injury or to directly evaluate the patient for urinary injury, especially those with an extravasation of urine. Scintigraphy is generally not useful in the acute trauma setting because of its low specificity and inability to evaluate for injuries outside the urinary tract.
Angiography
Findings
Prior to the common availability of CT, angiography was often used to initially diagnose renal arterial or parenchymal aberrations found on IVU. Today, however, faster CT scanners and the increased detection of active arterial extravasation have limited the use of angiography for the initial diagnosis of traumatic injuries. Moreover, CT can also depict many injuries not seen on angiography.
On the other hand, the role of angiography in the management of vascular and exsanguinating solid-organ injuries continues to rise in parallel with the increasing emphasis on nonoperative management of trauma. Angiography with transcatheter embolization is becoming the standard of care for patients with many vascular injuries, such as pseudoaneurysms and active arterial bleeding resulting from renal trauma (see Images 40-43) (Bruce, 2001; Bretan, 1986; Hagiwara, 2001).
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Further Reading
Keywords
kidney injury, renal trauma, renal injury, genitourinary trauma, blunt abdominal trauma, penetrating abdominal trauma, urinary tract, pelvic injury, renal laceration, renal contusion, renal vascular trauma, hematuria, perinephric hematomas, subcapsular hematomas, ureteropelvic junction, collecting system, renal segmental infarctions, hypovolemic shock
