Imaging of Blunt Abdominal Trauma

A. Luana Stanescu, MD, Joel A. Gross, MD, Michelle Bittle, MD, and F.A. Mann, MD

solated blunt abdominal trauma (BAT) represents about

5% of annual trauma mortality from blunt trauma. As part
of multiple-site injury (polytrauma), BAT contributes another 15% of trauma mortality.1 Exsanguination accounts for
80 to 90% of acute deaths from abdominal injury. More than
75% of such cases are amenable to surgery, and recent years
have seen safe extension of nonoperative, image-guided
treatments to most victims of blunt-force trauma.2-21 Early
recognition and treatment decisions have been greatly impacted by increasingly sophisticated cross-sectional imaging
and image-guided, minimally invasive therapies.22-32

Blunt Disruptions
of the Diaphragm,
Abdominal Wall, and Flank
The diagnosis of diaphragm rupture is often missed. A high
index of suspicion for diaphragmatic ruptures is warranted in
appropriate clinical circumstances, such as lateral impact vehicle crashes, especially when left-sided, and direct frontal
impacts. Classical findings are present in less than 40% of
left-sided and less than 15% of right-sided diaphragm ruptures.33-37 Diagnostic peritoneal lavage (DPL) is falsely negative in 10 to 15% of cases.37-41
Delayed diagnoses are not uncommon: 10 to 15% of cases
present with more than 24 hours delay,33,35,37,42 especially if
the commonly associated intrathoracic (90%) and intraabdominal (60%) injuries require endotracheal intubation
and positive-pressure ventilation.37,43 It is believed that the
positive intrathoracic pressure prevents or limits herniation
of abdominal contents through the diaphragm. New, unilateral elevation of hemidiaphragm following extubation may
represent herniation of abdominal contents through a previously unrecognized diaphragm rupture.
Conventional radiography (chest radiographs with enteral
tube placement; fluoroscopy) is abnormal in 60 to 90% of
acute traumatic diaphragmatic ruptures, but most findings
are nonspecific and cannot be distinguished from hemotho-

Harborview Medical Center, University of Washington, Seattle, Washington.

Address reprint requests to F.A. Mann, MD, 325 Ninth Ave., Box 359728,
Seattle, WA 98104-2499. E-mail: famann@u.washington.edu

196

0037-198X/06/$-see front matter 2006 Elsevier Inc. All rights reserved.

doi:10.1053/j.ro.2006.05.002

rax, atelectasis, etc. Sensitivity is 46% in detecting left-sided

diaphragm ruptures and only 17% for right-sided ruptures.44
There are two classical chest radiographic findings described
for diaphragmatic rupture: intrathoracical herniation of a
hollow viscus, with or without a collar sign (narrowed waist
of a herniated intraabdominal organ due to compression as it
squeezes through the diaphragmatic rupture), and detection
of a nasogastric tube above the left hemidiaphragm.45
In case series reports, diagnostic accuracy of computed
tomography (CT) was equivalent, but not clearly superior, to
conventional radiographic techniques.46 Thin-cut CT with
multiplanar reformations is expected to improve sensitivity.47 At CT, the so-called dependent viscera sign (intraabdominal contents abutting the posterior thoracic wall, especially where the scan level is in the upper third of the liver or
spleen) and the collar sign are nearly 100% specific. Other
findings, such as the discontinuous and thickened diaphragm signs, show intermediate sensitivity and specificity
(40 to 75%).46,48 Among reported series in which magnetic
resonance imaging (MRI) depicted no diaphragmatic disruptions, no delayed diagnoses have been reported.49-51
Injuries to the muscles and fascia surrounding the peritoneum may result in three types of injuries: the most common
are type I, small defects, usually located in the lower abdominal wall secondary to bicycle handlebar blunt trauma. Type
II includes larger abdominal wall defects after high-energy
injuries like motor vehicle accident (MVA) or a fall from
height, while type III are associated with intraabdominal herniations in the retroperitoneum following deceleration injuries.52 Contained hematomas also occur and do not typically
require intervention, but may require embolization for expanding hematomas.53-55 High-energy abdominal wall hernias, open or closed, almost always require surgical intervention.56-62

Injuries to the Solid

Intraperitoneal Organs
Hemodynamic instability and evidence of on-going blood
loss are the strongest indicators for the need of intervention
in spleen and liver injuries.8,24,63 Among hemodynamically
unstable patients that are not taken immediately to the operating suite, focused abdominal sonography for trauma
(FAST) and DPL are diagnostically equivalent in detecting

Imaging of blunt abdominal trauma

197

Figure 1 A 42-year-old female sustained a grade IV liver laceration in a fall from a building. (A) Contrast-enhanced axial
CT scan through the liver at the level of portal vein shows deep lacerations involving the dome of the liver and extending
to the portal veins and IVC. (B) Contrast-enhanced axial CT scan shows small thrombus in IVC (arrow) and perihepatic
hematoma. No evidence of active vascular extravasation.

surgically important intraperitoneal hemorrhage due to solid

organ injury(ie, selecting patients in whom laparotomy is
therapeutic).64
Among hemodynamically stable patients, adjunctive diagnostic tests and serial physical examinations support nonoperative management.65-72 CT shows sensitivity in the mid to
high 90% in the detection of surgically important injuries of
the liver (Fig. 1) and spleen (Fig. 2).73,74
Although useful for epidemiologic studies, CT grading of
liver and spleen injuries based on morphology of wounds
does not reliably predict the specific outcome in individual
cases.66,75-77 On the other hand, active hemorrhage shown by
CT (Fig. 3) commonly leads to endovascular or surgical interventions whether bleeding is focal (intraparenchymal:

pseudoaneurysms versus arteriovenous fistula), diffuse

(free-flowing intraperitoneal fluid), or multifocal (most commonly seen in pelvic retroperitoneum in patients sustaining
pelvic ring disruptions).10,78-84
Extravasated contrast appears as relatively discrete contrast collections that increase or pool on delayed imaging
and measures within 10 to 20 HU of density of an adjacent
major artery or aorta, during the vascular phase of imaging.
With current generation CT scanners, contrast-enhanced CT does not reliably distinguish between pseudoaneurysm (70% believed to progress to rupture in
adults) and AV fistula (natural history is uncertain).28,84-86
Parenchymal vascular lesions more often resolve spontaneously in children, and expectant observation may be

Figure 2 A 60-year-old male status post fall from ladder. (A, B) Contrast-enhanced CT scan through the dome of the
liver (A) and at the level of splenic vein (B) demonstrates extensive lacerations of spleen. Fluid is present around both
the liver and the spleen, but the fluid around the spleen is denser, indicating sentinel clot (arrow). More than 1 liter of
hemoperitoneum was found at surgery.

198

Figure 3 A 43-year-old male status post motor vehicle crash (MVC).

Contrast-enhanced axial CT scan through liver and spleen shows
anterior splenic laceration with active extravasation (long arrow).
Contrast extends into lateral perisplenic hematoma (short arrow).
Two liters of hemoperitoneum was present at surgery.

preferable to urgent intervention.87 Notably, larger proportions of blunt trauma patients show extravasation
when multidetector CT is used with higher injection rates
(2.5 ml/s) of intravenous contrast and scanning in early
to mid portal venous phases.74,84,88-92
Patients in whom CT detects multiorgan package injuries (eg, spleen and left kidney; left lobe of the liver; and
pancreas) are more likely to undergo surgical intervention.93
In addition, liver lacerations that involve the hilum, particularly those associated with partial avulsion of the gall bladder,
may benefit from repeated CT scanning or ultrasound,
cholescintigraphy, or direct cholangiography to detect possible biliary complications (Fig. 4).94-99
Liver lacerations involving the hepatic veins, especially
when associated with large regions (10 cm) of focal hypoperfusion, are associated with injuries to the retrohepatic vena cava that commonly require intervention
(Fig. 5).92,100,101
During postinjury monitoring, serial CT scans do not appear to be useful in altering therapy or determining the time
for return to full activities for patients without increasing
abdominal pain, falling hematocrit, or clinical features of intraabdominal sepsis.102,103 Nonetheless, if serial follow-up
imaging is believed to be indicated in specific cases, ultrasound is a more cost-effective alternative than CT.104

Blunt Injuries to Retroperitoneum:

Duodenum and Pancreas,
Adrenals; Kidneys and
Ureters; and Great Vessels
Retroperitoneal injuries are sometimes suspected based on
clinical history, physical examination findings, and laboratory tests (eg, microscopic hematuria),105 but often are oc-

A.L. Stanescu et al
cult. CT is the diagnostic procedure of choice, as neither
FAST nor DPL adequately assess the retroperitoneum.106
Conventional radiographic procedures (upper gastrointestinal positive-contrast fluoroscopy, intravenous, or retrograde
pyelography) may be helpful in secondary or follow-up evaluations of individuals known to have sustained injuries to the
duodenum and upper urinary tracts, respectively.107-110
In adults, the duodenum and pancreas are rarely injured in
isolation.111,112 However, children and adolescents may sustain isolated duodenal, or duodenal and pancreatic injuries,
especially from bicycle handlebar goring mechanisms
(Fig. 6).113
Pancreatic injuries range from contusions to lacerations,
fractures, and duodenal-pancreatic disjunctions.114 The majority (50%) of pancreatic injuries are contusions, hematomas, or superficial capsular lacerations. An additional 20 to
25% represent deeper pancreatic parenchymal lacerations
without involvement of a major pancreatic duct.115 Injuries
to the main pancreatic duct and combined pancreatico-duodenal injuries necessitate intervention and are often associated with complicated treatment courses.114,116-119
Compared with its performance at detecting acute injuries
to intraperitoneal solid organs, CT is relatively insensitive to
acute pancreatic injuries, even to severe injuries completely
disrupting the main pancreatic duct or pancreatico-duodenal
junction.120-123 Direct signs include a fracture plane traversing the neck, body, or tail of the pancreas, or separation of the
duodenum from the head of the pancreas. Indirect findings
on intravenous contrast-enhanced CT include heterogeneous
enhancement or focal enlargement of the pancreatic parenchyma and fluid around the pancreas, especially posteriorly,
where it may separate the pancreas from the splenic
vein.94,120,124,125 Definitive diagnosis and staging of main pancreatic duct injuries require either intraoperative, endoscopic, or MR cholangio-pancreatography.116,120,126,127
The range of duodenal injuries includes contusion, mural
hematoma, and lacerations (partial versus through-andthrough).118,124,128-131 CT depiction of retroperitoneal fluid
adjacent to the duodenum, especially when seen in conjunction with retroperitoneal gas, suggests duodenal injury.130,132
Intravenous contrast-enhanced CT may also demonstrate
asymmetric mural enhancement, and duodenal hematoma.130,133 Where intravenous contrast extravasation is
shown, delayed images (5 to 30 minutes) facilitate distinction
between medical and surgical bleeding (increased pooling
of contrast on delayed images) and may facilitate the decision
of whether and how to intervene.130,134 Oral contrast may be
helpful in delineating both pancreatic and duodenal pathology. While controversy exists as to whether positive or negative alimentary (eg, water) contrast provides more diagnostic information,128,135-139 we favor water orally or per enteral
tube. Although extraluminal positive enteral contrast can
make a specific diagnosis of bowel rupture by CT, it is rare
that this would be the only finding leading to surgical exploration, and positive contrast limits evaluation of wall and
mucosal abnormalities (such as absent perfusion, which is
better visualized with negative contrast agents).
Renal parenchymal injuries (Fig. 7), whether isolated or

Imaging of blunt abdominal trauma

199

Figure 4 A 7-year-old girl in high-speed MVC, front unrestrained

passenger. (A) Initial contrast-enhanced axial CT scan shows deep
liver lacerations extending to portal vein, porta hepatis, and gallbladder fossa. Spleen is poorly perfused, which can be a sign of
hypovolemia. Large hemoperitoneum is present. (B) Initial contrastenhanced axial CT scan shows that anterior gallbladder wall does
not enhance (arrows). (C) Follow-up contrast-enhanced axial CT
scan obtained 16 days later shows large biloma along inferior surface of left lobe of liver.

combined with retro- and intraperitoneal injuries, are more

common than duodenal or pancreatic injuries.140-142 Interventions are more often required when the collecting systems
or ureters are injured, and when renal injuries are combined
with pancreatic or bowel injuries.142 Even when FAST or DPL

are negative, contrast-enhanced CT is indicated for gross

hematuria (all age groups); children (15 years old) with
high levels of microscopic hematuria (50 red blood cells
per high-powered field, or 3 or greater on urine dipstick),
regardless of their hemodynamic status; and adults with he-

Figure 5 A 69-year-old female status post MVC. (A) Axial contrast-enhanced CT scan at the level of the pancreas shows
active vascular extravasation (arrow) in the region of the portal triad. (B) Axial contrast-enhanced CT scan shows
intraperitoneal accumulation of extravasated contrast inferiorly.

200

Figure 6 A 11-year-old male with bicycle handlebar trauma to upper

abdomen. IV contrast-enhanced axial CT scan at the level of second
and third portions of duodenum shows retroperitoneal periduodenal hemorrhage with focal bowel thickening and discontinuity at
the junction of 2nd and 3rd portions of duodenum (arrow).

A.L. Stanescu et al
maturia (1 or greater on urine dipstick, or 50 red blood
cells per high-powered field) who have any documented systolic hypotension (90 mm Hg).140,143-148
Dynamic contrast-enhanced CT ideally shows clinically
important renal vascular (vascular pedicle injuries including
dissection, thrombosis, pseudoaneurysms, and AV fistulae),
parenchymal (parenchymal lacerations), and collecting system injuries.109,142,149,150 When low- or iso-osmolar intravenous contrast agents are employed, imaging during late parenchymal phase and after a 5- to 10-minute delay detects the
presence of virtually all important upper urinary tract injuries.151 Repeated CT scanning 24 to 72 hours after trauma
aids in detection of complications among patients with highgrade renal injuries.152
Indirect intravenous contrast-enhanced CT findings of
upper urinary tract injury include perinephric stranding
and hematoma, and heterogenous parenchymal enhancement.153-156 Medial perinephric hematomas, especially
when large and extending into the root of the mesentery,
are associated with renal venous and uretero-pelvic junction (UPJ) injuries.144 Otherwise, the location and size of
perinephric hematoma poorly correlates with the severity

Figure 7 A 29-year-old male status post MVC. (A) Axial contrastenhanced CT scan in the interpolar region of right kidney shows
deep lacerations. (B) Axial contrast-enhanced CT scan at the level of
right upper pole shows active vascular extravasation (arrow). (C)
Axial contrast-enhanced CT scan delayed images show diffusion
and dilution of extravasated contrast within perinephric hematoma
at the same level as (A). Angiography demonstrated arterial extravasation, which was successfully embolized.

Imaging of blunt abdominal trauma

201

Figure 8 (A) A 40-year-old male status post three-story fall. Axial CT

cystogram scan at the level of acetabular roof shows molar tooth
configuration of contrast extravasation into the prevesical space. (B)
A 45-year-old male involved in a motorcycle accident (MCA). Axial
CT cystogram scan at the level of pubic symphysis shows anterior
bladder wall rupture with a large amount of contrast and small
amount of air extending to the abdominal wall. (C) A 45-year-old
male in MCA. Axial CT cystogram scan at the level of upper thighs
shows contrast extending into scrotum, outlining testicles, and to
fascial planes of the left leg.

of parenchymal injury or the need to intervene. However,

large subcapsular hematomas can be associated with subsequent hypertension (Page kidney).157
Direct intravenous contrast-enhanced CT findings of renal
injury include parenchymal lacerations and vascular and/or
urinary extravasations; the latter two necessitate intervention
or follow-up imaging.144,156,158 The frequency, timing, and
optimal methods for follow-up examination remain subjects
of debate. Our practice is to perform a portal venous phase of
the abdomen and pelvis, followed by 10-minute delayed images in patients with renal injuries or where unexplained
fluid is found adjacent to the kidney, ureter, or bladder.
Bladder ruptures may be intra- or extraperitoneal, or a
combination.159-163 Almost all extraperitoneal bladder ruptures (Fig. 8) are associated with high-energy osseous disruptions of the pelvic ring.162,164 Classical CT patterns of extraperitoneal extravasation are molar tooth configuration of
contrast extravasation in the prevesical space (Fig. 8A); abdominal wall extension of the contrast (Fig. 8B); or, in cases
with serious fascial plane disruptions, extension to scrotum,
and/or thigh (Fig. 8C).

Although most intraperitoneal ruptures are also associated

with high-energy osseous disruptions of the pelvis or acetabulum, an over-distended bladder rising out of the true pelvis
may rupture from direct blunt-force impact without pelvic
fracture.164 Contrast extravasation can be detected in paracolic gutters (Fig. 9A), inferior peritoneal recesses (rectovesical/rectouterine, vesicouterine) (Fig. 9B), or surrounding the
liver edge (Fig. 9C).
With combined intra- and extraperitoneal bladder rupture, if one component is large and the other is small, contrast
may exit only through the larger defect, leaving the other
component undiscovered.
Hematuria associated with high-energy pelvic ring disruptions, especially if perivesical hematoma or bladder wall
thickening is present, warrants positive-contrast cystography, which should not be considered adequate to exclude
injury unless intravesical pressure reaches at least 40
cmH2O.162,163,165 Delayed images of the pelvis, with passive
filling of the bladder by renal excretion of contrast, are not
adequate to evaluate for bladder injury, as the extent of bladder filling and intravesical pressure cannot be controlled.

202

A.L. Stanescu et al

Figure 9 (A) A 25-year-old female in car versus pedestrian accident.

Axial CT cystogram scan at the level of L2-L3 shows intraperitoneal
contrast in right paracolic gutter and around small bowel loops. (B)
A 33-year-old male in MCA. Axial CT cystogram scan at the level of
acetabular roof identifies intraperitoneal contrast in rectovesical recess (long arrow) and the right and left anterolateral inferior peritoneal recesses (short arrow). (C) A 51-year-old male post forklift
injury to the pelvis. Axial abdominal CT scan at the level of Morisons pouch following CT cystogram shows intraperitoneal contrast
surrounding the liver edge.

With the advent of CT, adrenal injuries are now recognized as the most common retroperitoneal injury.166,167
The right adrenal is injured much more often than the left,
and bilateral adrenal hemorrhage is relatively rare.167,168
An association also exists between right adrenal hemorrhage and liver lacerations involving the bare area.169 Despite their frequency, adrenal hemorrhages very rarely require treatment. Embolization may be done for large,
active extravasations associated with ongoing hemodynamic consequences.170,171
Adrenocortical replacement therapy may be needed for
hypoadrenalism, a very infrequent consequence of bilateral
adrenal hemorrhage.172
CT findings of adrenal injuries (Fig. 10) typically demonstrate irregular, globular enlargement of the gland, typically measuring 40 to 70 HU.173 However, definite distinction from preexisting nontraumatic adrenal pathology may require targeted follow-up CT, ultrasound, or
MRI.174

Figure 10 A 63-year-old male in MCA. Axial IV enhanced CT chest

scan shows new, bilateral adrenal hemorrhage.

Imaging of blunt abdominal trauma

203

Blunt Injuries to
Hollow Intraperitoneal
Abdominal Viscera
The small bowel sustains surgically important blunt injury
more frequently than the colon.175 The spectrum of bowel
injuries includes wall contusions, serosal injuries (deserosalization), perforations and transections, mesenteric rents,
and hematomas.176,177 When mural disruption occurs in the
proximal gastrointestinal tract (stomach through proximal
jejunum), leakage of alimentary tract contents into the peritoneum induces acute chemical peritonitis and related clinical findings.178 Distal small bowel and colon spillage tend to
present later as peritoneal sepsis.177 Delays in diagnosis of
bowel injury are associated with complicated clinical courses
and increased mortality.179,180 Serial physical evaluation of
the abdomen alone (ie, without adjunctive diagnostic tests,
such as CT, ultrasound or US, DPL) may be associated with
24-hour delay in diagnosis of surgically important bowel
injuries in 10 to 15% of individuals with distracting injuries,
such as femur fractures.181 DPL remains a somewhat more
sensitive test than CT for isolated hollow viscus injury, even
with intravenous and alimentary contrast enhancement,
thin-sections, and multidetector technologies.180,182,183 However, less than 1% of surgically important blunt-force hollow
visceral injuries occurring in adults are found in the absence
of other, often more obvious and clinically immediate, intraabdominal injuries.176 Conventional radiography, ultrasound, and MRI have little or no role in the routine diagnosis
of bowel injuries.184
CT performed without oral or intravenous contrast enhancement may show intramural hematoma as focal, asymmetric hyperdensity within bowel wall with adjacent mesenteric edema (misty mesentery).128,185 Bowel contusion may
be suggested on intravenous contrast-enhanced CT by focal
(Fig. 11) or multifocal (Fig. 12) bowel thickening and mural

enhancement. Oral contrast (positive or negative) may help

in appreciation of intramural hematomas.186,187
In contrast, diffuse bowel wall thickening and enhancement (Fig. 13), especially associated with slit-like infrahepatic inferior vena cava and hypodense and contracted
spleen, suggests under-resuscitation and the so-called hypoperfusion or shock bowel syndrome.188-190 Spillage of positive alimentary contrast or contents and free intraabdominal
gas are diagnostic of bowel perforation.132,191-194
While use of oral positive contrast appears to be
safe,138,195,196 its use does not seem to be diagnostically essential and may delay imaging in acutely ill patients.135,136 The
combination of triangular interloop collections within the
mesentery and abnormal-appearing bowel wall strongly suggests transmural bowel injury (Fig. 14).133
Likewise, nonphysiologic amounts of free intraperitoneal
fluid (75 mL in minimally resuscitated women of child-

Figure 11 A 38-year-old restrained driver, lapbelt only, in highspeed MVC. Axial contrast-enhanced abdominal CT scan at the level
of mid-abdomen shows focal thickening of jejunum in left abdomen.

Figure 13 A 23-year-old female, high-speed motorcycle crash. Axial

contrast-enhanced abdominal CT scan at the level of renal hilum
shows diffuse bowel thickening consistent with shock bowel, hemoperitoneum, and slit-like IVC; also noted is injury to right renal
hilum.

Figure 12 A 10-year-old girl involved in high-speed MVC, seat belt

sign. Contrast-enhanced axial abdominal CT scan at the level of
mid-abdomen (inferior pole of right kidney) shows free intraperitoneal fluid with multiple focal thickening in the jejunum and cecum.

A.L. Stanescu et al

204

Conclusions
Imaging modalities of choice in evaluating blunt trauma patients are CT and FAST. Intravenously contrast-enhanced CT
remains the most common and efficacious means of correctly
categorizing patients into those likely manageable with nonoperative techniques and those who need surgery. The increasing tendency of nonoperative management requires
early identification of the lesions, which is provided by the
increasing sophistication of the CT techniques. CT also provides a very important tool in following up the patients and
detecting complications not initially diagnosed.

Acknowledgments
Figure 14 A 54-year-old in MVC crash. Axial contrast-enhanced abdominal CT scan at the level of lower abdomen shows abnormal
thickening of the jejunum with triangular-shaped areas of mesenteric and interloop fluid (arrow).

bearing age, 25 mL in minimally resuscitated adult males,

and 25 mL in children) without evidence for intraperitoneal solid organ injury suggests occult hollow viscus injury
and should lead to additional diagnostic testing or serial examinations.179,197,198
Acute abdominal compartment syndrome (ACS), a potentially treatable and often fatal complication of trauma, is a
manifestation of shock-related capillary leak and is not uncommon among severely injured patients who have received
vigorous fluid resuscitation.199 Although ACS may be seen in
the absence of significant intraabdominal injury, hemodynamically significant major intraabdominal trauma is a common antecedent. Findings at intravenous contrast-enhanced
CT include slit-like infrahepatic vena cava, marked diffuse
edema and dense mural/mucosal staining of the bowel, flattening of the kidneys, expansion of the intraperitoneal space
(circular cross-section of the abdomen at the level of the renal
veins, elevation of the diaphragms that may invert to efface
the left and right cardiac ventricles, distension of the common femoral veins, and bilateral inguinal hernias).200-203

Injuries to the
Abdominal Aorta and Its Main
Tributaries, and the Vena Cava
Traumatic disruption of the midline great vessels is rare. Both
clinically and at imaging, the presence of a midline hematoma surrounding the aorta and infrahepatic vena cava warrants careful attention. Aortic injuries are commonly associated with lapbelt injuries (thoracolumbar spine distraction
injuries) and may present with an acute aortic syndrome.204-207 Infrahepatic vena cava injuries are suggested by
surrounding pericaval or juxtacaval hematoma, contour irregularity, and indistinct contrast interface with irregular lumen margins or contrast-extravasation on contrast-enhanced
CT.208,209

We thank Dr Lee B. Talner for proofreading the manuscript

and Dr Harigovinda R. Challa for case contributions.

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