ICM

Bagian Radiologi
Fakultas kedokteran Universitas Pelita Harapan
Approach to AXR
• Pre-peritoneal fat line

• Bowel gas pattern

• Extraluminal air

• Soft tissue masses

• Calcifications
Used In Trauma ?
• Plain X-Ray  used for basic fracture, available in emergency
department
• USG  Hemoperitoneum, portable in emergency department,
Keuntungan :
1.Noninvasif
2.Tidak menimbulkan rasa sakit
3.Dapat dilakukan dengan cepat dan aman serta tidak memiliki
kontraindikasi.
• CT Scan  Unstable patient, major trauma cases
• MRI  CNS trauma, stable patient, not available in emergency
department
WHAT ARE THE BASIC IMAGING

TESTS THAT SHOULD BE DONE

INITIALLY FOR MAJOR TRAUMA

PATIENT?
BEFORE SENDING PATIENT FOR X-RAYS

TRANSPORTING DEVICES FOR X-RAY

• Patient needs to be hemodynamically stable

• Stabilising devices

– Neck brace (C-spine injuries)

– Spinal board (Lumbar spine injuries)

– Facial and C-spine fractures can be ‘deadly’ if

neck flexed during CT scan positioning
TRAUMA IMAGING ON ADMISSION

IMAGING STUDY INJURY BEING ASSESSED

Lateral Cervical spine Fracture or dislocation

(& or L Spine): (to prevent paralysis)

Chest X-ray (AP view) Aortic rupture / pneumothorax

Abdominal US Check for hemoperitoneum

(major solid organ injury)
OPTION
CT Assess major CNS, Vascular & Solid
APPROACH TO IMAGING OF TRAUMA

TYPES OF TRAUMA

A: ORGAN SPECIFIC

1. MULTIPLE ORGAN INVOLVEMENT:

e.g: motor vehicle, bicycle involved with major motor vehicle

2. LOCALISED ORGAN INVOLVEMENT

e.g. Abdominal, chest, head injury

B: TYPE OF INJURY:

1. Penetrating

2. Blunt trauma
APPROACH TO IMAGING OF TRAUMA

IMAGING OF ORGAN SPECIFIC TRAUMA

A) MULTI ORGAN TRAUMA:

Requires aggressive imaging

- CT located in the Emergency Room

- Head. Chest and Abdomen CTs can be done quickly

- To triage the patient

- Do a Contrast CT of whole body
- Then refer patient to
- Neurosurgeon or Vascular surgeon or Orthopedic or Abdominal
surgeon
MULTI ORGAN TRAUMA

Liver

Stomach

Kidney
Kidney

A: Liver laceration B: Renal laceration

Hyper enhancing bowel wall

C: Shock Bowel

Small aorta
Single Organ Trauma
• Careful Clinical analysis before Imaging

• Since patient usually stable

• Can become unstable quickly

• E.g. delayed rupture of organs e.g spleen
• Also include the facial trauma and fractures

• May need specialised care

• Sent to other hospitals
• Complex Pelvic, C-spine fractures
SINGLE ORGAN TRAUMA

Liver

Spleen
Splenic
hematoma
 Etiologies
• Hemorrhage
• GI perforation
• Bowel obstruction
• Inflammatory disorder
• Circulatory impairment
 HEMORRHAGE
• Intraperitoneal hemorrhage
• Rupture:
• hepatoma
• aortic anuerysm
• ectopic pregnancy
• ovarian bleeding
• Gastrointestinal hemorrhage
• Upper GI hemorrhage
• Duodenal ulcer
• Gastric ulcer
• Hemorrhagic gastritis
• Esophageal or gastric varices ect.
• Lower GI hemorrhage
• Bleeding of colon cancer
• Ischemic colitis ect.
 Imaging
• US finding
• Free peritoneal fluid accumulation on the Morison’s pouch, the
rectovesical pouch, the pouch of Douglas, and the bilateral
subphrenic space
• Abdominal CT
• CTgold standars for specific intraabdominal pathology
 Gastrointestinal perforation

• Gastrointestinal perforation are serious disorder requiring

rapid diagnosis and treatment
• Since they may be severe enough to produce septic or
hypovolemic shockrapid decision-making for urgent
laparotomy is crucially important
● Radiological appearances:

Plain abdominal film:

- Oval/linear collection of gas:
♠ Subhepatic space
♠ Morison’s pouch
♠ Beneath the diaphragm (the cupola sign)
♠ In the centre of the abdomen over a fluid
collection (the football sign)
♠ Fissure for ligamentum teres
17
Abdomen
 Morrison’s Pouch

• probe is placed in the right mid- to posterior

axillary line at the level of the 11th and 12th
ribs
 ULTRASOUND

Ascites

Used in Emergency Department

Liver
to detect free fluid – specifically blood

idney
K
Blunt abdominal trauma. Normal Morison pouch (ie, no free
fluid).
Blunt abdominal trauma. Free fluid in the Morison pouch.
RUQ
• Image on screen:
• Liver cephalad
• Kidney inferiorly
• Morison’s Pouch*: *
*
space between
*
Glisson’s capsule and
Gerota’s fascia *
Normal RUQ
• Image kidney
• Longitudinally
• Transversely
• Two toned structure
• Cortex/medulla
• Renal sinus
Appearance of blood
• Fresh blood
• Anechoic (black)

• Coagulating blood
• First hypoechoic
• Later hyperechoic
 Normal
Morison’s Pouch

Free fluid in
Morison’s
Pouch
Blunt abdominal trauma. Normal splenorenal recess.
Blunt abdominal trauma. Free fluid in the splenorenal
recess.
To Evaluate the Thorax
• Move probe
• cephalad
• longitudinal
• Image
Liver

Diaphragm

Pleural space
Hemothorax

liver

fluid diaphragm
Small Pleural Effusion

Large Pleural Effusion

 Normal
Transverse
pelvic

Fluid in pelvis
Pelvic View – Sagittal
clot bladder
• Fluid in front of the
bladder
• If bladder is empty
or Foley already
placed:
Trick of trade
• IV bag on abdomen
• Scan through bag
Blood in the Pelvis
Free fluid in the pelvis
How good is FAST?
 As a decision making tool for identifying the need for laparotomy in
hypotensive patients (Systolic BP < 90), FAST has:
 a sensitivity of 92%,
 specificity of 96%
 Accuracy 93%
Plain film radiograph
Hepatic angle

Spenic angle

Renal shadow
Psoas muscle

Properitoneal fat
strip
Normal
Normal CT anatomy
1.LHV, left hepatic vein
2.MHV, middle hepatic
vein;
1
2 3.RHV, right hepatic vein;
3 4 5 6
4.IVC, inferior vena cava
5.Ao,aorta
6.Stomach
 1.LPV, left portal vein
2.Stomach
1 3.Speen
2
4.IVC, inferior vena
4 5
cava
3
5.Ao,aorta
 1.Gallbladder
3 2.RPV, right portal vein
1
4
3.antrum
1
4.duodenal bulb
 1.CA,celiac axis
2.Splenic artery
2 3.common hepatic artery
7 3 1 6
4.Duodenum
4
5.Kidney
5 5 6.Pancreas
7.Portal vein
8.Adrenal gland
CTA
SMA, superior
mesenteric artery
CA,celiac axis

Splenic artery

common hepatic
artery
main portal trunk;
right portal branch;
splenic vein;
inferior mesenteric
vein;
superior mesenteric
vein
RHV, right hepatic vein;

MHV, middle hepatic vein;

LHV, left hepatic vein

IVC, inferior vena cava

Organ specific injuries
 Spleen
 Liver
 Kidneys
 Bowel and mesentery
 ABDOMINAL ANATOMY

Traumatic injuries to
Sple
1. LIVER Liver en

2. SPLEEN
Kidney

3. KIDNEYS
IMAGING STUDIES BEST FOR ABDOMINAL TRAUMA

Liver
n ey
kid

Ultrasound

CT
Traumatic splenic injury
 Commonly injured in blunt trauma
 Clinical findings:
 Often no/non-specific symptoms
 Peritoneal irritation
 Signs/symptoms of acute hemorrhage
Traumatic splenic injury
 Imaging
 Plain film: not useful
 US: hemoperitoneum
 Contrast-enhanced CT: imaging modality of choice
 Angiography: therapeutic embolization
 Hematoma

 Laceration

 Infarction
Splenic hematoma
 CT
 The BEST IMAGING STUDY

 CT Findings:
 On Plain CT: High Density (Blood)

 With IV Contrast: No enhancement

 Density of hematoma decreases with time
Contrast enhanced CT:
splenic hematoma

Liver

Spleen
Splenic
hematoma
Splenic Laceration:
 Contrast-enhanced CT:
 Findings often undetectable

 CT Findings:
 Perisplenic fluid

 Low-density linear defects, within the spleen (usually

extending from the lateral border towards the hilum)

 Blood clot - “sentinal clot sign”

Traumatic liver injury
 Commonly injured in blunt trauma
 R lobe, post segment most often injured
 Clinical findings:
 RUQ pain
 Hypotension
 Shock
 Symptoms of bile peritonitis (bile duct injury)
 Plain film: not useful

 US: hemoperitoneum

 CT: imaging modality of choice

 Angiography: to detect vascular complications and for

therapeutic embolization
TYPES OF LIVER INJURIES
 Contusions
 Subcapsular hematoma

 Intraparenchymal hematoma

 Lacerations

 Complete hepatic fracture

Grade II
Grade III
Intraparenchymal
liver
hematoma
Severe stomach
intraparenchymal
bleeding
No enhancement
with contrast spleen
 Peripherally located
 Least common form of liver injury
  Peripherally located
 Least common form of liver injury

Subcapsular hematoma liver

Low attenuation,
lentiform collection stomach
displacing &
compressing the liver
spleen
 Most common liver injury

 The Liver capsule can be Intact or disrupted

 Intact liver capsule – stable injury

 Disrupted capsule – can result in Hemoperitoneum

Hepatic laceration Descending
aorta

Spleen
 Mechanism:
 Blunt trauma (80%)
 Laceration by lower ribs

Torn by rapid acceleration & deceleration

 Clinical findings:
 Back pain
 Hematuria
 Can be hemodynamically unstable
Can affect:
 Renal Parenchyma

 Renal collecting system

 Renal vessels
 US:
 Limited use
 Contrast enhanced CT:
 Study of choice
 Delayed images important to differentiate
between hematoma & leakage from collecting
system
Angiography:
 Not done routinely
 Now CT Angiography better study
 CTA done with IV contrast and during arterial phase

 Done only when embolization of bleeding

site is required
Contrast-enhanced CT:
pan
Low density areas in c rea
kidney parallel to
s
intervascular tissue planes

Kidney Kidney
Contrast-enhanced CT:
pan
Low density areas in c rea
kidney parallel to
s
intervascular tissue planes

Small perirenal Renal laceration

hematoma
Contrast-enhanced CT

• Contrast extravasation
around the kidney
Collecting system
leak

R kidney
Uncommon injury

 CT BEST TEST

 CT Findings:
 Absence of contrast enhancement (no flow)
 Hematoma surrounding the kidney
 Abrupt cut-off of contrast filled renal artery

 Sometimes contrast leaks out from artery into

tissues
R kidney:
Absence of contrast
enhancement
Perirenal
hematoma
Contrast extravasation
Laceration
quick quiz what organ is injured?
Plain abdominal film
Table 1 Plain abdominal film
 Supine abdomen
• Looking for
• Gas pattern
• Calcifications
• Soft tissue masses
• Substitute – none
 Erect abdomen
• Looking for
• Free air
• Air-fluid levels
• Substitute – left lateral
decubitus
 Etiologies
• Hemorrhage
• GI perforation
• Bowel obstruction
• Inflammatory disorder
• Circulatory impairment
 HEMORRHAGE
• Intraperitoneal hemorrhage
• Rupture:
• hepatoma
• aortic anuerysm
• ectopic pregnancy
• ovarian bleeding
• Gastrointestinal hemorrhage
• Upper GI hemorrhage
• Duodenal ulcer
• Gastric ulcer
• Hemorrhagic gastritis
• Esophageal or gastric varices ect.
• Lower GI hemorrhage
• Bleeding of colon cancer
• Ischemic colitis ect.
 Imaging
• US finding
• Free peritoneal fluid accumulation on the Morison’s pouch, the
rectovesical pouch, the pouch of Douglas, and the bilateral
subphrenic space
• Abdominal CT
• CTgold standars for specific intraabdominal pathology
US
CT
 Gastrointestinal
perforation
• Gastrointestinal perforation are serious disorder requiring
rapid diagnosis and treatment
• Since they may be severe enough to produce septic or
hypovolemic shockrapid decision-making for urgent
laparotomy is crucially important
● Radiological appearances:

Plain abdominal film:

- Oval/linear collection of gas:
♠ Subhepatic space
♠ Morison’s pouch
♠ Beneath the diaphragm (the cupola sign)
♠ In the centre of the abdomen over a fluid
collection (the football sign)
♠ Fissure for ligamentum teres
104
- Small triangular collections of gas between
loops of bowel.

- Visualisation of the outer as well as the

inner wall of a loop of bowel (Rigler’s sign).

USnot as sensitive as plain radiography for

demonstating pneumoperitoneum

CT:
Free gas over the liver, anteriorly in the mid
abdomen, & in the peritoneal recesses.
105
Plain photo
Pneumoperitoneum

Fissure for ligamentum Rigler’s sign

teres 107
Football
sign
 BOWEL OBSTRUCTION
• The first investigation when bowel obstruction is suspected is
the supine plain abdominal X-ray, together with an erect chest
film if perforation is a possibility
• Occasionally, all the dilated bowel may be fluid fill and not
visible on a plain X-ray and further imaging with contrast
studies, CT or US may be needed to demonstrate dilated
bowel
• Imaging aims: to confirm the presence of bowel obstruction,
define the level obstruction, identify the cause and detect
complications such as perforation
 Table 2. Cause of bowel obstruction

Extrinsic Bowel wall Intraluminal

Adhesions Neoplasia Intussusception

Hernia Strictures:inflamma Foreign body

tory,
radiation,chemical
Volvulus Intestinal Gallstone ileus
ischaemia

Inflammation/abscess

Malignant infiltration
(e.g. peritoenal
deposits)
 Small-Bowel Obstruction:

 Etiology:
- Adhesions due to previous surgery
- Strangulated hernias
- Volvulus
- Gallstone ileus
- Intussusception
- Neoplastic, etc.
 Small bowel obstruction (SBO)
• Plain filmprimary investigation of choice
• Plain film of SBO:
Dilated small bowel loops:
• Tend to the central
• Numerous
• 2.5-5.0 cm diameter
• Have a small radius of curvature
• Valvulae conniventes: thin, numerous, and
extend right across the bowel
• Do not contain solid faeces
• Multiple fluid levels on the erect film
• String of beads sign on the erect film
• Absent or little air in the large bowel
SBO: valvulae conniventes
SBO:stepladder pattern
Small-Bowel Obstruction:
String of beads sign

117
♥ Ultrasound:

- Dilated fluid-filled loops of small-bowel

obstruction.
- Assessment of the peristaltic activity.

118
US:SBO
• CT sign of SBO
• Small bowel loops measuring>2.5 cm in diameter
• Identifiable focal transition zone from prestenotic dilated bowel to
post-stenotic collapsed bowel loops
CT:SBO

Fluid-filled loops Bowel calibre change

LARGE-BOWEL OBSTRUCTION
• Etiology:
- Neoplastic (benign & malignant)
- Volvulus (caecal & sigmoid), etc.

• Radiological appearances:
Depends on the state of competence
of the ileocaecal valve:

122
 Large bowel obstruction (LBO)

 Plain-film signs of LBO:

› Dilated large bowel loops which:
 Tend to be peripheral
 Few in number
 Large: above 5.0 cm diameter
 Wide radius of curvature
 Haustra: thick and widely separated and may or may not extend
right across the bowel (compare these features with the valvulae
conniventes found in the small bowel
 Contain solid faeces
 • Caecum maybe dilated
• Small bowel may be dilated
• Contrast enema maybe helpful:
• To differentiate pseudo-obstruction and may be indistinguishable
on plain film from mechanical of obstruction
• To localized the point of obstruction
• To diagnose the cause of obstruction e.g. tumour, inflamatory
mass
Contrast-enema
Plain film:Sigmoid
volvulus

coffee bean sign

Plain film: Caecal Volvulus
 PARALYTIC ILEUS
 Generalised paralytic ileus:
 ●Etiology:
 - Peritonitis
 - Post-operative
 - Hypokalaemia
 - General debility or infection
 - Drugs: morphine
 - Congestive cardiac failure, renal colic, etc.

 ●Radiological appearances:
- Both small & large-bowel dilatation 128
- Horizontal-ray films: multiple fluid levels
PARALYTIC ILEUS

129
 INFLAMMATORY DISSORDERS

• Acute appendicitis
• Acute pancreatitis
• Acute cholecystitis
• Abdominal absces
• Peritonitis
 Acute appendicitis
• Abdominal x-ray (AXR)
• Non-specific finding
• Approximately 10%a calcified appendicolith
• US
• Generally, the normal cannot be defined with US, clear
visualization of the appendix is suggestif of inflammation
• Swollen, non compressible appendix greater than 7 mm in
diameter with a target or bulls-eye configuration is
produced by the hypoechoic dilated appendiceal lumen
• Assymetrical wall thickening due to phlegmonous infiltration,
an appendicolith with acoustic shadowing
• US finding
• Echogenic hallo form by omental tissues draped over the
appendix
• Free fluid in the culdesac
• Atony in the terminal ileum with compression US
• CT finding
• 90% diagnostic accuracy to detect acute appendicitis
• With the good contrastfilling of the terminal ileum
and the cecum (oral contrast given 1 hour before
examination)
• Tubular structure 4 mm to 20 mm in diameter with a
thickened wall that enhance after administration IV
contrast medium
• Pericecal fluid collection and calcified appendicolith
Plain film:apendicolith
CT
 Acute pancreatitis
 Severity of acute
pancreatitis
rangesmild edema
with minimal symptoms
to a severe necrotizing
process that culminates
in multiple organ failure
 US and CT most
precisely define the
anatomic extent of the
lesions and the detect
local complications
 Imaging
• Plain filmsno significant plain film findings in up to two-thirds of
patients wih acute pancreatitis
• Plain-film signs may include:
• Paralytic ileus in the left upper quadrant
• Generalized ileus
• Loss of left psoas outline
• Separation of greater curve of stomach from tranverse colon
• CXR signs that may be seen include:
• Left pleura effusion
• Atelectasis of left lower lobe
• Elevated left hemidiaphragm
• US finding:
• The acutely inflamed pancreasenlarged with decreased
echogenicity and blurred irregular margin
• Fluid collection are seen as hypoechoic areas
• US can be used to guide aspiration and the drainage
procedures, and for follow up
• CTimaging investigation of choice for acute
pancreatitis, and is particularly useful for the
following:
• Confirmation of the diagnosis
• Identification of necrotic gland tissue
• Diagnosis of complication
• Guidance of interventional procedures
• CT signs of acute pancreatitis include:
• Diffuse or focal pancreatic enlargement with decreased density and
indistinct gland margins
• Thickening of surrounding fascial planes e.g. left paranephric fascia
• Acute fluid collections, most commonly related to pancreas though also
in the lesser sac and in the left pararenal space
• Phlegmon appears as an irregular mass spreading along fascial planes
and can be quite extensive
• Abscess
• Pseudocyst
US
CT
 Acute cholecystitis
 Approximately 85%-90% of cases
with acute cholecystitis (AC)
develop as a complication of
cholelithiasis
 Conversely, approximately 10%-
20% of patients with gallstone
will require surgery for
complication, usually
cholecystitis, within 15 years
after their stone disease is
diagnosed
 Acalculous cholecystitis account
for 5%-15% of cases of acute
cholecystitis
(immunocompromize, critically
ill,iatrogenic, congenital etc)
 Imaging
• Plain filmsinsensitive for acute cholecystitis
• Plain films signnonspesific and include:
• Gallstone (only seen in 10%)
• Soft tissue mass in the right upper quadrant due to distended
gallbladeer
• Paralytic ileus in the right upper quadrant
 Imaging

• USinvestigation of choice for suspected acute

cholecystitis
• US signs of acute cholecystitis include:
• Gallstones:hyperechoic lesions with acoustic shadowing
which are mobile
• Thickening of gallbladder wall to greater than 4 mm
• Hypoechoic gallblader wall due to oedema
• Surrounding fluid or localized fluid collection
• Distended gallbladder
• Localized tenderness to direct probe pressure
• CTscanning contribute little to diagnosis of cholecystitis
• CTinvestigation of complicatiosbiliary or pericholecystic
abscess
US:Acute cholecystitis
US:Acute cholecystitis
US:Acute cholecystitis
 Peritonitis
• Peritonitisan inflammatory or suppurative reaction of the
peritoneum to direct irritation
• Cause:
• Inflammatory
• Infectious
• Ischemic Exudation,
Hematogenous,
Contiguous extension,
Iatrogenic manipulation
 Imaging

• Plain abdominal radiograph: cannot provide specific

• Air-fluid Levels
• Stones
• Ascites
• Eggshell calcification
• Air in Biliary tree.
• Obliteration of psoas-shadow in retro- peritoneal disease
• Right lower quadrant sentinel loops in acute appendicitis
• USnonspecific
• Abdominal CT
• CT signs 
• Ascites (free or encapsulated)
• Infiltration of the omentum and/or mesentery
• Thickening of the parietal peritoneum
• Angiography for ischaemia, hemorrhage
 ACUTE COLITIS
• Acute inflammatory colitis
• Toxic megacolon
• Pseudomembranous colitis
• Ischaemic colitis

155
Acute inflammatory colitis
• Plain film can assess :
♠ the extent of the colitis
♠ the state of mucosa:
It can be assessed from :
- the faecal residue:
In left-sided disease, the proximal limit of
faecal residue will indicate the extent of
active mucosal lesion.
- the width of the bowel lumen
- the mucosal edge
- the haustral pattern
156
 Toxic megacolon
• A fulminating form of colitis with transmural inflammation,
extensive & deep ulceration & neuromuscular degeneration.
• Involve the transverse colon
• Ro. Findings:
Mucosal islands (=pseudopolyps) & dilatation (8 cm)
• Common complication:
Perforation in the sigmoid & peritonitis

157
Toxic megacolon

158
 Ischaemic colitis
 Etiology:
Vascular insufficiency & bleeding into the wall
of the colon.
 Sudden onset of severe abd.pain in the early hours
of the morning, followed by bloody diarrhoea.
 In middle-aged & elderly patients.
 The wall of splenic flexure & descending colon is
greatly thickened→ thumb printing (plain films).
 The right side of colon is frequently distended.

159
Pathophysiology of mesenteric ischaemia
Ischaemic colitis

thumb printing

161
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