Can multidetector CT detect the site of gastrointestinal tract injury in trauma? – A retrospective study

PURPOSE :We aimed to assess the performance of computed tomography (CT) in localizing site of traumatic gastrointestinal tract (GIT) injury and determine the diagnostic value of CT signs in site localization.METHODS:CT scans of 97 patients with surgically proven GIT or mesenteric injuries were retrospectively reviewed by radiologists blinded to surgical findings. Diagnosis of either GIT or mesenteric injuries was made. In patients with GIT injuries, site of injury and presence of CT signs such as focal bowel wall hyperenhancement, hypoenhancement, wall discontinuity, wall thickening, extramural air, intramural air, perivisceral infiltration, and active vascular contrast leak were evaluated.RESULTS:Out of 97 patients, 90 had GIT injuries (70 single site injuries and 20 multiple site injuries) and seven had isolated mesenteric injury. The overall concordance between CT and operative findings for exact site localization was 67.8% (61/90), partial concordance rate was 11.1% (10/90), and discordance rate was 21.1% (19/90). For single site localization, concordance rate was 77.1% (54/70), discordance rate was 21.4% (15/70), and partial concordance rate was 1.4% (1/70). In multiple site injury, concordance rate for all sites of injury was 35% (7/20), partial concordance rate was 45% (9/20), and discordance rate was 20% (4/20). For upper GIT injuries, wall discontinuity was the most accurate sign for localization. For small bowel injury, intramural air and hyperenhancement were the most specific signs for site localization, while for large bowel injury, wall discontinuity and hypoenhancement were the most specific signs.CONCLUSION:CT performs better in diagnosing small bowel injury compared with large bowel injury. CT can well predict the presence of multiple site injury but has limited performance in exact localization of all injury sites

Transcatheter arterial embolization for traumatic mesenteric bleeding: a 15-year, single-center experience

PURPOSE:We aimed to assess the safety and effectiveness of transcatheter arterial embolization (TAE) for mesenteric bleeding following trauma.METHODS:From 2001 to 2015, 12 patients were referred to our interventional unit for mesenteric bleeding following trauma, based on clinical decisions and computed tomography (CT) images. After excluding one patient with no bleeding focus and one patient who underwent emergency surgery, a total of 10 patients (male:female ratio, 9:1; mean age, 52.1 years) who underwent super selective TAE of visceral arteries were included in this study. Technical and clinical success, complications, and 30-day mortality rate were analyzed.RESULTS:In 10 patients who underwent TAE, the types of trauma were motor vehicle collision (n=6), fall (n=2), assault (n=1), and penetrating injury (n=1), and the bleeding arteries were in the pancreaticoduodenal arterial arcade (n=4), jejunal artery (n=3), colic artery (n=2), and sigmoid artery (n=1). N-butyl-2-cyanoacrylate (NBCA) (n=2), microcoils (n=2), and combinations of NBCA, microcoils, or gelatin sponge particles (n=6) were used as embolic agents. Technical success was achieved in all 10 patients, with immediate cessation of bleeding. Clinical success rate was 90% (9/10), and all patients were discharged with no further treatment required for mesenteric bleeding. However, one patient showed rebleeding 10 days later and underwent repeated TAE with successful result. There were no TAE-related ischemic complications such as bowel infarction. The 30-day mortality rate was 0%.CONCLUSION:Our clinical experience suggests that TAE used to control mesenteric bleeding following trauma is safe and effective as a minimally invasive alternative to surgery

Successful minimally invasive management using transcatheter arterial embolization in a hemodynamically stable elderly patient with mesenteric vascular injury in a hybrid emergency room system cin Korea: a case report

Mesenteric injury occurs rarely in cases associated with blunt abdominal trauma. Despite its low incidence, mesenteric injury can lead to fatal outcomes such as hypovolemic shock due to hemoperitoneum or sepsis due to intestinal ischemia, or perforation-related peritonitis. For mesenteric injuries, especially those involving massive bleeding, intestinal ischemia, and perforation, the standard treatment is surgery. However, in the case of operative management, it should be borne in mind that there is a possibility of complications and mortality during and after surgery. The usefulness of transcatheter arterial embolization (TAE) is well known in solid organs but is controversial for mesenteric injury. We present a 75-year-old man with mesenteric injury due to blunt abdominal trauma. Initial abdominal computed tomography showed no hemoperitoneum, but a mesenteric contusion and pseudoaneurysm with a diameter of 17 mm were observed near the origin of the superior mesenteric artery. Since there were no findings requiring emergency surgery such as free air or intestinal ischemia, it was decided to perform nonoperative management with TAE using microcoils in hybrid emergency room system. TAE was performed successfully, and there were no complications such as bleeding, bowel ischemia, or delayed bowel perforation. He was discharged on the 23rd day after admission with percutaneous catheter drainage for drainage of mesenteric hematoma. The authors believe that treatment with TAE for highly selected elderly patients with mesenteric injuries has the positive aspect of minimally invasive management, considering the burden of general anesthesia and the various avoidable intraoperative and postoperative complications

Computed tomography in diagnostics and treatment decisions concerning multiple trauma and critically ill patients

AbstractTechnical improvements in computed tomography (CT) scanners have provided new possibilities to exploit the resources of this imaging modality in the evaluation of patients with multiple injuries or patients being treated in an intensive care unit (ICU). The purpose of this study was to assess the significance of multi-detector computed tomography (MDCT) in diagnostics and treatment decisions concerning multiple trauma and critically ill patients. Findings of MDCT using a dedicated trauma protocol in 133 patients exposed to high-energy blunt trauma were retrospectively evaluated. Diagnostic information about the injuries that would enable planning of treatment was sought. The imaging protocol consisted of axial scanning of the head and helical scanning of the facial bones, cervical spine, thorax, abdomen, and pelvis. Ninety-nine of the patients (74%) had at least one finding consistent with trauma. Nineteen false negative findings and two false positive findings were made. The overall sensitivity of MDCT was 94%, specificity 100%, and accuracy 97%.The reliability of a structured 5-min evaluation of MDCT images from the scanner’s console was prospectively evaluated in 40 high-energy trauma patients. The dedicated trauma protocol covering the thorax, abdomen, and pelvis was used in MDCT scanning. The findings were compared with the final radiological diagnosis of the MDCT data made on a picture archiving and communicating system (PACS) workstation, the operative findings, and the clinical follow-up. The evaluation from the scanner’s console enabled diagnosis of all potentially life-threatening injuries, the sensitivity for all injuries being 60% and specificity 98%.The effects of MDCT on the treatment of patients in a 12-bed medical-surgical ICU were observed prospectively. Sixty-four patients with an ICU stay longer than 48 h had had inconclusive findings with other modalities of radiological imaging. They underwent altogether 82 MDCT examinations. Fifty examinations (61%) resulted in a change in treatment, and 20 (24%) of them otherwise contributed to or supported clinical decision-making. Twelve examinations (15%) failed to provide any additional information relevant to the patient’s treatment. MDCT examination was helpful in general ICU patients, with inconclusive findings with other imaging modalities. CT images of 127 mixed medical-surgical ICU patients were retrospectively reviewed for the previously determined findings. Forty-three of these patients underwent open cholecystectomy, revealing eight cases with a normal gallbladder (GB), 26 with an edematous GB, and nine with necrotic acute acalculous cholecystitis (AAC). Abnormal CT findings were present in 96% of all the ICU patients. Higher bile density in the GB body and subserosal edema were associated with an edematous GB. The most specific findings predicting necrotic AAC were gas in the GB wall or lumen, lack of GB wall enhancement, and edema around the GB. The frequent prevalence of nonspecific abnormal imaging findings in the GB of ICU patients limits the diagnostic value of CT scanning. Academic dissertation to be presented with the assent of the Faculty of Medicine of the University of Oulu for public defence in Auditorium 7 of Oulu University Hospital, on 16 April 2010, at 12 noonAbstract Technical improvements in computed tomography (CT) scanners have provided new possibilities to exploit the resources of this imaging modality in the evaluation of patients with multiple injuries or patients being treated in an intensive care unit (ICU). The purpose of this study was to assess the significance of multi-detector computed tomography (MDCT) in diagnostics and treatment decisions concerning multiple trauma and critically ill patients. Findings of MDCT using a dedicated trauma protocol in 133 patients exposed to high-energy blunt trauma were retrospectively evaluated. Diagnostic information about the injuries that would enable planning of treatment was sought. The imaging protocol consisted of axial scanning of the head and helical scanning of the facial bones, cervical spine, thorax, abdomen, and pelvis. Ninety-nine of the patients (74%) had at least one finding consistent with trauma. Nineteen false negative findings and two false positive findings were made. The overall sensitivity of MDCT was 94%, specificity 100%, and accuracy 97%. The reliability of a structured 5-min evaluation of MDCT images from the scanner’s console was prospectively evaluated in 40 high-energy trauma patients. The dedicated trauma protocol covering the thorax, abdomen, and pelvis was used in MDCT scanning. The findings were compared with the final radiological diagnosis of the MDCT data made on a picture archiving and communicating system (PACS) workstation, the operative findings, and the clinical follow-up. The evaluation from the scanner’s console enabled diagnosis of all potentially life-threatening injuries, the sensitivity for all injuries being 60% and specificity 98%. The effects of MDCT on the treatment of patients in a 12-bed medical-surgical ICU were observed prospectively. Sixty-four patients with an ICU stay longer than 48 h had had inconclusive findings with other modalities of radiological imaging. They underwent altogether 82 MDCT examinations. Fifty examinations (61%) resulted in a change in treatment, and 20 (24%) of them otherwise contributed to or supported clinical decision-making. Twelve examinations (15%) failed to provide any additional information relevant to the patient’s treatment. MDCT examination was helpful in general ICU patients, with inconclusive findings with other imaging modalities. CT images of 127 mixed medical-surgical ICU patients were retrospectively reviewed for the previously determined findings. Forty-three of these patients underwent open cholecystectomy, revealing eight cases with a normal gallbladder (GB), 26 with an edematous GB, and nine with necrotic acute acalculous cholecystitis (AAC). Abnormal CT findings were present in 96% of all the ICU patients. Higher bile density in the GB body and subserosal edema were associated with an edematous GB. The most specific findings predicting necrotic AAC were gas in the GB wall or lumen, lack of GB wall enhancement, and edema around the GB. The frequent prevalence of nonspecific abnormal imaging findings in the GB of ICU patients limits the diagnostic value of CT scanning

Elective Abdominal Ultrasonography by Surgeons at MNH, Dar-Es-Salaam, Tanzania.

Background: Ultrasound scanning (USS) is an important diagnostic tool in most specialties of surgery. The abdomen is the most commonly scanned region and learning and practicing abdominal USS is the most rewarding. This study was aimed at sharing our experience of elective abdominal ultrasound scanning (USS) done by surgeons at the Department of Surgery, Muhimbili National Hospital (MNH).Methods: This is a retrospective audit of indications and sonographic findings in 1782 elective scannings done over a 42-month period. All scanning was done by surgeons using Aloka SSD 500scanner with a 3.5 MHz probe. Average patient scanning time was 5-10 minutes.Results: The most frequent indications for abdominal ultrasound scanning were abdominal pain (27%), urinary tract symptoms (25%) and abdominal swelling / mass (13%). Overall 47 % of all scanned patients and 58% of those with abdominal pain had normal findings. Of all the patients with abnormal USS findings 42% had abdominal mass. Stone disease was infrequent, seen in 49 (2.7% of all scanned) patients.Conclusion: Pain is the most frequent reason for requesting abdominal ultrasound scanning but it has a low yield of sonographic findings. Scanning for abdominal swelling/mass gave the highest proportion of abnormal findings. USS of a surgical patient done by surgeons expedites diagnostic workup, shortens hospitalization, facilitates biopsy and may help to avoid diagnostic laparotomy

Structured reporting of computed tomography in the polytrauma patient assessment. A Delphi consensus proposal

Objectives: To develop a structured reporting (SR) template for whole-body CT examinations of polytrauma patients, based on the consensus of a panel of emergency radiology experts from the Italian Society of Medical and Interventional Radiology. Methods: A multi-round Delphi method was used to quantify inter-panelist agreement for all SR sections. Internal consistency for each section and quality analysis in terms of average inter-item correlation were evaluated by means of the Cronbach’s alpha (Cα) correlation coefficient. Results: The final SR form included 118 items (6 in the “Patient Clinical Data” section, 4 in the “Clinical Evaluation” section, 9 in the “Imaging Protocol” section, and 99 in the “Report” section). The experts’ overall mean score and sum of scores were 4.77 (range 1–5) and 257.56 (range 206–270) in the first Delphi round, and 4.96 (range 4–5) and 208.44 (range 200–210) in the second round, respectively. In the second Delphi round, the experts’ overall mean score was higher than in the first round, and standard deviation was lower (3.11 in the second round vs 19.71 in the first round), reflecting a higher expert agreement in the second round. Moreover, Cα was higher in the second round than in the first round (0.97 vs 0.87). Conclusions: Our SR template for whole-body CT examinations of polytrauma patients is based on a strong agreement among panel experts in emergency radiology and could improve communication between radiologists and the trauma team

Diagnostic imaging strategies before and after transcatheter arterial embolization in patients with major abdominal and pelvic trauma

Selected trauma patients with severe abdomino-pelvic injuries can be treated with transcatheter arterial embolization (TAE). The present investigation has studied the usefulness of diagnostic imaging in the forefield and aftermaths of embolization. Aims: To evaluate specific radiological signs on trauma admission imaging prior to TAE that may help the interventional radiologist (IR) to rapidly assess the injured pelvic arteries. To investigate the hemodynamic changes over time after TAE of the splenic artery with means of Doppler. To evaluate the diagnostic accuracy of contrast-enhanced ultrasound after TAE of the spleen for posttraumatic lesion characterization and detection. Patients and methods: In 95 patients with pelvic trauma and suspected pelvic artery injury, fracture size and location on pelvic X-ray (PXR) and arterial blush and hematoma on computed tomography (CT) were compared with findings of arterial injury on angiography. Fisher’s exact test was used for comparison of categorical data and receiver operating characteristic curve statistic was used for comparison of continuous data with the reference method angiography. Of 22 patients with TAE of the splenic artery, intraparenchymal Doppler was performed at three different time intervals in 17 patients. Velocity parameters were sampled from three different sites and parameters for systolic inflow and intraparenchymal resistance were calculated. Seventeen healthy volunteers were used as control group. All 22 patients were also examined with contrast-enhanced ultrasound (CEUS) for detection of different posttraumatic lesions and injury severity at early (one week after TAE) and late (2-4 months after TAE) - follow up. Contrast-enhanced CT was used as standard of reference. Results: The overall presence or absence of fracture on PXR and of hematomas on CT was moderately accurate for arterial injuries in the same segment. Including only fractures with major displacements and larger hematomas increased the specificity to a clinically acceptable level at the cost of reduced sensitivity. Presence of arterial blush on CT was highly specific for arterial injury. Normalization of the Doppler parameters indicated recovery of intrasplenic blood flow by formation of collaterals. CEUS was accurate for detection of significant posttraumatic lesions and grading of the injury severity. Conclusions: In the hemodynamic unstable patient with pelvic injury, PXR is a useful tool for rapid assessment and occlusion of the injured arteries. Contrast enhanced CT of the hemodynamically stable patient can provide the IR with useful information about the site of arterial injury. Normalization of intrasplenic Doppler parameters over time indicates that the use of TAE of the splenic artery is a safe adjunct of the nonoperative management of splenic injury. TAE does not prevent formation of sufficient arterial collaterals. Finally, CEUS may compete with CT in follow-up imaging of posttraumatic lesions of the spleen

Diseases of the Abdomen and Pelvis 2023-2026

This open access book deals with imaging of the abdomen and pelvis, an area that has seen considerable advances over the past several years, driven by clinical as well as technological developments. The respective chapters, written by internationally respected experts in their fields, focus on imaging diagnosis and interventional therapies in abdominal and pelvic disease; they cover all relevant imaging modalities, including magnetic resonance imaging, computed tomography, ultrasound, and positron emission tomography. As such, the book offers a comprehensive review of the state of the art in imaging of the abdomen and pelvis. IDKD books are extensively re-written every four years. As a result, they offer a comprehensive review of the state of the art in imaging. The book is clearly structured with learning objectives, abstracts, subheadings, tables and take-home points, supported by design elements to help readers easily navigate through the text. As an IDKD book, it is particularly valuable for general radiologists, radiology residents, and interventional radiologists who want to update their diagnostic knowledge, and for clinicians interested in imaging as it relates to their speciality

Fundamentals of Frontline Surgery

Fundamentals of Frontline Surgery is an easy to read text, written by world class faculty, that provides clinicians with succinct and didactic information about what to do in high intensity, resource limited situations.With global conflicts and humanitarian emergencies on the rise, there has been a dramatic uptake in the number of volunteers for both military and humanitarian operations. This manual aids best practice and fast decision making in the field

Acute lung injury in paediatric intensive care: course and outcome

Introduction: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) carry a high morbidity and mortality (10-90%). ALI is characterised by non-cardiogenic pulmonary oedema and refractory hypoxaemia of multifactorial aetiology [1]. There is limited data about outcome particularly in children. Methods This retrospective cohort study of 85 randomly selected patients with respiratory failure recruited from a prospectively collected database represents 7.1% of 1187 admissions. They include those treated with High Frequency Oscillation Ventilation (HFOV). The patients were admitted between 1 November 1998 and 31 October 2000. Results: Of the 85, 49 developed acute lung injury and 47 had ARDS. There were 26 males and 23 females with a median age and weight of 7.7 months (range 1 day-12.8 years) and 8 kg (range 0.8-40 kg). There were 7 deaths giving a crude mortality of 14.3%, all of which fulfilled the Consensus I [1] criteria for ARDS. Pulmonary occlusion pressures were not routinely measured. The A-a gradient and PaO2/FiO2 ratio (median + [95% CI]) were 37.46 [31.82-43.1] kPa and 19.12 [15.26-22.98] kPa respectively. The non-survivors had a significantly lower PaO2/FiO2 ratio (13 [6.07-19.93] kPa) compared to survivors (23.85 [19.57-28.13] kPa) (P = 0.03) and had a higher A-a gradient (51.05 [35.68-66.42] kPa) compared to survivors (36.07 [30.2-41.94]) kPa though not significant (P = 0.06). Twenty-nine patients (59.2%) were oscillated (Sensormedics 3100A) including all 7 non-survivors. There was no difference in ventilation requirements for CMV prior to oscillation. Seventeen of the 49 (34.7%) were treated with Nitric Oxide including 5 out of 7 non-survivors (71.4%). The median (95% CI) number of failed organs was 3 (1.96-4.04) for non-survivors compared to 1 (0.62-1.62) for survivors (P = 0.03). There were 27 patients with isolated respiratory failure all of whom survived. Six (85.7%) of the non-survivors also required cardiovascular support.Conclusion: A crude mortality of 14.3% compares favourably to published data. The A-a gradient and PaO2/FiO2 ratio may be of help in morbidity scoring in paediatric ARDS. Use of Nitric Oxide and HFOV is associated with increased mortality, which probably relates to the severity of disease. Multiple organ failure particularly respiratory and cardiac disease is associated with increased mortality. ARDS with isolated respiratory failure carries a good prognosis in children