Pencitraan trauma abdomen pada anak

Oleh :Argadia Y.

IMAGING CHILDREN WITH ABDOMINAL TRAUMA

Journal Reading Tugas Stase Radiologi

Pembimbing :Prof. Dr. dr. Suyono, Sp.Rad(K)

Carlos J. Sivit

Latar Belakang Salah satu penyebab mortalitas dan

morbiditas pada anak

TRAUMA ABDOMENPADA ANAK

Penyebab :

Perbedaan anatomi dan fungsiAnak vs Dewasa

TIDAK SEMUA TRAUMA ABDOMEN PADA ANAK MEMERLUKAN TINDAKAN OPERASI

PENCITRAAN Trauma Abdomen• Diagnosis• Evaluasi

ANATOMI ABDOMEN

PRINSIP TRAUMA ABDOMEN PADA ANAK

KLINIS lebih penting

Anamnesis dan Pemeriksaan Fisik Pemeriksaan Penunjang (laboratorium, radiologi)

Anamnesis

• Keluhan Utama• Nyeri Perut• Hematuria

• Riwayat Penyakit Sekarang• Riwayat Penyakit Dahulu

PRINSIP

Pemeriksaan Fisik TANDA VITAL• Tekanan Darah• Laju Nadi• Laju Nafas• Suhu tubuh• Saturasi SiO2

Utamakan untuk mengatasi

kegawatan terlebih dahulu

PRINSIP

Higher risk of abdominal injury• gross hematuria,• abdominal tenderness,• ecchymoses, • a low trauma scoreLow risk of abdominal injury• Asymptomatic

hematuria • Neurologic impairment

in the absence of abdominal signs and symptoms

Pemeriksaan Fisik

(Taylor GA, dkk., 1994; Cotton BA, 2003)

PRINSIP TRAUMA ABDOMEN PADA ANAK

Suara usus berkurang Vomitus

Hematemeis/Melena

Hematuria•Indikator cedera renal

Pemeriksaan Fisik

PRINSIP

Hematuria,

Abdominal bruising /

ecchymosis,

Abdominal distention,

Abdominal pain,

INDIKASI PEMERIKSAAN RADIOLOGIDitemukan pemeriksaan fisik dan laboratorium yang menunjukkan kecurigaan ke arah injuri abomen, seperti :

Computed Tomography (CT)

Lebih akurat dalam mendeteksi dan kuantifikasi cedera organ abdomen baik pada organ solid maupun berongga

Dapat mengidentifikasi cairan-darah intraperitoneal atau extraperitoneal serta perdarahan aktif

Dapat memperlihatkan lesi trauma pada tulang rusuk, vetebrata, dan pelvis

Pemeriksaan pilihan untuk trauma abdomen

Computed Tomography (CT)

Injeksi Kontras I.V dapat digunakan untuk memperjelas pencitraan

Kontras peroral masih kontroversi

Pemeriksaan

KONTRA INDIKASI PENGGUNAAN CT PADA TRAUMA ABDOMEN :

Hemodinamika pasien tidak stabil

SONOGRAFI

MANFAAT Deteksi ada tidaknya hemoperitoneum Pilihan utama pada pasien trauma dengan hemodinamika tidak

stabil (mobile) focused abdominal sonography for trauma (FAST)

Sonografi punya keterbatasan

KEKURANGAN Sonografi tidak dapat meilhat cedera pelvis dan spinal Tidak dapat menilai organ berongga 25-30% kesalahan menilai cedera organ solid

CEDERA HEPARPencitraan Trauma Abdomen Pada Anak

CEDERA HEPARAnatomi liver

CEDERA HEPARANATOMI LIVER Segmen Hepar Fungsional :

• Lobus Kiri– Segment I - IV

• Lobus Kanan– Segmen V – VIII

• Masing-masing segmen disuplai oleh arteri dan vena yang berbeda

CEDERA HEPAR

Most commonly injured or second most commonly injured solid viscera after blunt trauma

Most hepatic injury occurs in the posterior segment of the right lobe

Liver Injury

lacerationhematoma

Cedera vascular

CEDERA HEPARAAST liver injury grading system

Grade Type of Injury Description of injury

IHaematoma • Sub capsular, < 10% surface area

Laceration • Capsular tear, < 1cm depth

IIHaematoma • Sub capsular, 10 - 50% surface area

• Intraparenchymal < 10cm diameter Laceration Capsular tear, 1 - 3cm depth, < 10cm length

IIIHaematoma • Sub capsular, > 50% surface area, or ruptured with active bleeding

• intraparenchymal > 10 cm diameterLaceration Capsular tear, > 3 cm depth

IVHaematoma Ruptured intraparenchymal with active bleeding

Laceration • Parenchymal distruption involving 25 - 75% hepatic lobes or • involves 1-3 Couinaud segments (within one lobe)

VLaceration • Parenchymal distruption involving >75% helpatic lobe or

• Involves > 3 Couinaud segments (within one lobe)Vascular Juxtahepatic venous injuries (IVC, major hepatic vein)

VI Vascular Hepatic avulsion

CEDERA HEPAR

Liver Laceration

Grade 1

•Less than ½ inch (1 cm).

Grade 2

•½ -1 inch deep (1 to 3 cm). It is less than 4 inches long (10 cm).

Grade 3

•more than 1 inch deep (3 cm).

Grades 4 and

•These lacerations are very deep. They affect a large part of the liver

CEDERA HEPARLiver Laceration

• 8-year-old boy with hepatic laceration. Coronal reformation of contrast-enhanced CT scan through upper abdomen shows complex hepatic laceration.

• Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick

http://uvmrads.org/clinical-resources/bodyct/86-liver-lacerations-aast-criteria-and-examples.html?showall=1&limitstart=

• Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter

• Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization

CEDERA HEPARLiver Subcapsular Hematoma • 12-year-old boy with

subcapsular hematoma of liver– A, Contrast-enhanced

CT scan through upper abdomen shows laceration extending to periphery of liver with associated subcapsular hematoma.

– B, CT scan obtained 2 cm below A shows inferior extension of subcapsular hematoma. Note compression of underlying hepatic parenchyma

CEDERA HEPARLiver Vascular Injury

5-year-old boy with vascular injury in posterior segment of right hepatic lobe.

Contrast enhanced CT scan through upper abdomen shows absence of contrast enhancement in posterior segment of right hepatic lobe.

CEDERA LIMFA / SPLEENPencitraan Trauma Abdomen Pada Anak

CEDERA LIMFA

Organ Solid Berukuran lebih kecil daripada

Pecah & terfragmen Nyeri perut kiri atas, fraktur iga kiri bawah, kontusio pada

abdomen regio kiri atas LESI : Contusion, parenchymal laceration, subcapsular

hematoma, perisplenic hematoma, fragmentation of parenchyma and disruption of hilar vessels Tidak selalu terjadi hemoperitonium

TRAUMA

CEDERA LIMFAAAST SPLENIC INJURY SCALE

Grade Keterangan

I Subcapsular hematoma of less than 10% of surface area or capsular tear of less than 1 cm in depth

IISubcapsular hematoma of 10%–50% of surface area, intraparenchymal hematoma of less than 5 cm in diameter, or laceration of 1–3 cm in depth and not involving trabecular vessels

IIISubcapsular hematoma of more than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma, intraparenchymal hematoma of more than 5 cm or expanding, or laceration of more than 3 cm in depth or involving trabecular vessels

IV Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen

V Shattred spleen or hilar vascular injury

Cedera LimfaKontusio

• Contusion = hypodense area within normally perfused splenic parenchyma

www.RiTradiology.com

CEDERA LIMFA

• 14-year-old boy with shattered spleen.

• A and B, Contrast-enhanced CT scans through upper abdomen (A) and 2 cm lower (B) show shat tered spleen

Cedera LimfaLaceration

• Laceration = linear perfusion defect

CEDERA LIMFALaceration

• 12-year-old boy with splenic laceration and associated intraparenchymal hematoma.

• Contrast enhanced CT scan through upper abdomen shows splenic laceration and associated intraparenchymal hematoma

CEDERA LIMFASubcapsular hematom

• Subcapsular hematoma = lenticular shape with compression of adjacent splenic paenchyma – Difficult to confidently

see splenic capsule– Sometimes difficult to

distinguish between subcapsular and perisplenic hematoma

CEDERA LIMFA• 15-year-old boy with

splenic injury and retroperitoneal extension of hemorrhage.

• Contrast enhanced CT scan through upper abdomen shows splenic laceration associated with blood in anterior pararenal space surrounding pancreas.

CEDERA RENALPencitraan Trauma Abdomen Pada Anak

CEDERA RENAL

Cedera organ solid abdomen tersering ketiga setelah trauma tumpul

Terutama trauma pada punggung Pemeriksaan CT jika :

Nyeri pinggang + Riw Trauma + Hematuria Hematuria Makroskopis + Pasien stabil + Tidak ada cedera

urethral JENIS LESI :

Contusion, laceration, subcapsular hematoma, shattered kidney, renal artery occlusion

CEDERA RENALRENAL CONTUSION

• Renal contusion: focal zones of decreased enhancement, striated nephrogram because of temporarily impaired tubular excretion

CEDERA RENALRENAL CONTUSION

• 10-year-old girl with renal contusion.

• Contrast-enhanced CT scan through mid abdomen shows rounded focus of low at tenuation in midpole of left kidney indicative of contusion

CEDERA RENALRENAL LACERATION

• Laceration: linear or wedge-shaped hypodense area – Fracture = involving

medial and lateral surface of kidney through hilum

– Shattered kidney = laceration crossing kidney resulting in multiple fragments

CEDERA RENALRENAL LACERATION • 14-year-old boy with

renal collecting system injury.

• A, Contrast-enhanced CT scan through mid abdomen shows left renal laceration with surrounding perinephric hematoma.

• B, Delayed image obtained 5 minutes af ter A shows extravasation of IV contrast material into perirenal space

CEDERA RENALLaceration + Extravasation

• Deep laceration results in urine extravasation

• Delayed scan for comfirmation

CEDERA RENALRENAL HEMATOMA • KIRI : 12-year-old boy with

subcapsular renal hematoma.

• Contrast-enhanced CT scan through mid abdomen shows large lef t-sided subcapsular hematoma compressing renal parenchyma

• Kanan : 10-year-old girl with perinephric hematoma.

• Sagittal reformation of contrast-enhanced CT scan through mid abdomen shows renal laceration associated with perinephric hematoma distributed through perirenal space

Renal hematom

Subcapsular Perinephric

CEDERA RENALOcclusion

• Occlusion of main renal artery

• Cortical enhancement du to patent capsular arteries originating proximal to occlusion should always raise suspicion of injury to main renal artery

CEDERAL RENALVASCULAR INJURY

15-year-old boy with vascular injury of left kidney. • Contrast-enhanced CT

scan through mid abdomen shows devascularization of left kidney after left renal artery avulsion

CEDERA PANKREASPencitraan Trauma Abdomen Pada Anak

CEDERA PANKREAS

Frekuensi lebih jarang (< 2%) Menyertai pada cedera organ multiple MEKANISME

Cedera pada badan pankreas : Kompresi dengan tulang vetebrate

Kepala / Ekor : Pecah: KLINIS :

Sering tidak bergejala karena berukuran kecil dan dikelilingi oleh lemak

CEDERA PANKREAS

Komplikasi : Pankreatitis berulang, fistula, abses, perdarahan

Resiko terjadinya abses & fistula• Disrupsi duktus (25-50%)• Tanpa Disrupsi duktus (10%)

LESI : Contusio, Laserasi superfisial atau parsial, transeksi komplit atau disrupsi

CEDERA PANKREAS

Memprediksi ada tidaknya disrupsi duktus dengan mengetahui kedalaman dan lokasi laserasi ;

GRADE A•Pancreatitis atau laserasi superfisial•<50% ketebalan pankreas

GRADE B•Laserasi dalam (>50% ketebalan) pada ekor

GRADE C•Laserasi dalam pada kepala

CEDERA PANKREASTRANSEKSI

11-year-old boy with pancreatic transection.• Contrast-enhanced CT

scan through upper abdomen shows pancreatic transection at junction of head and body.

CEDERA PANKREASPeripancreatic Fluid 10-year-old girl with

pancreatic injury and associated peripancreatic fluid. • Contrast-enhanced CT

scan through upper abdomen shows fluid is in anterior pararenal space surrounding pancreas.

• Also note fluid dissecting between splenic vein and pancreas

CEDERA PANKREAS

Pancreatitisfocal or diffuse gland enlargement, stranding of peripancreatic or mesenteric fat, thickening of the anterior renal fascia, and free peritoneal fluid

peripancreatic fluid collections Pseudocyst

KOMPLIKASI

CEDERA PANKREASPancreatic enlargement Direct CT signs:

• Pancreatic enlargement, focal linear nonenhancement, comminution, heterogeneous enhancement (subtle initially)

Indirect CT signs: • Peripancreatic fat

stranding, fluid collections, fluid separating splenic vein from parenchyma, hemorrhage, and thickening of left anterior pararenal fascia

CEDERA PANKREASPancreatitis

12-year-old boy with acute pancreatitis after pancreatic trauma. • Contrast-enhanced CT

scan through upper abdomen shows stranding of peripancreatic fat and ill-definition of pancreaticborders

CEDERA PANKREASPancreatic Pseudocyst 11-year-old boy with

pancreatic pseudocyst.• A, Contrast-enhanced

CT scan through upper abdomen shows laceration through head of pancreas.

• B, Follow-up CT scan obtained 5 weeks af ter A shows focal fluid collection representing pancreatic pseudocyst is in head of pancreas and is extending into anterior pararenal space.

PERDARAHAN AKTIFPencitraan Trauma Abdomen Pada Anak

PERDARAHAN AKTIF

Sign a contrast “blush,” which is defined as highattenuation Areas (> 90 HU) after IV contras

Hemoperitonium Tidak menggambarkan perdarahan aktif

Perdarahan AktifHemodinamika

Tidak stabil

Hemodinamika stabil Pemeriksaan CT

KONTRAINDIKASI CT

PERDARAHAN AKTIFLinear high-attenuation

8-year-old boy with active hemorrhage.• Contrast-enhanced CT

scan through mid abdomen shows linear high-attenuation collection representing IV contrast extravasation from splenic arterial tear

PERDARAHAN AKTIFhigh-attenuation fluid

11-year-old boy with active hemorrhage.• Contrast-enhanced CT

scan through pelvis shows high-attenuation fluid representing active hemorrhage.

• At surgery tear of right iliac vein was noted

PERDARAHAN AKTIFPseudoaneurysm

12-year-old boy with hepatic pseudoaneurysm. • Contrast-enhanced CT

scan through upper abdomen shows focal, rounded, enhancing lesion in posterior segment of right hepatic lobe. Also note large hepatic subcapsular hematoma

PERDARAHAN AKTIF12-year-old girl with active hepatic hemorrhage that did not require laparotomy.• A, Contrast-enhanced CT

scan through upper abdomen shows hepatic laceration with focal area of increased attenuation representing active hemorrhage. Patient was managed nonoperatively.

• B, Follow-up CT scan obtained 2 weeks af ter A shows resolving low-attenuation hematoma within liver

CEDERA USUSPencitraan Trauma Abdomen Pada Anak

CEDERA USUS

Jarang terjadi (3-7% trauma tumpul abdominal) Tanda dan gejala : kadang tidak bergejala, minimal, atau

delayed Lesi :

Intramural hematom : • tersering duodenum• Gambaran penebalan dinding tanpa adanya

extravasasi kontras Ruptur usus : • Tersering jejenum

CEDERA USUS

• Duodenal perforation vs hematoma– Perforation

Immediate surgery– Hematoma

Conservative

• Jika memungkinkan dapat diberika kontras peroral sebelum dilakukan CT

CEDERA USUSDuodenal Hematom (intramural hematom)

8-year-old boy with duodenal hematoma.• Contrast-enhanced CT

scan through upper abdomen shows rounded duodenal hematoma to left of midline

CEDERA USUS

Tanda Radiologi Udara Extraluminal 1/3 kasus Ekstravasasi kontras jarang terlihat “unexplained” peritoneal fluid (tanpa cedera organ solid dan

fraktur pelvis) 50% kasus Lain-lain :

• Abnormally intense bowel wall enhancement, • focal bowel wall discontinuity, • bowel dilatation, • Bowel wall thickening, • streaky infiltration of mesenteric fat • Associated mesenteric injury or • chemical irritation of the mesentery from spilled intestinal contents

Ruptur Usus

CEDERA USUSbowel rupture

10-year-old girl with bowel rupture associated with extraluminal air. • Contrast-enhanced CT

scan through upper abdomen shows extraluminal air.

CEDERA USUSbowel rupture

9-year-old boy with bowel rupture associated with oral contrast extravasation. • CT scan through upper

abdomen shows extravasated high-at tenuation oral contrast material in peritoneal cavity.

CEDERA USUS“unexplained” peritoneal fluid 12-year-old boy with bowel

rupture associated with large amount of “unexplained” peritoneal fluid.• A, Contrast-enhanced CT

scan through upper abdomen shows large amount of peritoneal fluid in perihepatic and perisplenic spaces.

• B, CT scan through mid abdomen shows large amount of fluid in right and left paracolic spaces. Patient did not have any other abnormalities at CT. At surgery, jejunal rupture was noted.

CEDERA USUSbowel wall discontinuity

9-year-old boy with bowel rupture associated with bowel wall discontinuity. • Contrastenhanced• CT scan through upper

abdomen shows discontinuity in wall of Duodenum indicative of bowel wall rupture

CEDERA USUS• Direct CT signs: 1)

Discontinuity of wall, spillage of contrast or luminal contents into peritoneal or retroperitoneal. 2) Extraluminal air (definite for blunt trauma but not for penetrating trauma)

• Indirect CT signs: 1) Focal bowel wall thickening, streaky mesenteric fat, unexplained free fluid between mesenteric loops. 2) Generalized bowel wall thickening nonspecificwww.RiTradiology.com

CEDERA KANDUNG KEMIHPencitraan Trauma Abdomen Pada Anak

CEDERA KANDUNG KEMIH Jarang terjadi Ekstravasasi ruptur

Intraperitonial• Trauma kandung kemih yang penuh• Perlu tindakan operasi segera

Ekstraperitonial• Lebih sering• Laserasi karena fraktur tulang pelvis

(obturator ring fractures, pubic symphysis diastasis, sacral fractures, and sacroiliac joint diastasis)

• Tidak memerlukan tindakan operasi segera

CT cystography retrogard

CEDERA KANDUNG KEMIH

Penentuan lokasi ekstravasi PENTING

INTRAPERITONIAL EKSTRAPERITONIAL

Lateral peravesical spaces superior to the bladder and anterior to the rectosigmoid Colon

• the peravesical space that surrounds the bladder superiorly and anteriorly to the umbilicus and posteriorly behind the rectum

• pelvic fluid is noted lateral to the bladder or behind the rectum,

Fluid superior and anterior to the bladder

more lateral location and will typically be contiguous with fluid in the lateral pericolic spaces

Fluid extend superiorly and anteriorly to the level of the umbilicus

Intraperitoneal rupture • More frequently

caused by direct perforation of bone fragment (> rupture of distended bladder)

• Plugged by omentum or bowel loops making it difficult to detect

• Surgical Rx

15-year-old girl with intraperitoneal bladder rupture.• Contrast-enhanced CT

scan through upper pelvis shows high-attenuation fluid in lateral pelvic recess secondary to intraperitoneal bladder ruptur

Extraperitoneal rupture • Direct perforation by

bony fragment, rupture of pubovesical ligament near bladder neck after symphysis injury or contusion of distended UB Often involves anterior bladder wall near neck

• Conservative Rx

CEDERA KANDUNG KEMIH12-year-old girl with extraperitoneal bladder rupture. • Contrast-enhanced CT

scan through pelvis shows high-attenuation fluid adjacent to right pelvic side wall and low-attenuation fluid posterior to rectum.

• These fluid collections are extraperitoneal in location, consistent with extraperitoneal bladder rupture

KOMPLEK HIPOPERFUSIPencitraan Trauma Abdomen Pada Anak

KOMPLEK HIPOPERFUSI

Tanda syok hipovolemik

Pasien Stabil Syok Hipovolemik

CT : komplek hipoperfusi

KOMPLEK HIPOPERFUSI

Komplek Hipoperfusi

Tanda awal syok hipovolemik Komponen :

KOMPLEK HIPOPERFUSIKomponen Vaskular

Flatening IVC• Reduced venous

return secondary to systemic hypotension

• Radigraph Definition :– AP diameter < 9 mm– Measured at 3 level

(Intrahepatic IVC, Renal artery, 2 cm below renal arteryNORMAL IVC NARROWED IVC

• Flat IVC, small aorta, hyperenhanced kidneys, hyperenhanced GI mucosa, and peripancreatic edema caused by hypoperfusion state from left pelvic ring injury

HALO SIGN• Circumferential zone

of low attenuation (<20HU) around a collapsed intrahepatic IVC

• Extracellular fluid• Common Location :

Superior segment of the liver

SMALL CALIBRE AORTA• Sering ditemukan• Define as calibre

<13mm at a level 2 cm below and above the origin of renal aorta

• Not spesificNORMAL IVC Small Calibre Aorta

Komplek HipoperfusiKomponen Viseral

Splenic Hypoperfusion• Arterial flow to the

spleen lacks autoregulatory mechnisms

• Highly sensitive to sympathetic stimulation vasocontriction in the situation of hypoperfusion

Normal Perfusion Spleen Hypoperfusion Spleen

KOMPLEK HIPOPERFUSIKomponen Visceral 2-year-old girl with

hypoperfusion complex.• A and B, Contrast-

enhanced CT scans through upper (A) and mid (B) abdomen show diffuse intestinal dilatation with fluid, intense contrast enhancement of bowel wall, and diminished caliber of great vessels indicative of systemic hypoperfusion.

KOMPLEK HIPOPERFUSI3-year-old boy with hypoperfusion complexand absence of pancreatic enhancement.• Contras tenhanced CT

scan through upper abdomen shows absence of pancreatic enhancement Pancreas appeared normal at surgery.

• Findings were thought to be secondary to systemic hypoperfusion.

Increased adrenal gland enhancement

• Attenuation value equal or greater than thos of IVC

• Usually symmetrical• May be due to a

protentive sympathetic respone to preserve the vital organ

Normal adrenal enhancement

Intense renal parenchymal enhancement

• ↓ systolic presure vasocontriction of glomerular arteriolar increased resorption of salt and water

• A prolonge, abnormally intense nephogram

Normal Kidney

SHOCK BOWEL• Increased mucosal

enhancement (HU > Poas muscle)

• Mural Thickening > 3mm

• MIRIP : Bowel perforation (+free fluid)Normal bowel

Increased bowel wall thickness

Increased Enhancement

KOMPLEK HIPOPERFUSI2-year-old boy with hypoperfusion complex associated with free peritoneal fluid. • Contrastenhanced CT

scan through mid abdomenshows diffuse intestinal dilatation with fluid, intense contrast enhancement of bowel wall, and diminished caliber of great vessels indicative of systemic hypoperfusion.

• Also note free peritoneal fluid in both paracolic spaces.

CLINICAL DECISIONPencitraan Trauma Abdomen Pada Anak

Pasien Datang

Pasien trauma Pasien lain tersangka trauma

Anamnesis & Px Fisik HEMATURIA

Hemodinamika Tidak Stabil

Hemodinamika Stabil

“FAST” Sonography CT

Hemodinamika

Pencitraan trauma abdomen pada anak

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