2. In the name of GOD

3. Abdominal Trauma & hollow viscous injury
EVALUATION AND INDICATIONS FOR CELIOTOMY

5. Abdominal injuries
Solid organ injuries
Hollow viscous injuries

6. Clinical findings
Abdominal pain
Guarding

7. Hollow viscous injuries
Delay diagnosis (8-12 h)
Hemorrhage
Peritonitis
Abdominal sepsis

8. Basic mechanisms of bowel and mesenteric injuries
Shearing injuries caused by deceleration
Crush injuries from direct impact
Burst injuries from sudden increases in intraluminal pressure

9. Site of injuries
Small bowel
Colon
Duodenum
Stomach

10. Imaging modalities
Plain radiography
Sonography
CT scan

11. Plain radiography
Chest X ray
Abdominal radiography (supine & upright)

12. Pneumoperitoan

13. Pneumoperitoan

14. Pneumoperitoan

15. Peritoneal fluid

16. Ultrasound examination
Free fluid
Pneumoperitoneum
Air in bowel wall
Wall thickening of bowel loops

17. Pneumoperitoan
Sagital sonographic section of the right hypochondrium using a curvilinear probe showing enhanced peritoneal stripe (empty arrow) and reverberation artefacts (small arrows) which partially obscure the right lobe of the liver (L) and right kidney (K). Laparotomy confirmed that the patient had perforated diverticulitis

18. Pneumoperitoan
 Transverse sonographic section of the right hypochondrium using a linear probe showing a hyperdence echogenic small area (arrow head) moving within a fluid collection. Laparotomy confirmed that the patient had a perforated duodenal ulcer

19. Air in Morrison’s pouch
 Sagital sonographic section of the right hypochondrium using a curvilinear probe showing a hyperdence interrupted echogenic lines under the liver in Morrison's pouch (arrow head), fluid collection (white arrow), and a hyperdense echogenic line in the anterior wall of the duodenum representing the scar of a duodenal ulcer (black arrow). Laparotomy confirmed that the patient had a perforated duodenal ulcer

20. Bowel loop hematoma

21. Bowel wall thickening, air bubble in its wall

22. CT Technique IV contrast (100-120 ml)
Portal venous phase (70 second delay)
Delay film (7 minute)
Oral contrast +/_
Rectal contrast +/_

23. CT signs of bowel loops injury
Wall transection with focal discontinuity (spe:100%& sen:7%)
Extraluminal oral contrast
Pneumoperitoneum (20-75%)
Pneumoretroperitoneum
Focal wall thickening
Abnormal wall enhancement
Ill defined increased attenuation of mesentry
Intra peritoneal fluid

24. Hemoperitoan

25. focal segment of thickened jejunum associated stranding of the small bowel mesentery

26. segment of thickened jejunum and hemoperitoneum

27. wall thickening in a segment of jejunum

28. segment of thickened and poorly enhancing small bowel

29. Mesenteric fat stranding

30. Other causes of pneumoperitoneum
Bladder rupture with an indwelling Foley catheter
Massive pneumothorax
Barotrauma
Benign pneumoperitoneum
Peritoneal lavage
Pseudopneumoperitoneum (air between abdominal wall and parietal peritoneum)

31. Pneumoperitoneum and pseudopneumoperitoneum

32. Diffuse bowel wall thickening
Fluid over load
Liver inhomogeneous enhancement(nutmeg appearance)
Periportal edema
Hypoperfusion complex(shock bowel)
Flat IVC
Increased enhancement of adrenal gland
Retroperitoneal edema

35. Diffuse thickening and hyperenhancement of the loops due to aggressive resuscitation with intravenous fluids

39. Duodenal injuries
More secondary to penetrating injuries and less likely due to blunt trauma
CT findings: wall thickening, discontinuity, contrast extravasation, fluid adjacent to the duodenum and pancreatic head and retroperitoneum air or fluid

40. Duodenal wall thickening and extensive hemoperitoneum

41. Colonic injuries Wall transection with focal discontinuity
Contrast extravasation
Pneumoperitoneum
Pneumoretroperitoneum
Focal wall thickening
Abnormal wall enhancement
Ill defined increased attenuation of mesentry
Intra peritoneal fluid

42. Transverse colonic wall thickening

43. focal segment of ascending colonic wall thickening,worsened pericolonic fat stranding in delayfilm

44. Sign mesenteric trauma
Mesenteric hematoma
Intraperitoneal extravasation of intravenous contrast
Abrupt termination of mesenteric vessels
Unequivocal irregularity of the wall of mesenteric vessels
Increased attenuation of the mesentery

45. small focal hematoma in the root of the mesentery

46.  Mesenteric hematoma

47.  Mesenteric hematoma

48. Mesenteric bleeding

49. Focal collection of high attenuation fluid is seen in the root of the mesentery

50. abnormally positioned in the right hemiabdomen , with subtle stranding of the corresponding mesentery due to traumatic internal hernia

51. Anorectal injury Mortality rate three times more than colonic injury
Associated with pelvic fracture
concomitant with bladder, urethral and vascular injuries
Divided into intraperitoneal and extraperitoneal

52. Extraluminal air is seen in the presacral space

53. rectal wall tear with retroperitoneum and pseudopneumoperitoneum

54. Injury of mesentery and mesenteric vessels
Extravasation of IV contrast
Mesentric hematoma
Mesentric infiltration
Beading or abrupt termination of mesentric vessels
Mesentric rent with internal hernia

55. Mesenteric hematoma

56. Mesenteric tear

57. Causes of retroperitoneal air
Colonic perforation (ascending and descending)
Duodenal injuries
Pneumothorax
Pneumomediastinum

58. Pneumoperitoneum and pseudopneumoperitoneum

59. Free peritoneal fluid Most common finding (most sensitive)
Absence of free fluid excludes surgical important injury
The attenuation is highest in the vicinity of the injured organ (sentinel clot)
Localized fluid (triangle sign)
Attenuation of hemoperitoan is high (>30-40) , simple fluid H.U is about 13

60. Lesser sac hematoma

61. Sentinel clot sign

62. Sentinel clot sign

63. hemoperitoneum (mean attenuation, 39 HU) due to small hepatic laceration

64. A small amount free pelvic fluid with mean attenuation of the 8 HU

65. Thank you