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BLUNT ABDOMINAL TRAUMA CT IMAGING Dr.Mahmoud Elrai Radiology departement KFH Blunt Abdominal Trauma : Blunt Abdominal Trauma Mechanisms Direct impact Acceleration-deceleration forces Shearing forces NB; No correlation between size of contact area and resultant injuries. Abdomen = potential site of major blood loss. Diagnostic Modalities in Blunt Abdominal Trauma : Diagnostic Modalities in Blunt Abdominal Trauma Diagnostic Peritoneal Lavage (DPL) CT Scan Ultrasound (FAST exam) INDICATIONS for CT : INDICATIONS for CT INDICATIONS for CT Blunt trauma with closed head injury Blunt trauma with spinal cord injury Gross hematuria Pelvic fx, +/- suspected bleeding Pt requiring serial exams (ie orthopedic procedures, general anesthesia) CONTRAINDICATIONS: unstable patients CT : CT ADVANT----DISADV Advantages Identifies specific injuries Good for hollow viscus and retroperitoneal injury High sensitivity and specificity Disadvantages Expensive equipment 30-60 minutes to complete study Only for stable patients Not for pregnant patients Diagnostic Peritoneal Lavage : Diagnostic Peritoneal Lavage Advantages Very sensitive for identifying intra-peritoneal blood Can be done at the bedside Can be done in 10-15 minutes Disadvantages Overly sensitive, may result in too high a laparotomy rate Invasive Difficult in pregnancy, or with many prior surgeries Can not be Repeated Focused Abdominal Sonography for Trauma (FAST) : Focused Abdominal Sonography for Trauma (FAST) Consists of 4 views Subxiphoid Right Upper Quadrant Left Upper Quadrant Pouch of Douglas ANATOMY : ANATOMY ANATOMY : ANATOMY ANATOMY : ANATOMY ANATOMY : ANATOMY Background : Background Trauma is third most common cause of death in US Trauma is leading cause of death in < 40 years Background : Background Two mechanisms for injury: compression- leads to solid organ & hollow viscus injury deceleration with stretching between moveable & fixed objects- leads to injuries of renal/mesenteric vessels Technique : Technique Multi-slice scanner Clamp Foley, reduce artifacts (leads, arms, etc.) If head CT needed, do before IV contrast 150 cc contrast @ 3-4 cc/sec, 70 sec delay (less if also doing chest) Inferior lungs to inferior edge of ischia Technique : Technique Delayed imaging as necessary to opacify urinary tract Soft tissue, bone with spine reconstructions as necessary, lung windows “Single pass” technique- arms on bolsters @ 35-50º, scan entire body with slight delay before chest for IV contrast Technique : Technique Enteric contrast- traditionally used oral contrast to at least opacity stomach, duodenum and proximal jejunum Benefit: extravasation of oral contrast is 100% sensitive for bowel injury Risk: aspiration, delays in scanning Technique : Technique Multi-detector CT without oral contrast may be adequate to depict bowel and mesenteric injuries Penetrating trauma- use of rectal contrast Major Imaging Goals : Major Imaging Goals Is surgery required? Hemodynamic instability Certain injuries Is conservative management likely to fail? Active arterial extravasation Higher grades of injury large hematoma in right lateral abdominal wall. : large hematoma in right lateral abdominal wall. 81-year-old man after fall from 5 m. Transverse section of contrast-enhanced multidetector CT scan obtained at level of right kidney shows extraperitoneal active hemorrhage (type 2) with diffuse accumulation of extravasated contrast material (arrows) in right lateral abdominal wall. Immediate surgical exploration revealed active hemorrahge from right lower intercostal arteries and large hematoma in right lateral abdominal wall. CT of Heamoperitoneum : CT of Heamoperitoneum CT can detect very small volumes of fluid Should prompt thorough search for organ injury Starts near site of injury and spreads by traditional pathways Large amounts from upper abdomen may collect in pelvis “Sentinel clot” as marker for source of bleed Extraluminal Fluid : Extraluminal Fluid Intra versus extra peritoneal location Intra peritoneal fluid in Morrison’s pouch wraps around tip of liver Retroperitoneal fluid in anterior para-renal space does NOT wrap around liver tip Extraluminal Fluid : Extraluminal Fluid Intra versus extra peritoneal location Extra peritoneal fluid in pre-vesicle space extends superiorly to umbilicus Slide 23: Intra peritoneal fluid Retroperitoneal fluid Slide 24: Blood in cul-de-sac and left inguinal hernia Attenuation Valuesof Intraperitoneal Blood : Attenuation Valuesof Intraperitoneal Blood > 100 HU - active hemorrhage 40-60 HU - clotted blood 30-45 HU - fresh unclotted blood 0-20 HU - serum (after clotting) Values can be affected by hematocrit, ascites, urine IV contrast extravasation indicates active bleeding Detection of Acute Hemorrhage : Detection of Acute Hemorrhage Various appearances: focal jet (42%), diffuse high density in hematoma (37%), focal high density(21%) 73% required immediate intervention Occurred in 13% pts with blunt trauma in retrospective review of 165 Exact bleeding rate unknown Slide 27: Acute bleeding into a mesenteric hematoma Findings of Hypotension : Findings of Hypotension Slit-like IVC, small aorta, normal colon ? enhancement of spleen ? enhancement adrenal glands, kidneys Diffuse thickening of small bowel wall with increased enhancement Dilatation with luminal fluid Recovery of normal bowel function after resuscitation Slide 29: Hemo-pneumo- peritoneum Small liver lacerations Free air Splenic Trauma : Splenic Trauma MOST FREQENTLY injured intraperitoneal organ in blunt abdominal trauma---spleen Associated with other solid vesceral/bowel injuries 29 % 10% lt kid Lower rib fracture 44 % Lt diaphra 2 % Scanning delayed of 60-70 seconds to avoid heterogenous splenic enhancement Hemoperitoneum indicates disruption of splenic capsule Sentinel clot [area of >60 HU adjacent to spleen] sensitive predictor of splenic injury=perisplenic hematoma Name this injury? : Name this injury? THIS Splenic laceration : THIS Splenic laceration Splenic laceration w/ active bleeding Most common solid organ injury s/p blunt trauma CT finding Hypodensity in an otherwise homogenous organ Can see surrounding fluid Contrast CT ~95% sensitive in detection Grade IV splenic rupture and perisplenic hematoma : splenic rupture and perisplenic hematoma CT scans of stomach wall obtained in two patients who sustained blunt abdominal trauma. Water appears to be superior to dilute Hypaque Sodium ([diatrizoic acid dihydrate] Amersham Health) for visualization of stomach wall in this child, although no statistically significant overall difference was found between these agents. 16-year-old boy with splenic rupture and perisplenic hematoma who received water as oral contrast agent. Stomach wall is well depicted when outlined internally by low-attentuation water and externally by low-attenuation mesenteric fat. Splenic Grading : Splenic Grading CT Grade of Splenic Injury Grade I [contusion] Hematoma: Subcapsular, <10% surface area, non-expanding Laceration <1cm parenchymal depth Grade II [subcapsular hematoma] Hematoma: Subcapsular, 10-50% surface area, non-expanding Laceration 1-3cm of parenchymal depth, no trabecular vessels Grade III [ Intrasplenic hematoma] Hematoma: Subcapsular, >50% surface area or expanding Laceration >3cm or involving trabecular vessels Grade IV [splenic fracture[ Hematoma: Ruptured intraparenchymal hematoma w/active bleeding Laceration: Involving segemental or hilar vessels Grade V [shattered spleen ] Shattered spleen Hilar vascular injury that devascularizes spleen Splenic Laceration : Splenic Laceration Splenic Laceration : Splenic Laceration Liver trauma 20% : Liver trauma 20% 2nd most frequently injured intraabdominal organs----- associated with Splenic injury 45% Rt>Lt Clinical manifistation often delayed by days/weeks CECT Hypoattenuating Hematoma—lenticular configuration [hypodense wedge extended to liver surface Focal hyperdense[80-350 HU] area=active hemorrhage Intrahepatic or subcapsular gas usually due to necrosis Name this finding? : Name this finding? Were you awake? Liver metastasis Guess the CT finding? : Guess the CT finding? Liver laceration 2nd most common injured organ in blunt trauma CT finding Lower attenuation than surrounding liver Can have surrounding fluid Most commonly right posterior lobe of liver Liver Laceration Grading Scale : Liver Laceration Grading Scale Grade I: Capsular tear, < 1cm parenchymal depth Grade II: Parenchymal tear, 1-3cm parenchymal depth Grade III: Parenchymal disruption, > 3cm parenchymal depth but < 25% of hepatic lobe Grade IV: Parenchymal disruption, 25-75% of hepatic lobe Grade V: Parenchymal disruption, > 75% of hepatic lobe Grade VI: Hepatic avulsion Liver Lacerations : Liver Lacerations Sweet Morrison’s Pouch Liver Lacerations : Liver Lacerations laceration (straight arrow) with active bleeding (curved arrow). Free intraperitoneal fluid (black arrowheads) is seen anterior to the liver. Air bubbles (white arrowheads) are seen along the knife track. (b, c) Linear laceration (arrow in b) in pancreatic body with free fluid in lesser sac (arrowheads). Gastric contrast material extravasation (arrow in c) is also seen in the lesser sac. Injuries to the liver, stomach, and pancreas were confirmed surgically. : laceration (straight arrow) with active bleeding (curved arrow). Free intraperitoneal fluid (black arrowheads) is seen anterior to the liver. Air bubbles (white arrowheads) are seen along the knife track. (b, c) Linear laceration (arrow in b) in pancreatic body with free fluid in lesser sac (arrowheads). Gastric contrast material extravasation (arrow in c) is also seen in the lesser sac. Injuries to the liver, stomach, and pancreas were confirmed surgically. Liver pancreas stomch injuries . Combinations of Injuries in Patients without Hemoperitoneum : . Combinations of Injuries in Patients without Hemoperitoneum Combinations of Injuries in Patients without Hemoperitoneum : Combinations of Injuries in Patients without Hemoperitoneum Combined injuries of both kidneys. (a) Axial CT image shows a grade IV liver laceration (arrows) involving the right lobe. Posterior pararenal hematoma is adjacent to the bare area (arrowheads) of the liver. (b, c) Axial CT images show a minor left (arrowhead in b) and a major right (solid arrow in c) renal injury with a large right paranephric hematoma (open arrows in c). No hemoperitoneum is seen. GB TRAUMA 5% : GB TRAUMA 5% Gallbladder injury occurs in 2% of blunt trauma victims], the low incidence being attributed to the organ's well-protected location. Most blunt gallbladder injuries result from motor vehicle crashes, falls, and kicks or blows to the abdomen Factors predisposing to blunt gallbladder injuries are a thin-walled normal gallbladder, a distended gallbladder, Blunt gallbladder injuries are classified as contusion, perforation, and avulsion,, has three subtypes: partial avulsion, in which the gallbladder is partially torn from the liver bed; complete avulsion, in which the gallbladder is completely torn from the liver bed but with intact cystic duct and artery; and total avulsion, in which the gallbladder lies free in the abdomen, torn from all attachments. also called "traumatic cholecystectomy GB TRAUMA 5% : GB TRAUMA 5% Associated intraabdominal injuries are common in patients with blunt gallbladder injury, Liver injury is especially likely, with a reported incidence of 83-91%. Duodenum and spleen injuries occur in up to 54% of patients CT findings of gallbladder injury are largely nonspecific Pericholecystic fluid is most common but least specific. Other signs of gallbladder injury are ill-defined contour of gallbladder wall, mass effect on duodenum, high-attenuation intraluminal material (blood), thickened gallbladder wall, and collapsed gallbladder in a fasting patient. Furthermore, major liver injury often dominates the CT picture and over-shadows subtle abnormalities of the gallbladder. It is not surprising that unsuspected gallbladder injury is often discovered during laparotomy for coexisting intraabdominal injuries Blunt gallbladder injuries : Blunt gallbladder injuries Contrast-enhanced helical CT scans in 26-year-old man with gallbladder avulsion and multiple associated major abdominal injuries resulting from motor vehicle crash. Image reveals grade 3 liver laceration. Blunt gallbladder injuries : Blunt gallbladder injuries Contrast-enhanced helical CT scans in 26-year-old man with gallbladder avulsion and multiple associated major abdominal injuries resulting from motor vehicle crash. Scan shows complete transection of proximal duodenum (arrow) and intact wall of gastric antrum (arrowheads). Note no perfusion of right kidney. Blunt gallbladder injuries : Blunt gallbladder injuries —Contrast-enhanced helical CT scans in 26-year-old man with gallbladder avulsion and multiple associated major abdominal injuries resulting from motor vehicle crash. Scan shows gallbladder wall thickening and focal hematoma with intraluminal bile—blood level Massive pneumoperitoneum outlines falciform ligament. Small amount of contrast material has refluxed from IV. PERITONEAL AND RETROPERITONEAL NOTES : PERITONEAL AND RETROPERITONEAL NOTES Abdominopelvic cavity is closed Serous membrane Parietal peritoneum Lines abdominopelvic cavity Peritoneal cavity Serous fluid Visceral peritoneum Surrounds GI tract Retroperitoneal Between posterior body wall & parietal peritoneum Stomach gross anatomy : Stomach gross anatomy Cardiac region Fundus Body Pyloric region Greater curvature Lesser curvature Stomach trauma : Stomach trauma Gastric contrast material extravasation (arrow in c) is also seen in the lesser sac. Injuries to the stomach Small intestine gross anatomy : Small intestine gross anatomy 2.7-5 m (~16.7’) tube From stomach to large intestine Duodenum – jejunum – ileum Structural specializations to increase surface area Proximal ileum perforation and mesenteric hematoma : Proximal ileum perforation and mesenteric hematoma Proximal ileum perforation and mesenteric hematoma in a 41-year-old man. Abdominal CT scan demonstrates at a lower level shows mucosal enhancement (arrowhead) of a more distal ileal segment. ileal perforation : ileal perforation CT scan acquired with intravenous but not oral contrast material in 27-year-old woman with ileal perforation after high-speed motor vehicle accident. Transverse image shows focal mesenteric hematoma (arrowhead) and pneumoperitoneum (arrow). Perforation of the duodenal C LOOP--- retroperitoneal air : Perforation of the duodenal C LOOP--- retroperitoneal air retroperitoneal air CT scan of the pelvis reveals foci of retroperitoneal air that have escaped from the duodenal perforation (arrowhead). Large intestine gross anatomy : Large intestine gross anatomy Cecum (ileocecal junction) Vermiform appendix Ascending colon Transverse colon Descending colon Sigmoid colon Rectum Anal canal CT Findings of Bowel or Mesenteric Injury : CT Findings of Bowel or Mesenteric Injury Duodenal and jejunal perforations in a 65-year-old woman. Abdominal CT scan reveals free fluid (black arrow), free intraperitoneal air (white arrowhead), retroperitoneal air (black arrowhead), and intraperitoneal contrast material (white arrow). RETROPERITONEAL HEMORRHAGE : RETROPERITONEAL HEMORRHAGE RETROPERITONEAL HEMORRHAGE Source: aorta, IVC, kidneys and ureters, pancreas, pelvic fx, retroperitoneal bowel. Minimal signs on examination; flank pain and contusion are late findings FAST/DPL negative; CT can identify The Pancreas : The Pancreas Is a retroperitoneal structure found posterior to the stomach and lesser omentum The gland is divided into four portions The head The neck The body The tail pancreas : pancreas The pancreas is injured in less than 2% of patients with abdominal trauma Two-thirds are associated with penetrating abdominal trauma If the pancreas is injured usually adjacent organs and major vascular structures are also injured The majority of fatal cases is due to damage from nearby vascular structures The second most common cause of death involves intra-abdominal sepsis In blunt abdominal trauma, the extent and location of pancreatic injury is determined by the mechanism of injury and location of impact What organ is damaged? : What organ is damaged? Pancreatic laceration Occurs secondary to compression of the abdominal wall against the spine Usually occurs in conjunction with other injuries Pancreatic Laceration : Pancreatic Laceration CT findings include: Hypodensities through the organ Linear hypodensity around the pancreatic parenchyma (fluid/edema) Retro-pancreatic fluid anterior to the splenic vein Kidney Injury… : Kidney Injury… Blunt trauma: 80-90% Rapid deceleration / Direct blow MUST be suspected if Trauma to back / flank / lower thorax / upper abdomen Flank pain / low rib # Hematuria / Ecchymosis over the flanks Sudden decelaration / Fall from height. Lumbar transverse process # Kidney ANATOMY : Kidney ANATOMY Retroperitoneal organ Cushoned by perinephric fat Gerota’s fascia Along T10 - L4 Ribs 10-12 Fixed only through pedicle. 1.2L of blood / min Classification of Injury Grade I : Classification of Injury Grade I Contusion Hematuria Urologic studies N Hematoma Subcapsular Non expanding Parenchyma N Grade II : Grade II Hematoma Perirenal Nonexpanding Laceration < 1.0 cm Renal cortex only No urinary extravasation Grade III : Grade III Laceration > 1.0 cm Renal cortex only No urinary extravasation Intact Grade III collecting system Grade IV : Grade IV Laceration Renal cortex Renal medulla Collecting system Vascular Main renal artery/vein injury with contained hemorrage. Grade V : Grade V Completely shattered kidney. Avulsion of renal hilum (pedicule) which devascularizes kidney. Renal Lacerations : Renal Lacerations Hypodensities of the cortex Can have leakage of contrast material Most managed non-operatively renal trauma : renal trauma 20-year-old man with right renal trauma from motor vehicle crash. CT scan obtained with IV contrast material shows fracture of right kidney and surrounding perinephric urinoma. AFTER 1 WEEK : AFTER 1 WEEK —20-year-old man with right renal trauma from motor vehicle crash. Delayed phase CT scan shows persistent perinephric urinoma 1 week after renal trauma. Right kidney grade III injury : Right kidney grade III injury 70-year-old man involved in motor vehicle crash. Sagittal oblique reformation of contrast-enhanced multidetector CT data set across hilum of right kidney shows grade III injury (>1 cm parenchymal depth of renal cortex). Large perirenal hematoma (arrowheads) and parenchymal defect (short arrow) at upper pole are visible. In addition, jet of extravasated contrast material (long arrows), indicating active hemorrhage (type 3), can be seen. Renal extravasation : Renal extravasation Anatomy of the posterior diaphragm : Anatomy of the posterior diaphragm Normal appearance of the posterior diaphragm. CT scan clearly shows the crura in the direct axial plane (arrows). Anatomy of the posterior diaphragm. CT scan shows the left arcuate ligament in the direct axial plane (arrowhead). The crura are also seen (arrows). DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE DIAPHRAGMATIC RUPTURE 3-5% of all abdominal injuries, L>R May p/w few signs, need high index of suspicion Injury mechanism: compartment intrusion, deformity of steering wheel, need for extrication, fall from great height Prominence/immobility of L hemithorax NGT in chest, bowel sounds in thorax CXR: (50% with non-dx initial CXR): Obliteration of L diaphragm on CXR Elevation/irregularity of costophrenic angle Pleural effusion Confirm with GI contrast studies, dx laparoscopy Ex-lap and repair DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE coronal ct reformatted images show the intrathoracic herniation of the stomach more clearly. (e) Image from laparoscopy shows the intrathoracic herniation of the stomach and the diaphragmatic tear. DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE Left diaphragmatic tear ---intrathoracic herniation of the stomach. Sagittal ct reformatted images show the intrathoracic herniation of the stomach. DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE . Left diaphragmatic tear in a 65-year-old patient after blunt trauma. S = stomach. CT scan of the midthoracic region shows intrathoracic herniation of the stomach. DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE CT scan obtained at the level of the hepatic hilum shows a defect in the continuity of the anterolateral left hemidiaphragm (arrows). C = colon. DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE Right diaphragmatic tear in a 46-year-old man who experienced multiple injuries in a motor vehicle accident. CT scan shows a subtle sign of a right diaphragmatic tear: a focal indentation in the posterolateral aspect of the liver with a contusion (arrow). DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE Coronal reformatted image clearly shows a waistlike constriction of the liver (arrowheads). Right diaphragmatic tear in a 46-year-old man who experienced multiple injuries in a motor vehicle accident. DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE Right diaphragmatic tear in a 46-year-old man who experienced multiple injuries in a motor vehicle accident Coronal contrast material-enhanced fat-suppressed fast gradient-echo MR image shows a high position of the liver in the thoracic cavity. The constricting rim of the diaphragm is seen as a low-signal-intensity structure around the herniated liver (arrowheads). DIAPHRAGMATIC RUPTURE : DIAPHRAGMATIC RUPTURE CT scan (direct axial section) of the anterior diaphragm shows incomplete visibility of the diaphragm where it abuts structures of similar attenuation, such as the liver (bottom arrow). The hemidiaphragms are well demonstrated when they are marginated by peritoneal, retroperitoneal, or extraperitoneal fat (top arrow). Extraperitoneal bladder rupture and normal bowel loops : Extraperitoneal bladder rupture and normal bowel loops Extraperitoneal bladder rupture and normal bowel loops in a 77-year-old woman. CT cystogram obtained after retrograde filling of the bladder shows an intravesicle air-contrast level (black arrow) and contrast material in the perivesicle extraperitoneal space (white arrows). Intraperitoneal bladder rupture and mesenteric lacerations : Intraperitoneal bladder rupture and mesenteric lacerations Intraperitoneal bladder rupture and mesenteric lacerations in a 29-year-old man. CT scan demonstrates free contrast material (black arrows) from an intraperitoneal bladder rupture that masks evidence of mesenteric bleeding. Contrast material extends into the subcutaneous tissue (white arrows) through a rupture at the origin of the oblique muscles CASE 1 : CASE 1 Distal jejunal perforation, mesenteric hematoma, and liver laceration : Distal jejunal perforation, mesenteric hematoma, and liver laceration . Distal jejunal perforation, mesenteric hematoma, and liver laceration in a 51-year-old woman. (a) Abdominal CT scan shows a large liver laceration (arrow) with hemoperitoneum (arrowhead). (b) On a CT scan obtained at a lower level, subtle collections of intramural air (black arrow) and intraperitoneal air (white arrows) in the region of the thick-walled jejunum were not appreciated CASE 2 : CASE 2 Diphr------------------------------duode Right diaphragmatic rupture and duodenal contusion : Right diaphragmatic rupture and duodenal contusion Right diaphragmatic rupture and duodenal contusion in a 43-year-old man. (a) Abdominal CT scan shows a posterior right rib fracture (arrow) at the site of a diaphragmatic hematoma (black arrowheads). (b) On a CT scan obtained at a lower level, extension of the diaphragmatic hematoma into the posterior pararenal space (arrow) was erroneously thought to be the source of the periduodenal hematoma in the anterior pararenal space. Subcutaneous air (white arrowheads in a and b) from barotraumas is visible CASE 3 : CASE 3 Contusion of the second portion of the duodenum, right adrenal hematoma and intraparenchymal liver laceration : Contusion of the second portion of the duodenum, right adrenal hematoma and intraparenchymal liver laceration Contusion of the second portion of the duodenum, right adrenal hematoma, and intraparenchymal liver laceration in a 36-year-old man. (a) Abdominal CT scan demonstrates an intraparenchymal liver laceration (white arrow) and adrenal hematoma (black arrow), with surrounding retroperitoneal blood (arrowhead). (b) On a CT scan obtained at a lower level, periduodenal hematoma thought to be from the other injuries masks the duodenal injury (arrows), which could be suspected on the basis of its ill-defined wall CASE 4 : CASE 4 Splenic and mesenteric laceration : Splenic and mesenteric laceration Splenic and mesenteric lacerations in a 41-year-old man. (a) Abdominal CT scan reveals a splenic laceration (arrow), which contributed to hemoperitoneum (arrowheads). (b) CT scan obtained at a lower level shows a focus of contrast material extravasations (arrow) and adjacent stranding, findings that help identify the mesenteric laceration. (Note: A low rate of intravenous administration of contrast material results in faint attenuation of the contrast material extravasations.) Adjacent interloop fluid (arrowhead) is present. CASE 5 : CASE 5 Duodenal and pancreatic contusions with adjacent hematoma : Duodenal and pancreatic contusions with adjacent hematoma Duodenal and pancreatic contusions with adjacent hematoma in a 36-year-old woman. CT scan shows a thick-walled duodenum (black arrows) with surrounding blood (white arrow) and additional blood surrounding mesenteric vessels (arrowhead). No free air is seen. The pancreas appeared normal on other CT images (not shown). Case 6 : Case 6 Placental separation in a pregnant patient after trauma : Placental separation in a pregnant patient after trauma Placental separation in a pregnant patient after trauma. CT scan shows submembranous and subchorionic hemorrhage (arrows). US demonstrated similar findings.. Case 7 : Case 7 Fetal injury in a pregnant patient after trauma : Fetal injury in a pregnant patient after trauma Fetal injury in a pregnant patient after trauma. CT scan shows intraventricular hemorrhage within the fetus (arrows). Thank you for your attention !!!!!!! : Thank you for your attention !!!!!!! . . You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.