Hepatic, renal and adrenal devascularisation in a multi-trauma patient
This 20 year old male was involved in a severe motorcycle accident. A CT trauma series was performed.
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Laparotomy, bilateral upper quadrant intraperitoneal packs and free intraabdominal air are consistent with recent surgery.
Extensive and severe hepatic and right renal vascular injuries are evident, with evidence of active intraperitoneal bleeding.
The majority of the right lobe of liver is devascularised, with a large amount of perihepatic hematoma (particularly subphrenic) and intraperitoneal blood within the right paracolic gutter and pelvis.
There is extensive right paracolic gutter and perihepatic contrast extravasation on the delayed images, consistent with fast active bleeding, parenchymal or venous in origin.
Blood is also seen to accumulate in the 2nd part of the duodenum on delayed images.
Approximately 50% of the right kidney and right adrenal does not demonstrate any contrast enhancement, consistent with renovascular injury, although this is not directly visualized.
There is extensive retroperitoneal hematoma, which extends across the midline, and to the left anterior pararenal space.
- Rapid intraperitoneal bleeding within the right hemiabdomen, probably of parenchymal/venous origin.
- Severe liver, right renal and right adrenal vascular injuries with subsequent devascularisations.
- Large amount of intraperitoneal and retroperitoneal hematoma.
- Intraluminal bleeding into the 2nd part of the duodenum.
- Hyperenhancing distal small bowel is nonspecific, however can be seen in 'shocked bowel' after a hypotensive episode.
1 case question available
Traumatic adrenal injury is an uncommon traumatic finding, mainly due to its protected, retroperitoneal location1. It has been noted to occur in 2-3% of blunt abdominal injury2, with motor vehicle accident being the most common cause.
It is worth noting that right sided adrenal trauma is much more common than the left, with a ratio of 3-4:1 being quoted1. This has been suggested to be caused by the short adrenal vein which directly connects to the inferior vena cava. In blunt trauma, rapid increases in IVC pressure are likely associated with right adrenal trauma.
Complications of adrenal injury include uncontrolled hemorrhage and adrenal insufficiency.
Traumatic renal injury is a relatively uncommon occurrence, which is found in 1-5% of all traumas3. They are typically caused by blunt injury mechanisms, in particular, motor vehicle accidents and falls from height.
Traumatic renal injury can be graded from 1 though to 5. The grading system is defined as follows4:
- Grade I - Contusion or non-expanding subcapsular hematoma; No laceration
- Grade 2 - Non-expanding perirenal hematoma; Cortical laceration <1cm deep without extravasation
- Grade 3 - Cortical laceration > 1 cm without urinary extravasation
- Grade 4 - Laceration through corticomedullary junction into collecting system OR Vascular segmental renal artery or vein injury with contained hematoma
- Grade 5 - Shattered kidney OR renal pedicle injury or avulsion
In this case, the patient has Grade 4 renal injury - a vascular segmental renal artery injury, with resulting devascularisation. The renal pelvis is intact, and small amounts of hyperdense contrast can be visualized on the coronal sections.
Liver injury is a common finding in many types of trauma5. This is because of its anterior location, as well as fragile parenchyma.
Investigations into traumatic liver injury involves focused assessment for trauma using ultrasound (FAST scans), CT or with diagnostic peritoneal lavage. Imaging such as radiography may reveal chest fractures or splenic lacerations, both common associated injuries.
Traumatic liver injury can be divided into six categories according to the American Association for the Surgery of Trauma7. This particular patient had a grade III hepatic laceration.
- Grade I – Hematoma: subcapsular <10 percent surface area. Laceration: capsular tear <1 cm parenchymal depth
- Grade II – Hematoma: subcapsular 10 to 50 percent surface areaintraparenchymal <10 cm in diameter. Laceration: capsular tear 1 to 3 cm parenchymal depth, <10 cm in length.
- Grade III – Hematoma: subcapsular >50 percent of surface area or ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding. Laceration >3 cm in depth.
- Grade IV – Laceration: parenchymal disruption involving 25 to 75 percent of a hepatic lobe, or 1 to 3 Couinaud segments.
- Grade V – Laceration: parenchymal disruption of >75 percent of a hepatic lobe, >3 Couinaud segments within a single lobe. Vascular: juxtahepatic venous injuries (retrohepatic vena cava, central major hepatic veins).
- Grade VI – Hepatic avulsion.
This patient has a grade V hepatic injury with almost complete devascularisation of the right hepatic lobe. Nevertheless, the remaining segments are intact.
Case contributed by A/Prof. Pramit Phal.
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