Traumatic intraperitoneal bladder rupture
Patient is a victim of high speed motor vehicle accident, brought to the hospital by a rescue team. He is haemodynamically stable, presenting with signs of peritonitis.
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Portal venous phase CT shows low density free intraperitoneal fluid (mean density around 5 HU) in the right para-colic gutter and supramesocolic space (peri-hepatic and peri-splenic). Renal excretory phase reveals extravasation of intra-venous administered contrast into the peritoneal cavity through a rupture of the urinary bladder dome. The contrast-stained fluid is seen in the right para-colic gutter and in between small bowel loops, confirming its intraperitoneal location. Kidneys and ureters are unremarkable. No pelvic fractures were seen.
A small traumatic hematoma with active bleeding (contrast blush) in the segment IVa of the liver is also worth mentioning.
Although urinary bladder ruptures can be seen in penetrating and blunt trauma, the latter is responsible for most of the cases. The probability of bladder injuries is related to the degree of bladder distention at the time of the trauma. Mortality caused by associated injuries can be as high as 44%. Delay in the diagnosis can lead to substantially increased morbidity and mortality 1.
Sandler et al. divided the bladder injuries into five types, as follows 1:
- type I: contusion - partial or incomplete tear of the mucosa
- type II: intraperitoneal rupture - usually caused by blunt trauma while the patient has a distended bladder, allowing for rupture of the bladder dome
- type III: interstitial injury - intramural or partial-thickness laceration with an intact serosa
- type IV: extraperitoneal - most commonly seen in penetrating trauma
- type V: combined rupture - simultaneous intra- and extraperitoneal rupture
Determining the type of rupture is fundamental since treatment and prognosis are different for each type. Most contusions, interstitial injuries and extraperitoneal ruptures can be treated solely with catheterization, whereas intraperitoneal and combined ruptures require laparotomy in most cases 1.
In the presented case, excretory phase CT alone sufficed to demonstrate contrast extravasation. However, usually a very delayed phase (15 to 30 min) is necessary to confirm bladder rupture, and that may not be feasible in busy emergency departments. A CT cystography can be used to determine the presence of bladder rupture without a need for further delaying examination 1.