Nordic Forum - Trauma & Emergency Radiology Acute ... · 1 Acute Abdominal Bleeding: Detection with...
Transcript of Nordic Forum - Trauma & Emergency Radiology Acute ... · 1 Acute Abdominal Bleeding: Detection with...
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Acute Abdominal Bleeding: Detection with MDCT
Nordic Forum - Trauma & Emergency Radiology
Borut MarincekInstitute of Diagnostic Radiology
University Hospital Zurich, Switzerland
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Trend in emergency radiology:
Greater use of MDCT in suspected acute abdominalbleeding to detect
• organ injuries• vascular anomalies• source of bleeding
Multidetector Row Computed Tomography (MDCT)
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• Trauma- blunt- penetrating
• Nontraumatic conditions- vascular: rupture of aneurysm- nonvascular: rupture of neoplasm- upper & lower gastrointestinal tract
Acute Abdominal Bleeding: Role of MDCT
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• Evidence of CM pooling caused by vascularor visceral organ pathologies
• Attenuation of CM pooling- similar aorta / major adjacent arteries- greater than surrounding parenchyma
• Types of CM pooling:- focal or diffuse, extravasated CM surroundedby hematoma
- „jet“ of extravasated CM
Diagnostic Criteria of Acute Bleeding on MDCT
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Focal
Diffuse
“Jet”
(Willmann, AJR 2002)
Acute Bleeding: Types of CM Pooling
� Blunt Trauma: Intrasplenic Lacerations
„Jet“ type of acute bleeding
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� Blunt Trauma: Mesenteric Avulsions
„Jet“ type of acute bleeding
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• Prevalence of acute bleeding detected on MDCT afterBAT 13-18% (Willmann, AJR 2002; Yao, AJR 2002)
• Spleen > liver > kidney > adrenal > mesentery• MDCT diagnosis requires rapid i.v. (>3.0 ml/sec) CM
bolus via automated power injector• Exact bleeding rate for diagnosis unknown• When visualized on MDCT: significant finding, may
mandate immediate surgery or image-guidedembolization
Acute Bleeding after Blunt Abdominal Trauma
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22/165 pts (13%) acute bleeding on MDCT after BAT(Willmann, AJR 2002)
Surgery13 (59%)
Selectiveembolization
3 (14%)
Emergency therapy16 (73%)
Conservative therapy6 (27%)
Delayed selectiveembolization
1 (5%)
Death5 (22%)
Clinical Outcome of Acute Abdominal Bleeding
� Acute Bleeding after Penetrating Trauma
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� Acute Bleeding after Penetrating Trauma
Replaced righthepatic artery
� Acute Bleeding: Rupture Infrarenal AAA
1-year incidences AAA rupture:5.5-5.9 cm 9.4%6.0-6.9 cm 10.2%
(6.5-6.9 cm 19.1%)>7 cm 32.5%
(Lederle, JAMA 2002)
MPRM
MIP VR
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� Acute Bleeding: Rupture Infrarenal AAA
� Acute Bleeding: Rupture HCC
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� Acute Bleeding: Rupture Renal Angiomyolipoma
� Acute Bleeding: Rupture Renal Angiomyolipoma
Aneurysm of arteryfeeding angiomyolipoma
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� Acute Bleeding: Complication of ESWL
Subcapsular, peri- & pararenal hematoma
Incidence rate 0.28% (Collado, Scand J Urol Nephrol 1999)
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• Right tube: ectopic pregnancy• Left tube: hydrosalpinx• ß-HCG 15’034
Acute Bleeding: Rupture Ectopic Pregnancy
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• Upper GI bleeding / lower GI bleeding: proximal / distal ligament of Treitz
• Overt: hematemesis, hematochezia, melena
• Obscure: persisting or recurring bleeding of unknown origin after negative endoscopy of upper and lower GI tract (AGA, Gastroenterology 2000)
Acute Gastrointestinal (GI) Bleeding: Definitions
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• Small bowel barium examination• Enteroclysis• Tc-labeled RBC scintigraphy• Catheter angiography• Wireless capsule endoscopy• CT enteroclysis• Catheter-directed CT angiography• MDCT: (1) acquisition of separated arterial and portal
venous phase images localization of extravasatedCM into bowel lumen before dilution; (2) animal model: bleeding rate for CT diagnosis 0.3 ml/min
(Kuhle, Radiology 2003)
Obscure GI Bleeding: Diagnostic Imaging Modalities
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Melana since 3 weeks, aorta-bifemoral Y-graft 11 years ago
Aortoduodenal Fistula
� Acute Upper & Lower GI Bleeding
• Acute = hematemesis, melena or hemochezia within 24 hours before MDCT
• Severe = hemodynamic instability (systol. pressure <100 / pulse rate >100); mild = no hemodynamic instability
• MDCT (pts) January 2001 - May 2006 :4-row (6), 16-row (11), 64-row (1)
• MDCT protocol: iv CM, arterial & portal venous phase(additional unenhanced scans in 9 pts), no oral CM
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coilingcystojejunal anastomosis8. Mild / pseudoaneursym lienal art.
embolizationduodenum10. Severe / ischemic anastomotic ulcer
stentgraftduodenum4. Severe / aortoenteric fistula
-duodenum9. Severe / arteriobiliary fistula
coilingbiliodigest. anastomosis5. Severe / pseudoaneurysm hepatic art.
coilingduodenum7. Mild / pseudoaneurysm gastroduod. art.
coilingbiliodigest. anastomosis6. Mild / pseudoaneurysm hepatic art.
stentgraftduodenum3. Severe / aortoenteric fistula
stentgraftduodenum2. Severe / aortoenteric fistula
excisionduodenum1. Severe / aortoenteric fistula
TreatmentBleeding sourceBlood loss / Pathology
Acute Upper GI Bleeding: MDCT Detection
� Aortoduodenal Fistula
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� Pseudoaneurysm Hepatic Artery
7 weeks after laparotomy & biliodigestive anastomosis forpancreatic carcinoma
� Pseudoaneurysm Hepatic Artery
Hypovolemic shocknon-occlusive mesentericischemia & pneumatosis
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� Pseudoaneurysm Hepatic Artery
Coil-embolization,stent-grafting
� Bleeding Complications after Pancreatic Surgery
Postoperative arterial bleeding 3-4% (Sohn, J Gastrointest Surg 2003)
University Hospital Zurich 1998-2004 (Pfammatter, CIRSE 2005)N = 11, average delay surgery – bleeding = 54 days (range 10-250 days)Type of surgery:
Whipple‘s procedure 6Partial pancreatic resection 3Pancreatic head mobilization 1Hepaticojejunostomy 1
Presentation of acute bleeding:Upper GI 2Lower GI 3Intraabdominal 6
Initial diagnosis of bleeding source:MDCT 7DSA 3Scintigraphy 1
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� Pseudoaneurysm Gastroduodenal Artery
Chronic tuberculous ulcerationof duodenum
� Pseudoaneurysm Gastroduodenal Artery
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� Arterio-biliary Fistula
Liver cirrhosis & portal hypertension, 1 week after transjugular liver biopsy
� Arterio-biliary Fistula
Liver cirrhosis & portal hypertension, 1 week after transjugular liver biopsy
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embolizationtransverse colon6. Severe / ischemic ulcer
endoscopical clippingcecum5. Severe / nonocclusive ischemic ulcer
embolizationsigmoid7. Severe / diverticulum
excisionileum3. Mild / neuroendocrine carcinoma
TIPSrectosigmoid8. Mild / varices
embolizationcecum4. Mild / nonocclusive ischemic ulcer
coilingjejunum1. Severe / mucositis
excisionileum2. Mild / stromal tumor
TreatmentBleeding sourceBlood loss / Pathology
Acute Lower GI Bleeding: MDCT Detection
� Ischemic Mucositis Jejunum
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� Ischemic Mucositis Jejunum
� Stromal Tumor Ileum
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� Nonocclusive Ischemic Ulcer Cecum
Anticoagulation, 10 d after myocardial infarction: sepsis, acute abdomen
art
ven
embolization
� Ischemic Ulcer Transverse Colon
Non-steroidal antirheumaticdrugs since 5 weeks
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� Ischemic Ulcer Transverse Colon
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Abdominal aortic aneurysm, Plavix loading dose aftercoronary stent, diverticulosis of sigmoid colon
Sigmoid Diverticulum
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Coil-embolization
Sigmoid Diverticulum
� Ectopic Varices Cecum
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University Hospital Zurich (N=18)• MDCT identification of bleeding source:
prospectively 15/18 (83%)retrospectively 3/18 (17%)
• CM extravsation: 11/11 pts with severe bleeding1/7 pts with mild bleeding
• Identification of underlying pathology:15/18 (83%)
Acute Upper & Lower GI-Bleeding
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Miller, 2 & 4-row ce-MDCT (Clin Imaging 2004):
• Identification of bleeding site in 9/18 pts
Tew, 4-row ce-MDCT (AJR 2004):
• Identification of bleeding site in 7/13 pts
Ko, 4-row ce-MDCT (RöFo 2005):
• Identification of bleeding site in 20/58 pts
Yoon, 4-row ce-MDCT (Radiology 2006):
• Identification of bleeding site in 23/26 ptsOverall accuracy 88.5%
Acute Obscure GI-Bleeding: MDCT
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Contrast-enhanced MDCT
• Rapid, noninvasive, and accurate in localizingacute abdominal bleeding in traumatic and in non-traumatic conditions
• Plays a complementary role to endoscopy for localization of obscure upper or lower GI-bleeding
• Can be used as a guidance for subsequent angiographic intervention
Acute Abdominal Bleeding: Conclusions