Pediatric
Abdominal
Trauma:
Evaluation
by
Computed
Tomography
Naomi
M. Kane,
MD,
John
J. Cronan,
MD,
Gary
S. Dorfman,
MD,
and
Frank
DeLuca,
MD
From the Departments of Diagnostic Radiology and Pediatric Surgery, Rhode Island Hospital, Brown University Program in Medicine, Providence
ABSTRACT. When indications for immediate
laparot-omy are not present, CT of the abdomen and pelvis can be used to evaluate pediatric blunt abdominal trauma. During 2-year period, the medical records and abdom-inal/pelvic CT scans of 100 consecutive pediatric
pa-tients who were evaluated for blunt abdominal trauma
were retrospectively reviewed. The scans appeared
nor-mal for 73 children. Of these children, 30 had severe
head injuries and a depressed sensorium. A total of 27
abdominal/pelvic CT scans were interpreted as
abnor-mal. Findings included nine splenic fractures, six renal
contusions, nine hepatic lacerations, one duodenal
he-matoma, one traumatic pancreatitis, four bony injuries,
six miscellaneous abnormalities, and one
intraperito-neal bleed. Only two of these 27 patients required
ab-dominal surgery. The remaining 25 patients were
treated conservatively based upon a stable clinical
state and CT delineation of the extent of injury. No
mortality resulted. CT is the radiographic examination
of choice for hemodynamically stable pediatric patients with blunt abdominal trauma. CT provided a reliable
adjunct examination technique when a physical
ex-amination could not be performed and a complete his-tory could not be obtained. The extent of abdominal/
pelvic injuries is well delineated and can often be
fol-lowed by diagnostic imaging, usually allowing for
con-servative therapy.Pediatrics 1988;82:1 1-15; abdominal trauma computed tomography, hemoperitoneum.
Trauma is the major cause of death in the
pe-diatric age group. More than 30,000 children
younger than 14 years of age die from trauma
an-nually, and more than 1 million children are
hos-pitalized.’ Abdominal injuries account for 10% of
trauma-related deaths. Injuries are often
multi-ple. Injuries to the spleen, liver, and kidney are
Received for publication July 10, 1987; accepted Sept 9, 1987. Reprint requests to (J.J.C.) Rhode Island Hospital, Radiology Special Procedures, 593 Eddy St, Providence, RI 02902.
PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the
American Academy of Pediatrics.
most common. The frequency of injuries to the
bowel, pancreas, and lower genitourinary tract
vary. Many times, a history of the incident is
un-available. The physical examination of children
is often difficult, provides inaccurate information,
and is compromised by neurologic injuries. As a
result, various imaging modalities are used to
de-termine the presence and extent of abdominal in-jury.26
CT has been successfully used in adults for the
evaluation and diagnosis of abdominal trauma.7
10 More recently, CT has been used to evaluate
pediatric blunt abdominal trauma.26” We
re-viewed 100 consecutive pediatric cases of
sus-pected abdominal injury that were studied by CT.
MATERIALS AND METHODS
All pediatric trauma abdominal/pelvic CT scans
performed between June 1984 and May 1986 were
retrospectively reviewed. In the 100 cases studied
during this period, CT scans had been performed
within six hours of the children’s arrival to the
emergency room.
CT was performed with a high resolution
scan-ner (GE 9800, Milwaukee). Contrast media were
routinely given intravenously and orally.
Intra-venous infusion of 60% meglumine diatrizoate
(Hypaque, 60%) was administered as a bolus
in-jection in a dose of 1 mL/0.45 kg ofbody weight in the 0- to 9-year age group. Children 10 years of age and older received a 50-mL bolus followed by an intravenous infusion of 50 to 100 mL for the
duration of the scanning. Oral contrast material
was a 1.5% diluted solution of diatrizoate sodium
(Hypaque) given either orally or through a
na-sogastric tube. The doses for specific age groups
were as follows: 0 to 2 years, 60 mL; 3 to 5 years, 120 mL; 6 to 9 years, 180 mL; and 9 years and
mi-Fig 1. Eight-year-old girl suffered frontal lobe
con-tusions when struck by car. Admission abdominal CT scan demonstrated contused and fractured kidney as well as splenic hematoma. She subsequently had hem-isplenectomy and splenorraphy. Top, Splenic paren-chyma (5) is inhomogeneous and has unsharp contour consistent with splenic injury. There is lack of en-hancement in upper pole of left kidney (K). There is also a perirenal hematoma (arrows). Bottom, Section
caudad to section at top shows fractured left kidney (K)
with extravasation of contrast material admixed with
blood in perirenal space (arrows). Note blood (b) in
hep-atorenal fossa and posterior to spleen.
tially present, was withdrawn from the abdomen
to above the gastroesophageal junction prior to
scanning. Scans were obtained with 1-cm beam
collimation and 1-cm table incrementation (5-mm
collimation and table incrementation if less than
2 years old) from the top of the diaphragm to the
inferior margin of the kidneys and then at 2-cm table incrementation (1-cm if less than 2 years old) through the pelvis to the symphysis pubis.
CT was performed ifone or more ofthe following four indications was present: (1) clinical or
radi-ographic evidence of abdominal injury, (2) mild
suspicion of abdominal injury, (3) unreliable
ab-dominal physical examination findings, and (4)
neurologic deficit with an unknown mechanism
of injury.
The study population consisted of 59 male and
41 female patients, 6 weeks to 17 years of age.
Injuries were due to motor vehicle accidents
(51%), pedestrian-vehicular accidents (22%), falls
(12%), sporting accidents (9%), and miscellaneous other causes (6%).
All patients were initially evaluated and sta-bilized in the emergency department. All CT
ex-aminations were performed under the auspices of
the pediatric trauma surgery team in conjunction with the department of radiology within three
hours of the initial evaluation. During CT
scan-ning, all patients were directly observed and were
constantly evaluated with a cardiorespiratory
monitor. Emergency equipment was immediately available in the scanning room. Sedation was
sometimes required in particularly young or
ag-itated patients. Neurosurgical consultation was
obtained prior to sedation of patients with
sus-pected head injury.
Medical records were reviewed retrospectively to assess clinical management, morbidity,
mor-tality, and outcome. CT scans were reread by two
radiologists who had no knowledge of the original
interpretation, and no substantial changes or ad-ditional findings were revealed.
RESULTS
For 73 patients, abdominal/pelvic CT scan
find-ings were normal. However, 30 of these patients
had associated severe head injuries as
demon-strated by abnormal findings on noncontrasted
cranial CT scans that preceded the abdominal CT.
Subsequently, three of these patients died. In 27
patients, 36 abnormalities were demonstrated by
CT. The CT findings included nine cases each of
splenic laceration/hematoma and hepatic
lacera-tion/hematoma. Six patients had renal injuries,
including two with renal fractures. There was one
case each of traumatic pancreatitis, duodenal
he-matoma, and hemoperitoneum not associated
with organ damage (this examination was
sub-optimal because of motion artifact). Four patients
had bony injuries defined by CT. Five patients had
six miscellaneous or incidental findings,
includ-ing an ovarian cyst, parametrial mass,
hepato-megaly, pleural effusion, column of Bertin, and
soft tissue laceration.
Six of these 27 patients with abnormal
abdom-inal CT scan findings also had concomitant head
injuries identified on noncontrasted cranial CT
that preceded the trauma abdominal CT. Eleven
patients had associated orthopedic
optimal because of motion, but the scan did
dem-onstrate hemoperitoneum with a perisplenic fluid
collection. In one of the two patients who
sus-tamed a fractured kidney a urinoma developed
that subsequently was drained percutaneously
(Fig 2).
The remaining 24 patients were successfully
treated nonoperatively. Seven had follow-up by
CT; three had follow-up by radionuclide
liver-spleen scans; the remainder were followed
clini-cally. There was no mortality. All patients who
had normal abdominal CT scan findings also had
uncomplicated hospital courses (concerning the
abdomen), and none required reevaluation or
op-erative intervention for missed injury.
Fig 2. Fractured kidney in 14-year-old boy injured in motorbike accident. On admission, he was unconscious and had gross hematuria but responded well to con-servative treatment. His hospitalization was compli-cated by urinoma development which was subsequently
drained percutaneously. Top, Admission trauma CT
demonstrates multiple fracture planes in right kidney
(K) with extravasation ofopacified urine and blood into
perirenal and pararenal spaces (arrows). Bottom,
Fol-low-up intravenous urogram 2#{189}months later shows
bilaterally functioning kidneys.
with abnormal abdominal CT scan findings had
diagnostic peritoneal lavage performed several
hours prior to the CT.
Only two patients required operative
abdomi-nal exploration. One patient had a
hemisplenec-tomy and splenorraphy for injuries that were
de-fined on the CT scan (Fig 1). The second patient
also had a splenorraphy. His CT scan was
sub-DISCUSSION
Annually, in the United States, 160,000 people
die as a result of trauma, more than 30,000 of
whom are children. Approximately 10% of these
deaths are secondary to abdominal injury.2 It is,
therefore, imperative to accurately assess the
presence and extent of abdominal injury. In many
medical centers, CT has supplanted other imaging
modalities in the evaluation of blunt abdominal
trauma.9’1#{176} CT has expedited evaluation of
pa-tients needing surgical intervention and
treat-ment. It also allows for more confident
nonoper-ative management of patients with less serious
injuries. The trend among pediatric surgeons is
toward nonoperative management of abdominal
trauma in an attempt to preserve organ tissue and
maintain immune competence.’2’4 This goal is
aided by CT imaging, which is noninvasive and
can be repeated to follow the status of a known
visceral injury.
The history and physical examination remain
the cornerstone of trauma assessment.
Unfortu-nately, a history of the incident may be
unavail-able and the physical examination in children is
often technically difficult and the findings
mac-curate. As a result, various diagnostic studies to
determine the presence and extent of
intraabdom-inal injury are used.
Plain radiographs have been regarded as
non-specific and insensitive indicators of the real
ex-tent of abdominal injury.
With a high degree of accuracy scintigraphy,
specifically liver-spleen scanning, can be used to
diagnose injuries. However, the anatomic detail
is poor. Peritoneal bleeding and visceral or
retro-peritoneal injuries cannot be detected. It is useful
for follow-up of hepatic or splenic injuries.25
Diagnostic ultrasound also has a limited role in
the assessment of acute abdominal injury.
de-Fig 4. Liver laceration in 7-year-old female
pedes-trian struck by automobile who was subsequently
man-aged conservatively. Note low-density fracture plane in
right hepatic lobe (arrows). Scan through pelvis
re-vealed hemoperitoneum. L, liver; 5, spleen.
tected with ultrasound, the paralytic ileus that often accompanies acute abdominal injury de-creases its ability to completely image the abdom-inal cavity.2’5
Diagnostic peritoneal lavage received much
ac-claim in the early 1960s. The utility of lavage is limited because only the presence of hemoperi-toneum can be identified and not the specific organ injured. More important, because certain
injuries can be managed nonoperatively, the
pres-ence of intraabdominal blood does not guide man-agement decisions in children.’5’8
CT
evaluation of adult abdominal injuries has been successfully reported since the late 1970s.CT
defines superior anatomic detail as comparedwith other modalities. It surveys the entire ab-domen and retroperitoneum and, therefore, mul-tiple organ injuries, which are present in about 20% of trauma patients, can be detected. Small
amounts of free intraperitoneal blood or gas are
accurately detected by CT. Bony structures are well visualized, and when contrast enhancement
is used, vascular integrity of all of the
intraab-dominal organs is easily assessed.7”926
Meticulous attention to scanning technique is crucial. Artifacts are commonly encountered and can degrade image quality.27 In our series, for ex-ample, one patient examined by CT was found to have hemoperitoneum not associated with any organ damage. The examination was suboptimal
because of motion artifact, and he had an
explor-atory laparotomy with splenorraphy.
In the hemodynamically stable patient, absence ofa parenchymal laceration on a CT scan is strong evidence that laparotomy is unnecessary, even if a small hemoperitoneum is demonstrated.28 Non-operative management of splenic or hepatic
lac-erations is accepted clinical practice.’3’29 In our
series, six patients with hepatic lacerations, five
patients with splenic lacerations, and three
pa-tients with both splenic and hepatic lacerations
were treated conservatively (Figs 3 and 4). Delin-eation of the extent of injury is critical for the successful management of these patients. The pe-nod of recommended bed rest and limitation of activity is different for a person with liver lac-eration than for one with a splenic laceration. However, patients with these conditions require recuperative management, unlike a patient who
has normal abdominal CT scan findings.
CT findings in a patient with pancreatic trauma
can be subtle.3#{176} We diagnosed traumatic pan-creatitis in one patient by CT. Treatment was con-servative and serum and urine amylase values
re-turned to normal in four days.
Hollow viscus injuries are difficult, but not
im-possible, to detect by CT.3’ We found one duodenal
Fig 3. Splenic fracture with hemoperitoneum in
14-year-old boy who complained of right upper quadrant
tenderness following dirt bike accident. He was
man-aged conservatively. Top, Splenic parenchyma (5) is
disrupted by cleavage plane which is filled with blood
(b). Bottom, Scan through pelvis shows blood (b) in
hematoma. CT findings include distortion of the
viscus lumen and an intramural high-density
mass representing the acute hematoma.
Mesen-teric injury may result in minor peritoneal
hem-orrhage.
CT is invaluable in the assessment of renal trauma.’4’2526 Our spectrum of injury spanned from focal contusion to renal fracture. The extent
of renal parenchymal damage, perirenal
hema-toma, extravasation of urine, and renal vascular pedicle injury are well delineated by CT.
Repeat CT studies in the patient with
paren-chymal injuries allows assessment ofhealing. The
need for bedrest can be individually assessed
based upon follow-up results of CT scanning.
We conclude that CT is an accurate tool in de-tecting and defining the extent of abdominal
in-jury and an invaluable aide in determining
op-erative or nonoperative treatment. In the pediatic
population with limited language skills or altered
sensorium following concomitant head trauma,
normal findings on a CT scan provide support for
conservative therapy. The postrauma period need
not include a period of bed rest if parenchymal
injury is absent. The results of surgery, clinical
follow-up, and repeated radiographic procedures
all confirm the validity of the initial CT findings
in these 100 patients.
ACKNOWLEDGMENT
The authors acknowledge the clerical and secretarial
assistance of Gayle Pascetta, Carolyn Elderkin, and
Maria DaRocha.
REFERENCES
1. Burrington JD: Presentation of the traumatized spleen in children. Contemp Surg 1979;15:11
2. Kuhn JP: Diagnostic imaging for the evaluation of ab-dominal trauma in children. Pediatr Clin North Am
1985;32:1427-1447
3. Kuhn JP, Berger PE: Computed tomography in the eval-uation ofblunt abdominal trauma in children. Radiol Clin North Am 1981;19:503-513
4. Mohamed G, Reyes HM, Fantus R, et al: Computed to-mography in the assessment of pediatric abdominal trauma. Arch Surg 1986;121:703-707
5. Kaufman RA, Babcock GS: An approach to imaging the upper abdomen in the injured child. Semin Roentgenol
1984;19:308-320
6. Kaufman RA, Towbin R, Babcock DS, et al: Upper abdom-inal trauma in children: Imaging evaluation. AJR 1984; 142:449-460
7. Federle MP, Goldberg HI, Kaiser JA, et al: Evaluation of abdominal trauma by computed tomography. Radiology
1981;138:637-644
8. Toombs BD, Lester RG, Ben-Menachem Y, et al: Computed tomography in blunt trauma. Radiol Clin North Am
1981;19:17-35
9. Federle MP, Crass BA, Jeffrey RB, et al: Computed to-mography in blunt abdominal trauma. Arch Surg 1982; 117:645-650
10. Federle MP: Computed tomography of blunt abdominal trauma. Radiol Clin North Am 1983;21:461-474
11. Berger PE, Kuhn JP: CT of blunt abdominal trauma in childhood. AJR 1981;136:105-110
12. King DR, Lobe TE, Haase GM, et al: Selective
manage-ment of injured spleen. Surgery 1981;90:677-682
13. Meyer AA, Crass RA, Lim RC, et al: Selective non-oper-ative management of blunt liver injury using computed tomography. Arch Surg 1985;120:550-554
14. Evins SC, Thomason B, Rosenblum R: Non-operative man-agement ofsevere renal lacerations. J Urol 1980;123:247-249
15. Bivins BA, Jona JZ, Belin NP: Diagnostic peritoneal la-vage in pediatric trauma. J Trauma 1976;16:739-742 16. Bivins BA, Sachatello CR, Daugherty ME, et al:
Diag-nostic peritoneal lavage is superior to the clinical evalu-ation in blunt abdominal trauma. Am Surg 1978;44:637-641
17. Fischer RP, Beverlin BC, Engrav LH, et al: Diagnostic
peritoneal lavage-Fourteen years and 2,586 patients
later. Am J Surg 1978;136:701-704
18. Thal ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. Am J Surg 1973;125:64-69
19. Nelson EW, Holliman CJ, Juell BE, et al: computerized tomography in the evaluation ofblunt abdominal trauma.
Am J Surg 1983;146:751-754
20. Sherck JP, McCort JJ, Oakes DD: Computed tomography in thoracoabdominal trauma. J Trauma 1984;24:1015-1021
21. Mall JC, Kaiser JA: CT diagnosis of splenic laceration.
AJR 1980;134:265-269
22. Korobkin M, Moss AA, Callen PW, et al: Computed to-mography of subcapsular splenic hematoma. Radiology
1978;129:441-445
23. Jeffrey RB, Laing FC, Federle MP, et al: Computed to-mography ofsplenic trauma. Radiology 1981;141:729-732 24. Moon KL, Federle MP: Computed tomography in hepatic
trauma. AJR 1983;141:309-314
25. Federle MP, Kaiser JA, McAninch JW, et al: The role of computed tomography in renal trauma. Radiology 1981; 141:455-460
26. Sandler CM, Toombs BD: Computed tomographic evalu-ation in blunt renal injuries. Radiology 1981;141:461-466
27. Cook DE, Walsh JW, Vick CW, et al: Upper abdominal
trauma: pitfalls in CT diagnosis. Radiology 1986;159:65-69
28. Federle MP, Jeffrey RB: Hemoperitoneum studied by corn-puted tomography. Radiology 1983;148:187-192
29. Mucha P: Changing attitudes towards the management of blunt splenic trauma in adults. Mayo Clin Proc
1986;61:472-477
30. Jeffrey RB, Federle MP, Crass RA: Computed tomography of pancreatic trauma. Radiology 1983;147:491-494
