DOI: 10.1148/rg.251045079
CT in Blunt Liver Trauma1
Woong Yoon, MD,
Yong Yeon Jeong, MD,
Jae Kyu Kim, MD,
Jeong Jin Seo, MD,
Hyo Soon Lim, MD,
Sang Soo Shin, MD,
Jung Chul Kim, MD,
Seong Wook Jeong, MD,
Jin Gyoon Park, MD and
Heoung Keun Kang, MD
1 From the Departments of Radiology (W.Y., Y.Y.J., J.K.K., J.J.S., H.S.L., S.S.S., J.G.P., H.K.K.), Surgery (J.C.K.), and Anesthesiology (S.W.J.), Chonnam National University Hospital, Chonnam National University Medical School, 8 Hak-dong, Dong-Ku, Gwangju 501–757, South Korea. Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Scientific Assembly. Received April 19, 2004; revision requested May 17 and received June 4; accepted June 7. All authors have no financial relationships to disclose. Address correspondence to W.Y. (e-mail: radyoon@chonnam.ac.kr).
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Figure 1. Hepatic laceration. Contrast-enhanced CT scan shows multiple linear and branching low-attenuation areas in the right hepatic lobe (arrows) that represent lacerations.
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Figure 2. Complex hepatic laceration. Contrast-enhanced CT scan shows multiple linear lacerations ("bear claw" lacerations) in the left hepatic lobe (arrows). Note that the lacerated area extends to the porta hepatis. This type of laceration is commonly associated with biliary system injury.
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Figure 3. Bare area hepatic injury. Contrast-enhanced CT scan shows multiple lacerations (arrowheads) and a parenchymal hematoma that extend into the bare area of the liver, resulting in retroperitoneal hematoma. Note the hemorrhagic fluid surrounding the IVC and the associated hematoma in the right adrenal gland (arrow).
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Figure 4. Subcapsular hematoma. Contrast-enhanced CT scan shows multiple subcapsular hematomas in the right and left hepatic lobes (arrows). Multifocal intraparenchymal hematomas are also seen (arrowheads).
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Figure 5. Intraparenchymal hematoma. Contrast-enhanced CT scan shows a 5-cm intraparenchymal hematoma in the medial segment of the left hepatic lobe (arrow). Arrowheads indicate associated hemoperitoneum in the right subphrenic space.
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Figure 6. Hepatic hematoma. Unenhanced CT scan shows a high-attenuation hematoma in the anterior segment of the right hepatic lobe (arrow). Note the halo of low attenuation surrounding the hematoma (arrowheads).
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Figure 7a. Active hemorrhage. (a) Arterial phase contrast-enhanced CT scan shows high-attenuation contrast material extravasation (arrow) within a massive hematoma in the posterior right hepatic lobe. (b) Radiograph obtained after injection of contrast material through a microcatheter in the right hepatic artery (arrowheads) shows active contrast material extravasation from the superior segmental branch of the artery (arrows).
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Figure 7b. Active hemorrhage. (a) Arterial phase contrast-enhanced CT scan shows high-attenuation contrast material extravasation (arrow) within a massive hematoma in the posterior right hepatic lobe. (b) Radiograph obtained after injection of contrast material through a microcatheter in the right hepatic artery (arrowheads) shows active contrast material extravasation from the superior segmental branch of the artery (arrows).
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Figure 8a. Active hemorrhage. (a) Contrast-enhanced CT scan shows high-attenuation arterial extravasation (arrow) within an intraparenchymal hematoma in the right hepatic lobe. (b) Celiac arteriogram shows active extravasation from a branch of the right hepatic artery (arrow).
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Figure 8b. Active hemorrhage. (a) Contrast-enhanced CT scan shows high-attenuation arterial extravasation (arrow) within an intraparenchymal hematoma in the right hepatic lobe. (b) Celiac arteriogram shows active extravasation from a branch of the right hepatic artery (arrow).
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Figure 9a. Active hemorrhage. (a) Contrast-enhanced CT scan shows active arterial bleeding (arrows). (b) Celiac arteriogram shows contrast material extravasation from a branch of the right hepatic artery (arrow). The patient was treated with transarterial embolization. (c) Postembolization angiogram shows embolized microcoils (arrows) and no further extravasation.
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Figure 9b. Active hemorrhage. (a) Contrast-enhanced CT scan shows active arterial bleeding (arrows). (b) Celiac arteriogram shows contrast material extravasation from a branch of the right hepatic artery (arrow). The patient was treated with transarterial embolization. (c) Postembolization angiogram shows embolized microcoils (arrows) and no further extravasation.
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Figure 9c. Active hemorrhage. (a) Contrast-enhanced CT scan shows active arterial bleeding (arrows). (b) Celiac arteriogram shows contrast material extravasation from a branch of the right hepatic artery (arrow). The patient was treated with transarterial embolization. (c) Postembolization angiogram shows embolized microcoils (arrows) and no further extravasation.
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Figure 10. Hepatic venous injury. Contrast-enhanced CT scan shows a laceration that extends into the IVC and cutoff of right hepatic venous drainage (arrow). Hemorrhagic fluid is seen around the IVC. Surgery revealed a laceration of the right hepatic vein.
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Figure 11. Periportal low attenuation. Contrast-enhanced CT scan shows low-attenuation areas around the portal vein and its branches (arrowheads). Note the laceration that extends into the porta hepatis (arrow). A finding of marked distention of the IVC may indicate vigorous fluid replacement.
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Figure 12. Flat IVC. Contrast-enhanced CT scan shows the IVC with a flat appearance (arrow) below the level of the right renal vein, a finding that suggests hypovolemia or shock. Active hemorrhage into the peritoneal cavity is also seen (arrowheads).
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Figure 13. Grade I hepatic injury. Contrast-enhanced CT scan shows a focal capsular tear in the posterior right hepatic lobe (arrow). An associated small perihepatic hemorrhage is also seen (arrowheads).
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Figure 14. Grade II hepatic injury. Contrast-enhanced CT scan demonstrates a hepatic laceration less than 3 cm in depth in the posterior right hepatic lobe (arrow). Note also the small fluid collection in the hepatorenal fossa (arrowheads).
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Figure 15. Grade II hepatic injury. Contrast-enhanced CT scan shows a lentiform, low-attenuation fluid collection (arrows) between the liver capsule (arrowheads) and enhancing liver parenchyma, a finding that suggests subcapsular hematoma. Note also the rib fracture.
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Figure 16. Grade III hepatic injury. Contrast-enhanced CT scan shows a subcapsular hematoma in the right hepatic lobe (arrows). Note the high-attenuation foci within the hematoma (arrowhead), findings that indicate active contrast material extravasation.
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Figure 17. Grade III hepatic injury. Contrast-enhanced CT scan shows hepatic lacerations greater than 3 cm in parenchymal depth, with a focus of active hemorrhage (arrowhead).
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Figure 18. Grade IV hepatic injury. Contrast-enhanced CT scan shows a ruptured intraparenchymal hematoma with active bleeding in the right hepatic lobe. Note also the associated large hemoperitoneum.
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Figure 19. Grade IV hepatic injury. Contrast-enhanced CT scan shows multiple hepatic lacerations in the right hepatic lobe, resulting in parenchymal disruption of about 50% of the lobe.
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Figure 20. Grade V hepatic injury. Contrast-enhanced CT scan shows a large intraparenchymal hematoma and lacerations that involve the entire right hepatic lobe and the medial segment of the left hepatic lobe.
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Figure 21. Grade V hepatic injury. Contrast-enhanced CT scan shows a deep hepatic laceration that extends into the major hepatic veins. Note the discontinuity of the left hepatic vein (arrowhead), a finding that indicates laceration. This finding was confirmed at surgery.
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Figure 22a. Delayed hemorrhage. (a) Initial contrast-enhanced CT scan shows multiple hepatic lacerations and hematoma in both hepatic lobes. One month later, the patient complained of a sudden onset of right quadrant abdominal pain. (b) Follow-up contrast-enhanced CT scan shows marked resolution of the parenchymal injury but a newly developed subcapsular hematoma due to delayed hemorrhage (arrowheads). The patient was successfully treated conservatively.
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Figure 22b. Delayed hemorrhage. (a) Initial contrast-enhanced CT scan shows multiple hepatic lacerations and hematoma in both hepatic lobes. One month later, the patient complained of a sudden onset of right quadrant abdominal pain. (b) Follow-up contrast-enhanced CT scan shows marked resolution of the parenchymal injury but a newly developed subcapsular hematoma due to delayed hemorrhage (arrowheads). The patient was successfully treated conservatively.
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Figure 23a. Hepatic abscess. (a) Aortogram shows active extravasation from a branch of the right hepatic artery (arrows). Arterial embolization was performed. (b) Contrast-enhanced CT scan obtained 3 weeks after embolization shows an encapsulated low-attenuation fluid collection (arrows) with multifocal gas bubbles, an appearance that suggests an abscess. Percutaneous catheter drainage was performed, and pus was aspirated. (c) Radiograph shows an abscess cavity (arrows) and embolized microcoils in the right hepatic artery (arrowheads).
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Figure 23b. Hepatic abscess. (a) Aortogram shows active extravasation from a branch of the right hepatic artery (arrows). Arterial embolization was performed. (b) Contrast-enhanced CT scan obtained 3 weeks after embolization shows an encapsulated low-attenuation fluid collection (arrows) with multifocal gas bubbles, an appearance that suggests an abscess. Percutaneous catheter drainage was performed, and pus was aspirated. (c) Radiograph shows an abscess cavity (arrows) and embolized microcoils in the right hepatic artery (arrowheads).
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Figure 23c. Hepatic abscess. (a) Aortogram shows active extravasation from a branch of the right hepatic artery (arrows). Arterial embolization was performed. (b) Contrast-enhanced CT scan obtained 3 weeks after embolization shows an encapsulated low-attenuation fluid collection (arrows) with multifocal gas bubbles, an appearance that suggests an abscess. Percutaneous catheter drainage was performed, and pus was aspirated. (c) Radiograph shows an abscess cavity (arrows) and embolized microcoils in the right hepatic artery (arrowheads).
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Figure 24a. Subphrenic abscess. (a) Initial contrast-enhanced CT scan shows a grade IV injury involving the hepatic dome. The patient was treated conservatively. (b) Follow-up contrast-enhanced CT scan obtained 21 days later reveals a well-defined low-attenuation fluid collection in the subphrenic region (arrows). Percutaneous catheter drainage was performed because the patient complained of high fever. (c) Contrast-enhanced CT scan obtained 28 days after percutaneous catheter drainage shows complete resolution of the abscess cavity.
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Figure 24b. Subphrenic abscess. (a) Initial contrast-enhanced CT scan shows a grade IV injury involving the hepatic dome. The patient was treated conservatively. (b) Follow-up contrast-enhanced CT scan obtained 21 days later reveals a well-defined low-attenuation fluid collection in the subphrenic region (arrows). Percutaneous catheter drainage was performed because the patient complained of high fever. (c) Contrast-enhanced CT scan obtained 28 days after percutaneous catheter drainage shows complete resolution of the abscess cavity.
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Figure 24c. Subphrenic abscess. (a) Initial contrast-enhanced CT scan shows a grade IV injury involving the hepatic dome. The patient was treated conservatively. (b) Follow-up contrast-enhanced CT scan obtained 21 days later reveals a well-defined low-attenuation fluid collection in the subphrenic region (arrows). Percutaneous catheter drainage was performed because the patient complained of high fever. (c) Contrast-enhanced CT scan obtained 28 days after percutaneous catheter drainage shows complete resolution of the abscess cavity.
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Figure 25a. Posttraumatic pseudoaneurysm. (a) Initial contrast-enhanced CT scan shows a large hematoma in the medial segment of the left hepatic lobe (arrows). (b) Contrast-enhanced CT scan obtained 14 days later shows a newly developed, well-circumscribed pseudoaneurysm within the hepatic hematoma (arrow). (c) On a celiac arteriogram, the pseudoaneurysm (arrow) is seen to arise from the left hepatic artery.
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Figure 25b. Posttraumatic pseudoaneurysm. (a) Initial contrast-enhanced CT scan shows a large hematoma in the medial segment of the left hepatic lobe (arrows). (b) Contrast-enhanced CT scan obtained 14 days later shows a newly developed, well-circumscribed pseudoaneurysm within the hepatic hematoma (arrow). (c) On a celiac arteriogram, the pseudoaneurysm (arrow) is seen to arise from the left hepatic artery.
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Figure 25c. Posttraumatic pseudoaneurysm. (a) Initial contrast-enhanced CT scan shows a large hematoma in the medial segment of the left hepatic lobe (arrows). (b) Contrast-enhanced CT scan obtained 14 days later shows a newly developed, well-circumscribed pseudoaneurysm within the hepatic hematoma (arrow). (c) On a celiac arteriogram, the pseudoaneurysm (arrow) is seen to arise from the left hepatic artery.
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Figure 26a. Hemobilia due to posttraumatic pseudoaneurysm in a 31-year-old man with a grade IV liver injury. The patient was treated conservatively. Twenty days later, the patient presented with massive hematemesis. (a) Contrast-enhanced CT scan shows a round, high-attenuation lesion within the hepatic contusion (arrow). (b) Radiograph obtained after injection of contrast material through a microcatheter demonstrates a pseudoaneurysm (arrow) that arises from a superior segmental branch of the right hepatic artery. (c) Common hepatic angiogram obtained after embolization shows complete occlusion of the segmental branch of the right hepatic artery with microcoils (arrow). The clinical outcome was uneventful.
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Figure 26b. Hemobilia due to posttraumatic pseudoaneurysm in a 31-year-old man with a grade IV liver injury. The patient was treated conservatively. Twenty days later, the patient presented with massive hematemesis. (a) Contrast-enhanced CT scan shows a round, high-attenuation lesion within the hepatic contusion (arrow). (b) Radiograph obtained after injection of contrast material through a microcatheter demonstrates a pseudoaneurysm (arrow) that arises from a superior segmental branch of the right hepatic artery. (c) Common hepatic angiogram obtained after embolization shows complete occlusion of the segmental branch of the right hepatic artery with microcoils (arrow). The clinical outcome was uneventful.
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Figure 26c. Hemobilia due to posttraumatic pseudoaneurysm in a 31-year-old man with a grade IV liver injury. The patient was treated conservatively. Twenty days later, the patient presented with massive hematemesis. (a) Contrast-enhanced CT scan shows a round, high-attenuation lesion within the hepatic contusion (arrow). (b) Radiograph obtained after injection of contrast material through a microcatheter demonstrates a pseudoaneurysm (arrow) that arises from a superior segmental branch of the right hepatic artery. (c) Common hepatic angiogram obtained after embolization shows complete occlusion of the segmental branch of the right hepatic artery with microcoils (arrow). The clinical outcome was uneventful.
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Figure 27a. Biloma and pseudoaneurysm. (a) Initial contrast-enhanced CT scan shows multiple lacerations and a hematoma in the right hepatic lobe and the medial segment of the left hepatic lobe. (b) Follow-up contrast-enhanced CT scan obtained 26 days later shows development of a biloma (arrow) and a pseudoaneurysm (arrowhead). The patient underwent transarterial embolization and percutaneous catheter drainage. Clear noninfected bile was drained. (c) Radiograph shows a drainage catheter within the biloma (arrow), partial filling of the pseudoaneurysm with contrast material (arrowhead), and embolized microcoils.
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Figure 27b. Biloma and pseudoaneurysm. (a) Initial contrast-enhanced CT scan shows multiple lacerations and a hematoma in the right hepatic lobe and the medial segment of the left hepatic lobe. (b) Follow-up contrast-enhanced CT scan obtained 26 days later shows development of a biloma (arrow) and a pseudoaneurysm (arrowhead). The patient underwent transarterial embolization and percutaneous catheter drainage. Clear noninfected bile was drained. (c) Radiograph shows a drainage catheter within the biloma (arrow), partial filling of the pseudoaneurysm with contrast material (arrowhead), and embolized microcoils.
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Figure 27c. Biloma and pseudoaneurysm. (a) Initial contrast-enhanced CT scan shows multiple lacerations and a hematoma in the right hepatic lobe and the medial segment of the left hepatic lobe. (b) Follow-up contrast-enhanced CT scan obtained 26 days later shows development of a biloma (arrow) and a pseudoaneurysm (arrowhead). The patient underwent transarterial embolization and percutaneous catheter drainage. Clear noninfected bile was drained. (c) Radiograph shows a drainage catheter within the biloma (arrow), partial filling of the pseudoaneurysm with contrast material (arrowhead), and embolized microcoils.
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Figure 28a. Biloma. (a) Initial contrast-enhanced CT scan shows lacerations in the left hepatic lobe. Note the extensive hemoperitoneum (H). (b) Follow-up contrast-enhanced CT scan obtained 1 week later reveals complete resolution of parenchymal injury. A small amount of hemoperitoneum persists in the left perihepatic space (arrowheads). The patient presented with fever and left upper quadrant pain 1 month after sustaining blunt liver trauma. (c) Follow-up contrast-enhanced CT scan reveals a large cystic lesion that had developed in the left upper abdominal cavity. (d) Radiograph obtained during percutaneous catheter drainage reveals a noninfected bile collection.
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Figure 28b. Biloma. (a) Initial contrast-enhanced CT scan shows lacerations in the left hepatic lobe. Note the extensive hemoperitoneum (H). (b) Follow-up contrast-enhanced CT scan obtained 1 week later reveals complete resolution of parenchymal injury. A small amount of hemoperitoneum persists in the left perihepatic space (arrowheads). The patient presented with fever and left upper quadrant pain 1 month after sustaining blunt liver trauma. (c) Follow-up contrast-enhanced CT scan reveals a large cystic lesion that had developed in the left upper abdominal cavity. (d) Radiograph obtained during percutaneous catheter drainage reveals a noninfected bile collection.
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Figure 28c. Biloma. (a) Initial contrast-enhanced CT scan shows lacerations in the left hepatic lobe. Note the extensive hemoperitoneum (H). (b) Follow-up contrast-enhanced CT scan obtained 1 week later reveals complete resolution of parenchymal injury. A small amount of hemoperitoneum persists in the left perihepatic space (arrowheads). The patient presented with fever and left upper quadrant pain 1 month after sustaining blunt liver trauma. (c) Follow-up contrast-enhanced CT scan reveals a large cystic lesion that had developed in the left upper abdominal cavity. (d) Radiograph obtained during percutaneous catheter drainage reveals a noninfected bile collection.
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Figure 28d. Biloma. (a) Initial contrast-enhanced CT scan shows lacerations in the left hepatic lobe. Note the extensive hemoperitoneum (H). (b) Follow-up contrast-enhanced CT scan obtained 1 week later reveals complete resolution of parenchymal injury. A small amount of hemoperitoneum persists in the left perihepatic space (arrowheads). The patient presented with fever and left upper quadrant pain 1 month after sustaining blunt liver trauma. (c) Follow-up contrast-enhanced CT scan reveals a large cystic lesion that had developed in the left upper abdominal cavity. (d) Radiograph obtained during percutaneous catheter drainage reveals a noninfected bile collection.
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Figure 29a. Bile peritonitis. (a) Initial contrast-enhanced CT scan shows foci of arterial extravasation (arrows) within a hepatic contusion in segment VI of the liver. (b) Unenhanced CT scan obtained 5 weeks later shows a large intraperitoneal fluid collection (F). The peritoneum is slightly thickened (arrowheads). The presence of intraperitoneal bile and bile peritonitis was confirmed at aspiration. The patient died of sepsis and acute renal failure 1 month later.
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Figure 29b. Bile peritonitis. (a) Initial contrast-enhanced CT scan shows foci of arterial extravasation (arrows) within a hepatic contusion in segment VI of the liver. (b) Unenhanced CT scan obtained 5 weeks later shows a large intraperitoneal fluid collection (F). The peritoneum is slightly thickened (arrowheads). The presence of intraperitoneal bile and bile peritonitis was confirmed at aspiration. The patient died of sepsis and acute renal failure 1 month later.
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Figure 30a. Nonsurgical management of severe hepatic injury. (a) Contrast-enhanced CT scan obtained at the time of admission shows grade IV injury with contrast material extravasation in the posterior right hepatic lobe (arrow). The patient was successfully treated with transcatheter arterial embolization. (b) Follow-up contrast-enhanced CT scan obtained 2 weeks later reveals resolution of the hepatic injury, with a well-defined subcapsular hematoma (H). Note the microcoils in the right hepatic artery (arrow).
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Figure 30b. Nonsurgical management of severe hepatic injury. (a) Contrast-enhanced CT scan obtained at the time of admission shows grade IV injury with contrast material extravasation in the posterior right hepatic lobe (arrow). The patient was successfully treated with transcatheter arterial embolization. (b) Follow-up contrast-enhanced CT scan obtained 2 weeks later reveals resolution of the hepatic injury, with a well-defined subcapsular hematoma (H). Note the microcoils in the right hepatic artery (arrow).
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Figure 31a. Complete resolution of a grade II liver injury with conservative treatment. (a) Contrast-enhanced CT scan obtained at the time of admission demonstrates a grade II injury with lacerations less than 3 cm deep in the posterior right hepatic lobe. (b) Follow-up contrast-enhanced CT scan obtained 1 week later shows complete resolution of the hepatic injury. The patient was discharged 1 day after undergoing follow-up CT.
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Figure 31b. Complete resolution of a grade II liver injury with conservative treatment. (a) Contrast-enhanced CT scan obtained at the time of admission demonstrates a grade II injury with lacerations less than 3 cm deep in the posterior right hepatic lobe. (b) Follow-up contrast-enhanced CT scan obtained 1 week later shows complete resolution of the hepatic injury. The patient was discharged 1 day after undergoing follow-up CT.
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Copyright © 2005 by the Radiological Society of North America.
