Abdominal CT: spleen, liver, and pancreas injury

Diagnosing splenic injuries

The spleen is the most commonly injured organ in abdominal trauma

When the spleen is injured, there is usually blood around it. Additionally, the presence of overlying lower left rib fractures can raise suspicion of a possible splenic injury as the two often occur together. Preserving the spleen is a priority following trauma due to its important role in immune function. Accurately reporting splenic injuries helps the trauma team understand the extent of parenchymal and vascular injury, which will help direct the next steps in management.

Haematoma

Subtle injuries on the surface of the spleen are small hematomas with subcapsular blood indenting the spleen.

Laceration

In the CT shown next, you can see tearing of the organ tissue, which is called a laceration. Lacerations often follow a linear or branching pattern and can extend partially or completely through the spleen. When they extend to the hilum, there is an increased risk of vascular injury.

Complex laceration

Next is a more severe injury, with a large, branching laceration, which extends toward the hilum and has caused vascular injury. On the coronal image below, the lower half of the spleen is seen to have lost blood flow and is infarcted.

Pseudoaneurysm

This little blush of bright contrast within a laceration indicates a traumatic pseudoaneurysm where an injured blood vessel wall has caused blood to leak and collect outside of the artery. Pseudoaneurysms need to be followed and considered for embolization therapy due to the risk of further bleeding.

Shattered spleen

A shattered spleen is the most severe type of splenic injury, and it usually requires surgical attention.

In the axial image below, the case of severe splenic trauma has branching, complex lacerations causing complete disruption of the organ tissue. This type of injury is often associated with active bleeding.

On the coronal image below, you can see bright jets of contrast emanating from the injury. Active arterial bleeding will be similar in brightness to the aorta, as they are both comprised of contrast-opacified arterial blood.

Delayed scans

Many trauma scans will have delayed phase images taken a few minutes after the initial scan. On the initial scan, active bleeding will be a similar brightness to the aorta. On the delayed images, that bright contrast will disperse and fade into the surrounding blood.

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Diagnosing liver injuries

The liver follows a similar pattern of injury as the spleen. Liver injuries range from subtle subcapsular hematoma to lacerations of various depths and complexity.

Thin and Complex lacerations

Thin lacerations are relatively subtle linear areas of decreased enhancement.

The image shows an example of thin lacerations of the posterior liver (left) and branching, complex lacerations throughout the liver extending toward the hilum (right)

Devascularization

Below you see an extensive, complex injury to the liver with large, branching lacerations anteriorly and a severe devascularization injury resulting in decreased or absent enhancement to much of the posterior right hepatic lobe.

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Pancreatic injuries

Pancreatic injury is relatively uncommon due to its deep positioning in the abdomen. It is caused by severe blunt trauma and is usually associated with severe trauma to other organs, especially duodenal injury.

Pancreatic injury should be considered when there is surrounding blood, linear lacerations through the pancreas tissue, or disrupted enhancement.

Thin laceration

In our next example, there is a thin linear laceration through the pancreas tail. This might be easy to overlook, but the surrounding dense fluid and adjacent splenic injury help raise your suspicion

Transection

In the example below, a more severe injury has resulted in transection of the pancreas neck. The direction of blunt trauma through the anterior abdomen can be inferred from a large liver laceration that points directly at the pancreas injury.

Devascularization

In the next example, the pancreatic tissue is enlarged and enhances less than would be expected, especially compared to the normal pancreatic tail. This is consistent with a large devascularization injury which was later confirmed by magnetic resonance imaging (MRI).

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References

• Top 100 CT scan quiz. LITFL

Radiology Library: Abdominal Trauma. Solid organ injury

• Hartung MP. Abdominal Trauma: solid organ injuries
• Hartung MP. Abdominal Trauma: spleen, liver, and pancreas injury
• Hartung MP. Abdominal Trauma: renal, ureter, and adrenal injury
• Hartung MP. Abdominal Trauma: solid organ injury [case study]

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