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Pencitraan trauma abdomen pada anak
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Oleh :Argadia Y.
IMAGING CHILDREN WITH ABDOMINAL TRAUMA
Journal Reading Tugas Stase Radiologi
Pembimbing :Prof. Dr. dr. Suyono, Sp.Rad(K)
Carlos J. Sivit
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Latar Belakang Salah satu penyebab mortalitas dan
morbiditas pada anak
TRAUMA ABDOMENPADA ANAK
Penyebab :
Perbedaan anatomi dan fungsiAnak vs Dewasa
TIDAK SEMUA TRAUMA ABDOMEN PADA ANAK MEMERLUKAN TINDAKAN OPERASI
PENCITRAAN Trauma Abdomen• Diagnosis• Evaluasi
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ANATOMI ABDOMEN
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ANATOMI ABDOMEN
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ANATOMI ABDOMEN
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PRINSIP TRAUMA ABDOMEN PADA ANAK
KLINIS lebih penting
Anamnesis dan Pemeriksaan Fisik Pemeriksaan Penunjang (laboratorium, radiologi)
Anamnesis
• Keluhan Utama• Nyeri Perut• Hematuria
• Riwayat Penyakit Sekarang• Riwayat Penyakit Dahulu
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PRINSIP
Pemeriksaan Fisik TANDA VITAL• Tekanan Darah• Laju Nadi• Laju Nafas• Suhu tubuh• Saturasi SiO2
Utamakan untuk mengatasi
kegawatan terlebih dahulu
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PRINSIP
Higher risk of abdominal injury• gross hematuria,• abdominal tenderness,• ecchymoses, • a low trauma scoreLow risk of abdominal injury• Asymptomatic
hematuria • Neurologic impairment
in the absence of abdominal signs and symptoms
Pemeriksaan Fisik
(Taylor GA, dkk., 1994; Cotton BA, 2003)
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PRINSIP TRAUMA ABDOMEN PADA ANAK
Suara usus berkurang Vomitus
Hematemeis/Melena
Hematuria•Indikator cedera renal
Pemeriksaan Fisik
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PRINSIP
Hematuria,
Abdominal bruising /
ecchymosis,
Abdominal distention,
Abdominal pain,
INDIKASI PEMERIKSAAN RADIOLOGIDitemukan pemeriksaan fisik dan laboratorium yang menunjukkan kecurigaan ke arah injuri abomen, seperti :
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Computed Tomography (CT)
Lebih akurat dalam mendeteksi dan kuantifikasi cedera organ abdomen baik pada organ solid maupun berongga
Dapat mengidentifikasi cairan-darah intraperitoneal atau extraperitoneal serta perdarahan aktif
Dapat memperlihatkan lesi trauma pada tulang rusuk, vetebrata, dan pelvis
Pemeriksaan pilihan untuk trauma abdomen
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Computed Tomography (CT)
Injeksi Kontras I.V dapat digunakan untuk memperjelas pencitraan
Kontras peroral masih kontroversi
Pemeriksaan
KONTRA INDIKASI PENGGUNAAN CT PADA TRAUMA ABDOMEN :
Hemodinamika pasien tidak stabil
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SONOGRAFI
MANFAAT Deteksi ada tidaknya hemoperitoneum Pilihan utama pada pasien trauma dengan hemodinamika tidak
stabil (mobile) focused abdominal sonography for trauma (FAST)
Sonografi punya keterbatasan
KEKURANGAN Sonografi tidak dapat meilhat cedera pelvis dan spinal Tidak dapat menilai organ berongga 25-30% kesalahan menilai cedera organ solid
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CEDERA HEPARPencitraan Trauma Abdomen Pada Anak
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CEDERA HEPARAnatomi liver
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CEDERA HEPARANATOMI LIVER Segmen Hepar Fungsional :
• Lobus Kiri– Segment I - IV
• Lobus Kanan– Segmen V – VIII
• Masing-masing segmen disuplai oleh arteri dan vena yang berbeda
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CEDERA HEPAR
Most commonly injured or second most commonly injured solid viscera after blunt trauma
Most hepatic injury occurs in the posterior segment of the right lobe
Liver Injury
lacerationhematoma
Cedera vascular
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CEDERA HEPARAAST liver injury grading system
Grade Type of Injury Description of injury
IHaematoma • Sub capsular, < 10% surface area
Laceration • Capsular tear, < 1cm depth
IIHaematoma • Sub capsular, 10 - 50% surface area
• Intraparenchymal < 10cm diameter Laceration Capsular tear, 1 - 3cm depth, < 10cm length
IIIHaematoma • Sub capsular, > 50% surface area, or ruptured with active bleeding
• intraparenchymal > 10 cm diameterLaceration Capsular tear, > 3 cm depth
IVHaematoma Ruptured intraparenchymal with active bleeding
Laceration • Parenchymal distruption involving 25 - 75% hepatic lobes or • involves 1-3 Couinaud segments (within one lobe)
VLaceration • Parenchymal distruption involving >75% helpatic lobe or
• Involves > 3 Couinaud segments (within one lobe)Vascular Juxtahepatic venous injuries (IVC, major hepatic vein)
VI Vascular Hepatic avulsion
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CEDERA HEPAR
Liver Laceration
Grade 1
•Less than ½ inch (1 cm).
Grade 2
•½ -1 inch deep (1 to 3 cm). It is less than 4 inches long (10 cm).
Grade 3
•more than 1 inch deep (3 cm).
Grades 4 and
5:
•These lacerations are very deep. They affect a large part of the liver
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CEDERA HEPARLiver Laceration
• 8-year-old boy with hepatic laceration. Coronal reformation of contrast-enhanced CT scan through upper abdomen shows complex hepatic laceration.
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CEDERA HEPARLiver Laceration
• Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick
http://uvmrads.org/clinical-resources/bodyct/86-liver-lacerations-aast-criteria-and-examples.html?showall=1&limitstart=
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CEDERA HEPARLiver Laceration
• Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter
http://uvmrads.org/clinical-resources/bodyct/86-liver-lacerations-aast-criteria-and-examples.html?showall=1&limitstart=
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CEDERA HEPARLiver Laceration
• Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization
http://uvmrads.org/clinical-resources/bodyct/86-liver-lacerations-aast-criteria-and-examples.html?showall=1&limitstart=
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CEDERA HEPARLiver Subcapsular Hematoma • 12-year-old boy with
subcapsular hematoma of liver– A, Contrast-enhanced
CT scan through upper abdomen shows laceration extending to periphery of liver with associated subcapsular hematoma.
– B, CT scan obtained 2 cm below A shows inferior extension of subcapsular hematoma. Note compression of underlying hepatic parenchyma
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CEDERA HEPARLiver Vascular Injury
5-year-old boy with vascular injury in posterior segment of right hepatic lobe.
Contrast enhanced CT scan through upper abdomen shows absence of contrast enhancement in posterior segment of right hepatic lobe.
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CEDERA LIMFA / SPLEENPencitraan Trauma Abdomen Pada Anak
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CEDERA LIMFA
Organ Solid Berukuran lebih kecil daripada
hepar
Pecah & terfragmen Nyeri perut kiri atas, fraktur iga kiri bawah, kontusio pada
abdomen regio kiri atas LESI : Contusion, parenchymal laceration, subcapsular
hematoma, perisplenic hematoma, fragmentation of parenchyma and disruption of hilar vessels Tidak selalu terjadi hemoperitonium
TRAUMA
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CEDERA LIMFAAAST SPLENIC INJURY SCALE
Grade Keterangan
I Subcapsular hematoma of less than 10% of surface area or capsular tear of less than 1 cm in depth
IISubcapsular hematoma of 10%–50% of surface area, intraparenchymal hematoma of less than 5 cm in diameter, or laceration of 1–3 cm in depth and not involving trabecular vessels
IIISubcapsular hematoma of more than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma, intraparenchymal hematoma of more than 5 cm or expanding, or laceration of more than 3 cm in depth or involving trabecular vessels
IV Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen
V Shattred spleen or hilar vascular injury
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Cedera LimfaKontusio
• Contusion = hypodense area within normally perfused splenic parenchyma
www.RiTradiology.com
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CEDERA LIMFA
• 14-year-old boy with shattered spleen.
• A and B, Contrast-enhanced CT scans through upper abdomen (A) and 2 cm lower (B) show shat tered spleen
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Cedera LimfaLaceration
• Laceration = linear perfusion defect
www.RiTradiology.com
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CEDERA LIMFALaceration
• 12-year-old boy with splenic laceration and associated intraparenchymal hematoma.
• Contrast enhanced CT scan through upper abdomen shows splenic laceration and associated intraparenchymal hematoma
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CEDERA LIMFASubcapsular hematom
• Subcapsular hematoma = lenticular shape with compression of adjacent splenic paenchyma – Difficult to confidently
see splenic capsule– Sometimes difficult to
distinguish between subcapsular and perisplenic hematoma
www.RiTradiology.com
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CEDERA LIMFA• 15-year-old boy with
splenic injury and retroperitoneal extension of hemorrhage.
• Contrast enhanced CT scan through upper abdomen shows splenic laceration associated with blood in anterior pararenal space surrounding pancreas.
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CEDERA RENALPencitraan Trauma Abdomen Pada Anak
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CEDERA RENAL
Cedera organ solid abdomen tersering ketiga setelah trauma tumpul
Terutama trauma pada punggung Pemeriksaan CT jika :
Nyeri pinggang + Riw Trauma + Hematuria Hematuria Makroskopis + Pasien stabil + Tidak ada cedera
urethral JENIS LESI :
Contusion, laceration, subcapsular hematoma, shattered kidney, renal artery occlusion
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CEDERA RENALRENAL CONTUSION
• Renal contusion: focal zones of decreased enhancement, striated nephrogram because of temporarily impaired tubular excretion
www.RiTradiology.com
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CEDERA RENALRENAL CONTUSION
• 10-year-old girl with renal contusion.
• Contrast-enhanced CT scan through mid abdomen shows rounded focus of low at tenuation in midpole of left kidney indicative of contusion
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CEDERA RENALRENAL LACERATION
• Laceration: linear or wedge-shaped hypodense area – Fracture = involving
medial and lateral surface of kidney through hilum
– Shattered kidney = laceration crossing kidney resulting in multiple fragments
www.RiTradiology.com
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CEDERA RENALRENAL LACERATION • 14-year-old boy with
renal collecting system injury.
• A, Contrast-enhanced CT scan through mid abdomen shows left renal laceration with surrounding perinephric hematoma.
• B, Delayed image obtained 5 minutes af ter A shows extravasation of IV contrast material into perirenal space
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CEDERA RENALLaceration + Extravasation
• Deep laceration results in urine extravasation
• Delayed scan for comfirmation
www.RiTradiology.com
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CEDERA RENALRENAL HEMATOMA • KIRI : 12-year-old boy with
subcapsular renal hematoma.
• Contrast-enhanced CT scan through mid abdomen shows large lef t-sided subcapsular hematoma compressing renal parenchyma
• Kanan : 10-year-old girl with perinephric hematoma.
• Sagittal reformation of contrast-enhanced CT scan through mid abdomen shows renal laceration associated with perinephric hematoma distributed through perirenal space
Renal hematom
Subcapsular Perinephric
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CEDERA RENALOcclusion
• Occlusion of main renal artery
• Cortical enhancement du to patent capsular arteries originating proximal to occlusion should always raise suspicion of injury to main renal artery
www.RiTradiology.com
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CEDERAL RENALVASCULAR INJURY
15-year-old boy with vascular injury of left kidney. • Contrast-enhanced CT
scan through mid abdomen shows devascularization of left kidney after left renal artery avulsion
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CEDERA PANKREASPencitraan Trauma Abdomen Pada Anak
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CEDERA PANKREAS
Frekuensi lebih jarang (< 2%) Menyertai pada cedera organ multiple MEKANISME
Cedera pada badan pankreas : Kompresi dengan tulang vetebrate
Kepala / Ekor : Pecah: KLINIS :
Sering tidak bergejala karena berukuran kecil dan dikelilingi oleh lemak
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CEDERA PANKREAS
Komplikasi : Pankreatitis berulang, fistula, abses, perdarahan
Resiko terjadinya abses & fistula• Disrupsi duktus (25-50%)• Tanpa Disrupsi duktus (10%)
LESI : Contusio, Laserasi superfisial atau parsial, transeksi komplit atau disrupsi
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CEDERA PANKREAS
Memprediksi ada tidaknya disrupsi duktus dengan mengetahui kedalaman dan lokasi laserasi ;
GRADE A•Pancreatitis atau laserasi superfisial•<50% ketebalan pankreas
GRADE B•Laserasi dalam (>50% ketebalan) pada ekor
GRADE C•Laserasi dalam pada kepala
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CEDERA PANKREASTRANSEKSI
11-year-old boy with pancreatic transection.• Contrast-enhanced CT
scan through upper abdomen shows pancreatic transection at junction of head and body.
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CEDERA PANKREASPeripancreatic Fluid 10-year-old girl with
pancreatic injury and associated peripancreatic fluid. • Contrast-enhanced CT
scan through upper abdomen shows fluid is in anterior pararenal space surrounding pancreas.
• Also note fluid dissecting between splenic vein and pancreas
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CEDERA PANKREAS
Pancreatitisfocal or diffuse gland enlargement, stranding of peripancreatic or mesenteric fat, thickening of the anterior renal fascia, and free peritoneal fluid
peripancreatic fluid collections Pseudocyst
KOMPLIKASI
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CEDERA PANKREASPancreatic enlargement Direct CT signs:
• Pancreatic enlargement, focal linear nonenhancement, comminution, heterogeneous enhancement (subtle initially)
Indirect CT signs: • Peripancreatic fat
stranding, fluid collections, fluid separating splenic vein from parenchyma, hemorrhage, and thickening of left anterior pararenal fascia
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CEDERA PANKREASPancreatitis
12-year-old boy with acute pancreatitis after pancreatic trauma. • Contrast-enhanced CT
scan through upper abdomen shows stranding of peripancreatic fat and ill-definition of pancreaticborders
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CEDERA PANKREASPancreatic Pseudocyst 11-year-old boy with
pancreatic pseudocyst.• A, Contrast-enhanced
CT scan through upper abdomen shows laceration through head of pancreas.
• B, Follow-up CT scan obtained 5 weeks af ter A shows focal fluid collection representing pancreatic pseudocyst is in head of pancreas and is extending into anterior pararenal space.
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PERDARAHAN AKTIFPencitraan Trauma Abdomen Pada Anak
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PERDARAHAN AKTIF
Sign a contrast “blush,” which is defined as highattenuation Areas (> 90 HU) after IV contras
Hemoperitonium Tidak menggambarkan perdarahan aktif
Perdarahan AktifHemodinamika
Tidak stabil
Hemodinamika stabil Pemeriksaan CT
KONTRAINDIKASI CT
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PERDARAHAN AKTIFLinear high-attenuation
8-year-old boy with active hemorrhage.• Contrast-enhanced CT
scan through mid abdomen shows linear high-attenuation collection representing IV contrast extravasation from splenic arterial tear
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PERDARAHAN AKTIFhigh-attenuation fluid
11-year-old boy with active hemorrhage.• Contrast-enhanced CT
scan through pelvis shows high-attenuation fluid representing active hemorrhage.
• At surgery tear of right iliac vein was noted
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PERDARAHAN AKTIFPseudoaneurysm
12-year-old boy with hepatic pseudoaneurysm. • Contrast-enhanced CT
scan through upper abdomen shows focal, rounded, enhancing lesion in posterior segment of right hepatic lobe. Also note large hepatic subcapsular hematoma
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PERDARAHAN AKTIF12-year-old girl with active hepatic hemorrhage that did not require laparotomy.• A, Contrast-enhanced CT
scan through upper abdomen shows hepatic laceration with focal area of increased attenuation representing active hemorrhage. Patient was managed nonoperatively.
• B, Follow-up CT scan obtained 2 weeks af ter A shows resolving low-attenuation hematoma within liver
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CEDERA USUSPencitraan Trauma Abdomen Pada Anak
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CEDERA USUS
Jarang terjadi (3-7% trauma tumpul abdominal) Tanda dan gejala : kadang tidak bergejala, minimal, atau
delayed Lesi :
Intramural hematom : • tersering duodenum• Gambaran penebalan dinding tanpa adanya
extravasasi kontras Ruptur usus : • Tersering jejenum
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CEDERA USUS
• Duodenal perforation vs hematoma– Perforation
Immediate surgery– Hematoma
Conservative
• Jika memungkinkan dapat diberika kontras peroral sebelum dilakukan CT
www.RiTradiology.com
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CEDERA USUSDuodenal Hematom (intramural hematom)
8-year-old boy with duodenal hematoma.• Contrast-enhanced CT
scan through upper abdomen shows rounded duodenal hematoma to left of midline
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CEDERA USUS
Tanda Radiologi Udara Extraluminal 1/3 kasus Ekstravasasi kontras jarang terlihat “unexplained” peritoneal fluid (tanpa cedera organ solid dan
fraktur pelvis) 50% kasus Lain-lain :
• Abnormally intense bowel wall enhancement, • focal bowel wall discontinuity, • bowel dilatation, • Bowel wall thickening, • streaky infiltration of mesenteric fat • Associated mesenteric injury or • chemical irritation of the mesentery from spilled intestinal contents
Ruptur Usus
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CEDERA USUSbowel rupture
10-year-old girl with bowel rupture associated with extraluminal air. • Contrast-enhanced CT
scan through upper abdomen shows extraluminal air.
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CEDERA USUSbowel rupture
9-year-old boy with bowel rupture associated with oral contrast extravasation. • CT scan through upper
abdomen shows extravasated high-at tenuation oral contrast material in peritoneal cavity.
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CEDERA USUS“unexplained” peritoneal fluid 12-year-old boy with bowel
rupture associated with large amount of “unexplained” peritoneal fluid.• A, Contrast-enhanced CT
scan through upper abdomen shows large amount of peritoneal fluid in perihepatic and perisplenic spaces.
• B, CT scan through mid abdomen shows large amount of fluid in right and left paracolic spaces. Patient did not have any other abnormalities at CT. At surgery, jejunal rupture was noted.
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CEDERA USUSbowel wall discontinuity
9-year-old boy with bowel rupture associated with bowel wall discontinuity. • Contrastenhanced• CT scan through upper
abdomen shows discontinuity in wall of Duodenum indicative of bowel wall rupture
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CEDERA USUS• Direct CT signs: 1)
Discontinuity of wall, spillage of contrast or luminal contents into peritoneal or retroperitoneal. 2) Extraluminal air (definite for blunt trauma but not for penetrating trauma)
• Indirect CT signs: 1) Focal bowel wall thickening, streaky mesenteric fat, unexplained free fluid between mesenteric loops. 2) Generalized bowel wall thickening nonspecificwww.RiTradiology.com
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CEDERA KANDUNG KEMIHPencitraan Trauma Abdomen Pada Anak
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CEDERA KANDUNG KEMIH Jarang terjadi Ekstravasasi ruptur
Intraperitonial• Trauma kandung kemih yang penuh• Perlu tindakan operasi segera
Ekstraperitonial• Lebih sering• Laserasi karena fraktur tulang pelvis
(obturator ring fractures, pubic symphysis diastasis, sacral fractures, and sacroiliac joint diastasis)
• Tidak memerlukan tindakan operasi segera
CT cystography retrogard
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CEDERA KANDUNG KEMIH
Penentuan lokasi ekstravasi PENTING
INTRAPERITONIAL EKSTRAPERITONIAL
Lateral peravesical spaces superior to the bladder and anterior to the rectosigmoid Colon
• the peravesical space that surrounds the bladder superiorly and anteriorly to the umbilicus and posteriorly behind the rectum
• pelvic fluid is noted lateral to the bladder or behind the rectum,
Fluid superior and anterior to the bladder
more lateral location and will typically be contiguous with fluid in the lateral pericolic spaces
Fluid extend superiorly and anteriorly to the level of the umbilicus
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CEDERA KANDUNG KEMIH
Intraperitoneal rupture • More frequently
caused by direct perforation of bone fragment (> rupture of distended bladder)
• Plugged by omentum or bowel loops making it difficult to detect
• Surgical Rx
www.RiTradiology.com
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CEDERA KANDUNG KEMIH
15-year-old girl with intraperitoneal bladder rupture.• Contrast-enhanced CT
scan through upper pelvis shows high-attenuation fluid in lateral pelvic recess secondary to intraperitoneal bladder ruptur
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CEDERA KANDUNG KEMIH
Extraperitoneal rupture • Direct perforation by
bony fragment, rupture of pubovesical ligament near bladder neck after symphysis injury or contusion of distended UB Often involves anterior bladder wall near neck
• Conservative Rx
www.RiTradiology.com
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CEDERA KANDUNG KEMIH12-year-old girl with extraperitoneal bladder rupture. • Contrast-enhanced CT
scan through pelvis shows high-attenuation fluid adjacent to right pelvic side wall and low-attenuation fluid posterior to rectum.
• These fluid collections are extraperitoneal in location, consistent with extraperitoneal bladder rupture
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KOMPLEK HIPOPERFUSIPencitraan Trauma Abdomen Pada Anak
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KOMPLEK HIPOPERFUSI
Tanda syok hipovolemik
Pasien Stabil Syok Hipovolemik
CT : komplek hipoperfusi
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KOMPLEK HIPOPERFUSI
Komplek Hipoperfusi
Tanda awal syok hipovolemik Komponen :
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KOMPLEK HIPOPERFUSIKomponen Vaskular
Flatening IVC• Reduced venous
return secondary to systemic hypotension
• Radigraph Definition :– AP diameter < 9 mm– Measured at 3 level
(Intrahepatic IVC, Renal artery, 2 cm below renal arteryNORMAL IVC NARROWED IVC
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KOMPLEK HIPOPERFUSIKomponen Vaskular
• Flat IVC, small aorta, hyperenhanced kidneys, hyperenhanced GI mucosa, and peripancreatic edema caused by hypoperfusion state from left pelvic ring injury
www.RiTradiology.com
84
KOMPLEK HIPOPERFUSIKomponen Vaskular
HALO SIGN• Circumferential zone
of low attenuation (<20HU) around a collapsed intrahepatic IVC
• Extracellular fluid• Common Location :
Superior segment of the liver
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KOMPLEK HIPOPERFUSIKomponen Vaskular
SMALL CALIBRE AORTA• Sering ditemukan• Define as calibre
<13mm at a level 2 cm below and above the origin of renal aorta
• Not spesificNORMAL IVC Small Calibre Aorta
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Komplek HipoperfusiKomponen Viseral
Splenic Hypoperfusion• Arterial flow to the
spleen lacks autoregulatory mechnisms
• Highly sensitive to sympathetic stimulation vasocontriction in the situation of hypoperfusion
Normal Perfusion Spleen Hypoperfusion Spleen
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KOMPLEK HIPOPERFUSIKomponen Visceral 2-year-old girl with
hypoperfusion complex.• A and B, Contrast-
enhanced CT scans through upper (A) and mid (B) abdomen show diffuse intestinal dilatation with fluid, intense contrast enhancement of bowel wall, and diminished caliber of great vessels indicative of systemic hypoperfusion.
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KOMPLEK HIPOPERFUSI3-year-old boy with hypoperfusion complexand absence of pancreatic enhancement.• Contras tenhanced CT
scan through upper abdomen shows absence of pancreatic enhancement Pancreas appeared normal at surgery.
• Findings were thought to be secondary to systemic hypoperfusion.
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Komplek HipoperfusiKomponen Viseral
Increased adrenal gland enhancement
• Attenuation value equal or greater than thos of IVC
• Usually symmetrical• May be due to a
protentive sympathetic respone to preserve the vital organ
Normal adrenal enhancement
90
Komplek HipoperfusiKomponen Viseral
Intense renal parenchymal enhancement
• ↓ systolic presure vasocontriction of glomerular arteriolar increased resorption of salt and water
• A prolonge, abnormally intense nephogram
Normal Kidney
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Komplek HipoperfusiKomponen Viseral
SHOCK BOWEL• Increased mucosal
enhancement (HU > Poas muscle)
• Mural Thickening > 3mm
• MIRIP : Bowel perforation (+free fluid)Normal bowel
Increased bowel wall thickness
Increased Enhancement
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KOMPLEK HIPOPERFUSI2-year-old boy with hypoperfusion complex associated with free peritoneal fluid. • Contrastenhanced CT
scan through mid abdomenshows diffuse intestinal dilatation with fluid, intense contrast enhancement of bowel wall, and diminished caliber of great vessels indicative of systemic hypoperfusion.
• Also note free peritoneal fluid in both paracolic spaces.
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CLINICAL DECISIONPencitraan Trauma Abdomen Pada Anak
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Pasien Datang
Pasien trauma Pasien lain tersangka trauma
Anamnesis & Px Fisik HEMATURIA
Hemodinamika Tidak Stabil
Hemodinamika Stabil
“FAST” Sonography CT
Hemodinamika
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