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Abdominal trauma
Traumatismo abdominal
G. Arenaza Choperenaa,
Corresponding author
, J. Cuetos Fernándezb, V. Gómez Usabiagaa, A. Ugarte Nuñoa, P. Rodriguez Calvetea, J. Collado Jiméneza
a Radiología de Urgencias, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
b Servicio de Radiología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Traumatic injuries continue to be the leading cause of death in people under the age of 45&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Because the effects of trauma on the body are random and it can affect different organs and systems&#44; an overall assessment of the patient must be performed&#46; Patients with multiple trauma require a rapid and accurate diagnosis focusing on the situations that may be imminently life-threatening&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this article&#44; we focus on blunt abdominal trauma&#44; which is much more common in our setting&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Aetiopathogenesis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Up to 75&#37; of abdominal injuries are due to road traffic accidents or falls from a height&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Intra-abdominal injuries are the result of different&#44; possibly co-existing&#44; pathophysiological mechanisms&#44; including<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Crushing&#58; direct collision of abdominal structures against the spine or other fixed structures&#46; Often the cause of solid visceral lesions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Compression&#58; the sudden increase in intra-abdominal pressure can cause a rupture of hollow viscera&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Deceleration&#58; this causes shearing forces that damage the anchorage points of hollow and solid viscera&#44; as well as vascular structures&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnosis</span><p id="par0040" class="elsevierStylePara elsevierViewall">The Advanced Trauma Life Support guidelines &#40;ATLS&#174;&#41;&#44; developed by the American College of Surgeons&#44; are based on a primary survey &#40;ABCDE&#41; and a secondary survey&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a> In the primary survey&#44; only plain X-rays of the chest&#44; pelvis and cervical spine are considered together with Focused Assessment with Sonography for Trauma &#40;FAST&#41; ultrasound&#44; reserving computed tomography &#40;CT&#41; for the secondary survey in stable patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However&#44; these recommendations run counter to the current trend of incorporating CT scanners into critical care areas&#44; and so being able to perform CT whenever the clinical situation allows&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The effectiveness of plain X-rays for detecting abdominal trauma injuries is poor&#46; Ultrasound is an accessible&#44; fast&#44; non-invasive tool that can be performed at the bedside&#44; which is why it has replaced diagnostic peritoneal lavage as technique of choice for the detection of peritoneal fluid&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> The most widely used protocol is FAST&#44; which consists of examining the right flank&#44; the left flank&#44; the pelvis and the subxiphoid area &#40;to rule out pericardial effusion&#41;&#46; The extended version &#40;E-FAST&#41; also examines the chest for pleural effusion or pneumothorax&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">According to the ATLS&#174; guidelines&#44; the presence of free fluid in unstable patients corresponds to intra-abdominal haemorrhage and is an indication for emergency laparotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However&#44; there are situations in which there may be fluid but not caused by trauma&#44; for example&#44; in women of childbearing potential&#44; in ascites or in patients treated with intensive fluid therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Ultrasound has low sensitivity for detecting visceral injuries and it does not identify bleeding foci&#46; For these reasons&#44; it would not be indicated in stable patients&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In order to overcome the limitations of ultrasound&#44; certain centres have tried introducing contrast-enhanced ultrasound &#40;CEUS&#41; to assess abdominal traumatic injuries&#46; Recent studies show a sensitivity of 79&#37; in the detection of spleen and liver injuries&#44; and a positive predictive value of 100&#37;&#46; However&#44; these values drop sharply for the detection of retroperitoneal injuries and active bleeding foci&#44; added to the limitations of ultrasound for assessing multisystem injuries in the context of patients with major multiple trauma&#46; It could be a useful technique for assessing mild trauma with no suspected extra-abdominal injuries or instability criteria&#44; for assessing the paediatric population and in the follow-up of traumatic injuries initially identified by CT&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The limited availability&#44; poor accessibility and the time the scans take to complete make magnetic resonance imaging an inappropriate technique for assessing patients with multiple trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The diagnosis of injuries is based almost exclusively on CT images&#46; It is a fast&#44; accessible technique with a sensitivity of 97&#37; and specificity of 99&#37; for the detection of significant abdominal injuries&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;12</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protocol</span><p id="par0070" class="elsevierStylePara elsevierViewall">The protocols used vary greatly&#46; Both in view of the limited effectiveness and to avoid unnecessary radiation&#44; performing a non-contrast phase is not recommended&#46; Of the post-contrast phases&#44; the venous phase is a definite requirement&#44; in order to characterise visceral injuries and to identify any bleeding&#46; The arterial phase is recommended to characterise bleeding&#44; diagnose vascular injuries and plan possible intravascular treatment&#46; If there is any injury to the urinary tract&#44; and whenever possible&#44; the scan should be completed by a renal elimination phase after 3&#8722;5<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Scanning the same anatomical region in arterial and venous phases obviously means more radiation&#46; To avoid this&#44; &#8220;split bolus&#8221; techniques have been proposed&#44; in which two or three boluses of contrast are administered with pauses &#40;serum boluses&#41; in between&#44; so that a dual phase &#40;arterial and venous&#41; or even a triple phase &#40;arterial&#44; venous and elimination&#41; is obtained in a single acquisition&#46; One of the potential drawbacks of these protocols is decreased sensitivity for detecting spleen and liver vascular injuries&#44; and those in the neck and pelvis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Classification of traumatic injuries</span><p id="par0080" class="elsevierStylePara elsevierViewall">Solid abdominal organs can suffer two types of injury&#58; parenchymal and vascular&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1</span><p id="par0085" class="elsevierStylePara elsevierViewall">Parenchymal lesions&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Laceration&#58; hypodense lesions of linear morphology&#46; The worst case is a shattered spleen&#46; They tend to involve a capsule tear&#44; which is why they frequently also have haemoperitoneum&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Haematoma&#58; poorly defined hypodense area&#46; If they are peripheral and the capsule is preserved&#44; subcapsular haematomas can form&#58; collections with defined borders which and obtuse angles with respect to the parenchyma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Contusion&#58; hypodense focus with poorly defined borders due to the presence of oedema or haemorrhage secondary to damage to small capillaries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Infarction&#58; absence of enhancement due to interruption of the vascular supply&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2</span><p id="par0110" class="elsevierStylePara elsevierViewall">Vascular injuries&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">Contained vascular injury&#58; rounded lesions that behave similarly to the vessel on which they depend&#44; are hyperdense in the arterial phase&#44; sometimes becoming isodense with the parenchyma in the venous phase&#44; which is why an arterial phase is necessary for diagnosis&#46; These are pseudoaneurysms and arteriovenous fistulas &#40;AVF&#41;&#44; often indistinguishable by CT&#44; except on occasion&#44; when a draining vein is seen with early enhancement&#44; indicative of AVF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Non-contained vascular injury or active bleeding&#58; accumulation of extravascular contrast with formation of a hyperdense collection in the arterial phase that increases in size and remains hyperdense in subsequent phases&#46; Bleeding can be free into the peritoneum or exclusively intraparenchymal&#44; which has a better prognosis&#46; It is important to perform an arterial phase to try to identify the origin of the bleeding&#46;</p></li></ul></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Computed tomography findings</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">General findings</span><p id="par0340" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Haemoperitoneum&#58; usually secondary to solid visceral injuries with capsular involvement&#46; Blood close to the point of origin of the bleeding usually has higher densitometric values &#40;45&#8211;70 HU&#41;&#44; giving rise to the sentinel clot sign&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Pneumoperitoneum&#47;pneumoretroperitoneum&#58; common finding in open abdominal trauma&#46; In blunt abdominal trauma it usually indicates a hollow viscus injury&#46;</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">It is important to distinguish it from pseudopneumoperitoneum&#44; in which free gas is seen between the abdominal wall and the parietal peritoneum&#46; It is usually secondary to rib fractures&#44; pneumothorax&#44; pneumomediastinum or even extraperitoneal rectal injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Abdominal wall injuries&#58; an important marker of an intra-abdominal injury&#44; as they are the consequence of high-energy impacts&#46; Very typical is contusion of the anterior abdominal wall caused by the seat belt in road traffic accidents &#40;seat belt sign&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Injuries to the wall are usually mild and consist of contusions&#47;haematomas in the subcutaneous cellular tissue and small fibrillar tears or intramuscular haematomas &#40;generally affecting the rectus abdominis&#41;&#46; Where bleeding is detected within the rectus abdominis muscle&#44; it will generally be dependent on the inferior epigastric artery&#44; and if the bleeding affects the lateral wall&#44; it corresponds to the territory of the deep circumflex iliac artery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Traumatic hernias are rare and the most common are lumbar hernias&#44; with protrusion of abdominal structures through the inferior lumbar &#40;Petit&#39;s&#41; triangle&#46; They are often underdiagnosed and in up to 25&#37; of cases present as late complications when the hernia becomes strangulated or incarcerated&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Spleen</span><p id="par0155" class="elsevierStylePara elsevierViewall">Highly vascular organ with a fragile capsule&#44; which is why it is frequently injured in abdominal trauma&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The American Association for the Surgery of Trauma &#40;AAST&#41; classification categorises imaging findings into grades I&#8211;V from least to most severe &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#59; the most severe findings &#40;grade V&#41; being shattered spleen or active bleeding into the peritoneal cavity&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">CT has a very high sensitivity for the detection of traumatic spleen injuries&#46; Vascular injuries are much better visualised in the arterial phase&#44; mainly helping to detect contained vascular injuries &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The venous phase facilitates not only the detection of parenchymal lesions&#44; but also the confirmation of bleeding&#44; by giving more time for the contrast to leak out&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The most common errors tend to be due to the analysis of the parenchyma in the arterial phase&#44; in which the typical pattern of &#8220;striped&#8221; enhancement can simulate lacerations&#44; and to the existence of clefts&#44; linear and peripheral images&#44; consequence of incomplete fusion of the splenic lobulation&#44; which can simulate a laceration&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Lacerations tend to be irregular&#44; less well defined&#44; and form more acute angles with the capsule&#46; On occasion&#44; splenic cysts and haemangiomas can also be indistinguishable from haematomas&#44; in which case the assessment of associated injuries &#40;for example&#44; rib fractures&#44; haemoperitoneum&#41; may be useful&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">There is no consensus on treatment&#44; although the general trend is towards conservative management&#46; This consists of close monitoring&#44; follow-up imaging and angiography with embolisation&#44; whether urgent &#40;for active bleeding&#41; or elective &#40;for contained vascular lesion&#41;&#46; Some authors recommend embolisation of all high-grade &#40;III&#8211;V&#41; injuries&#44; regardless of whether or not a vascular injury is visible on CT&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Surgery should be reserved for patients with high-grade or haemodynamically unstable injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> After embolisation it is common to see intrasplenic gas&#59; if it increases&#44; forms a level or is associated with collections or pneumoperitoneum&#44; abscess formation should be suspected&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Splenic trauma is a dynamic process and it is therefore advisable to perform a follow-up CT in arterial and portal phase 24&#8722;48<span class="elsevierStyleHsp" style=""></span>h after the initial CT in all patients with spleen injury&#46; This helps detect new contained vascular injuries and improves the prognosis of patients treated conservatively&#44; reducing the risk of delayed ruptures&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Liver</span><p id="par0185" class="elsevierStylePara elsevierViewall">Along with the spleen&#44; the liver is one of the organs most frequently affected in abdominal trauma&#46; There are many similarities with the spleen&#44; but also a number of differences&#46; The liver has a dual vascular supply&#44; which means that arterial-portal and portal-venous fistulas can develop in addition to the classic arterial-venous fistulas&#46; In addition&#44; the liver has a bare area not covered by peritoneum&#44; so extraparenchymal bleeding involving this area will cause retroperitoneal haematomas without haemoperitoneum&#44; making it undetectable by FAST ultrasound&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Lastly&#44; the gallbladder and bile duct may be affected&#44; usually in the case of high-grade lesions&#46; Gallbladder injuries are difficult to identify on CT&#44; where the signs would be a thickened&#44; poorly defined wall and perivesicular fluid&#46; It is unlikely we would be able to see a gallbladder wall defect&#46; Bile duct injuries will lead to free fluid indistinguishable from haemoperitoneum&#44; and some authors recommend scintigraphy or MRI with liver-specific contrast for diagnosis&#44; with the MRI option being the most widely used in our setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;28&#44;29</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Parenchymal injuries must be assessed over parenchyma with homogeneous enhancement in a portal venous phase&#46; As in the spleen&#44; lacerations and haematomas may be seen&#46; Lacerations are hypodense images with a more linear or branched pattern&#44; while haematomas are less well-defined hypodense areas and may be subcapsular&#46; Vascular injuries may also be found&#44; either contained &#40;pseudoaneurysms and fistulas&#44; arterial-venous&#44; arterial-portal or portal-venous&#41; or not contained &#40;active bleeding&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">As with the spleen&#44; the AAST published an update to the scoring scale in 2018 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; to include vascular injuries&#46; They are divided into five grades&#44; from minor to major severity&#44; with grade V consisting of lacerations involving more than 75&#37; of the parenchyma and injury to juxtahepatic veins &#40;inferior vena cava and suprahepatic veins&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">On occasion&#44; there may be uncertainty about the diagnosis in patients with hepatic steatosis&#44; and areas of focal steatosis should not be confused with lacerations or haematomas&#46; We should keep in mind the typical areas of fatty deposits in the perivesicular area and surrounding the falciform ligament&#46; If diffuse periportal hypodensity is observed&#44; it may indicate periportal oedema&#44; but if it is focal&#44; it may be related to a haematoma that crosses through the periportal space&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The treatment is conservative whenever the patient&#39;s situation allows&#44; and injuries of a vascular nature will be treated by embolisation&#46; Routine follow-up imaging is not recommended unless clinical or laboratory tests suggest a complication&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Bowel and mesentery</span><p id="par0210" class="elsevierStylePara elsevierViewall">Traumatic bowel and mesenteric injury is more common in open trauma&#46; In blunt trauma&#44; it has classically been associated with abdominal wall injury and Chance fracture of vertebrae from seat belts&#44; and is a result of high-energy mechanisms&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The most specific radiological findings are discontinuity of the bowel wall&#44; the extravasation of enteric content and pneumoperitoneum &#40;important to distinguish it from pseudopneumoperitoneum&#41;&#46; Unfortunately&#44; these are not very sensitive findings as it is generally not possible to visualise the bowel wall defect and with the majority of perforations there is no pneumoperitoneum&#46; Both wall thickening and enhancement abnormalities are more sensitive findings&#46; There may be loops with increased enhancement due to contusion or as a compensatory phenomenon due to ischaemia secondary to a mesenteric vascular injury &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">If intestinal involvement is diffuse with mural enhancement and mucosal thickening in a patient with hypotension&#44; shock bowel should be considered rather than direct traumatic involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;32&#44;33</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The findings in duodenal injury are similar to those described for bowel injury&#44; but there are certain distinctions because of its anatomical relationships&#46; It is important to remember that the first portion is the only part that is intraperitoneal&#44; while the second contains the ampulla of Vater&#44; so its involvement may mean a biliary injury&#46; The presence of a submucosal haematoma is typical&#59; this can even make gastric emptying difficult and is often associated with a pancreatic injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The most specific findings of mesenteric injury are haematoma and vascular injury&#44; which may result in active bleeding&#44; pseudoaneurysm&#44; occlusion or intimal injury&#46; Other less specific findings are increased density of the mesentery&#44; fat striation and the presence of peritoneal fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Treatment of these lesions is usually surgical due to the risk of peritonitis and sepsis&#46; Some small mesenteric haematomas and focal thickening not suspected of being at risk of perforation can be treated conservatively&#44; but with close monitoring&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pancreas</span><p id="par0240" class="elsevierStylePara elsevierViewall">Injury to the pancreas is generally a result of direct trauma against a steering wheel or handlebars&#46; The lesions become more evident in successive imaging tests where the contusions will show up as oedematous areas&#46; Different injuries may involve contusions &#40;hypodense areas&#41;&#44; lacerations &#40;linear hypodensities&#41; or transection &#40;full thickness laceration&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;38</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Urinary system</span><p id="par0245" class="elsevierStylePara elsevierViewall">The kidneys are well protected in the retroperitoneum immersed in the fat inside the renal fascia&#44; with the renal pelvis and the vascular pedicle as the only anchorage points&#46; This makes them particularly sensitive to acceleration&#47;deceleration forces&#44; which cause injuries at the ureteropelvic junction or intimal injuries in the arteries or veins&#44; which can go on to cause thrombosis of the vessel&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">The only sign of a possible urinary injury is haematuria and the severity is not dictated by the amount of blood&#59; in fact&#44; in some of the most severe injuries &#40;pedicle injury or ureteropelvic junction avulsion&#41; there may not be haematuria&#46; There are significant limitations with ultrasound as&#44; because the kidneys are retroperitoneal&#44; patients will not have free intraperitoneal fluid&#44; and the sensitivity of CEUS for detecting urinary tract injuries is also low&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The technique of choice is therefore CT in arterial and portal phases&#44; performing an excretory phase after 5&#8722;10<span class="elsevierStyleHsp" style=""></span>min if urinary tract injury is suspected&#46; Most injuries to the urinary tract occur at the level of the kidneys due to lacerations involving the collecting system&#44; but it is not uncommon for the ureteropelvic junction to be affected&#46; In such cases&#44; it is important to identify whether the injury is partial&#44; in which case dye can be seen in the ureter distal to the injury&#44; or complete&#44; where there is no dye in the distal ureter &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;17&#44;39</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">As with the classifications of liver and spleen injuries&#44; the latest update of the AAST severity scale includes vascular injuries &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; The most severe injuries&#44; grade V&#44; are laceration of the vascular hilum&#44; shattered kidney or devascularisation with bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">Treatment is generally conservative&#44; except in complete injury of the ureteropelvic junction&#44; when surgery will be required&#46; Barring clinical deterioration&#44; routine follow-up imaging of kidney injuries is not generally recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;41</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Bladder rupture is usually secondary to complex fractures of the pelvic ring and is generally extraperitoneal &#40;90&#37;&#41;&#46; Treatment of these ruptures is conservative&#44; unlike intraperitoneal ruptures&#44; which will generally require surgical repair&#46; For accurate diagnosis&#44; a CT cystogram will very often be necessary with retrograde distension of the bladder by injecting iodinated contrast diluted to 10&#37; through a catheter&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0345" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">The widespread use of CT and the implementation of new protocols have made it possible for patients with multiple trauma to be managed increasingly conservatively&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">This is feasible largely thanks to the endovascular treatment of vascular lesions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">Abdominal trauma will have general findings along with certain features particular to each organ&#46; We need to be familiar with these in order to alert the surgeon to the minority of injuries that are going to require urgent surgical management&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authorship</span><p id="par0350" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1</span><p id="par0285" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study&#58; GA and JC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2</span><p id="par0290" class="elsevierStylePara elsevierViewall">Study conception&#58; GA and JC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">3</span><p id="par0295" class="elsevierStylePara elsevierViewall">Study design&#58; JC and GA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">4</span><p id="par0300" class="elsevierStylePara elsevierViewall">Data collection&#58; GA and JC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">5</span><p id="par0305" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; GA and JC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">6</span><p id="par0310" class="elsevierStylePara elsevierViewall">Statistical processing&#58; not applicable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">7</span><p id="par0315" class="elsevierStylePara elsevierViewall">Literature search&#58; JC and GA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">8</span><p id="par0320" class="elsevierStylePara elsevierViewall">Drafting of the article&#58; JC and GA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">9</span><p id="par0325" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant contributions&#58; JC&#44; GA&#44; VG&#44; AU and PR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">10</span><p id="par0330" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; JC&#44; GA&#44; VG&#44; AU&#44; PR and JC&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0335" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Traumatic injuries are the leading cause of death in people aged<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>45 years&#44; and abdominal trauma is a source of significant morbidity and mortality and high economic costs&#46; Imaging has a fundamental role in abdominal trauma&#44; where CT is a fundamental tool for rapid&#44; accurate diagnosis that will be key for patients&#8217; clinical outcomes&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CT of abdomen in arterial &#40;a&#41; and venous &#40;c&#41; phases showing a spleen haematoma &#40;asterisk&#41;&#46; In the follow-up CT at 48<span class="elsevierStyleHsp" style=""></span>h in the arterial &#40;b&#41; and venous &#40;d&#41; phases&#44; a newly appearing pseudoaneurysm &#40;arrow&#41; was identified&#44; practically indistinguishable in venous phase &#40;d&#41; as the lesion was isodense with the splenic parenchyma&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Coronal reconstruction in the elimination phase showing extravasation of contrast in both renal pelvises suggestive of bilateral ureteropelvic avulsion&#46; The presence of staining in the left distal ureter &#40;arrow&#41; would prompt endourological treatment to be considered&#44; as it would indicate a partial injury&#44; while the right injury probably requires a surgical approach as it is a complete injury&#46;</p>"
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                      "doi" => "10.1016/s0020-1383(02)00067-0"
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