Abdominal Pain - ED

Victoria Morris November 7, 2019 Diagnostic Radiology, RAD 4001 Ronald M. Bilow, MD Clinical History • 61 y.o. male with HTN and recent Auto-Ped and “abdominal surgery” presents with abdominal pain and swelling. • Surgery: ORIF of pubic symphysis and bilateral SI joints • Current symptoms: • Pain in lower abdomen, 2 days lower abdominal distension, “clicking sound” with walking, urinary frequency • Physical exam findings: • Stable vitals: 98.8 F, HR: 72, RR: 18, BP: 174/81, SpO2: 98% • Firm Abdominal distension under 10cm incision, incision clean/dry/intact, mild erythema, warm to touch. • Work-up (notable labs): • CBC with differential: mild anemia 10.3 • Lactic Acid: 2.7

McGovern Medical School ACR Appropriateness Criteria • Acute Abdominal Pain: Post-operative patient • Imaging was appropriate according to ACR appropriateness criteria1

Image 1: Acute non-localized abdominal pain. Not otherwise specified, Initial Imaging

McGovern Medical School Pelvis X-RAY • 10/25/19: AP Pelvis

Image Key • Fractured Symphysis Pubis Hardware with 1cm diastasis • Contrast in bladder from CT performed prior • Sacroiliac Joint Hardware in Place

McGovern Medical School CT Abdomen and Pelvis with Contrast • 10/25/19: CT Abdomen Pelvis w/contrast

Image 76 Image 87 Image 95 • Sacroiliac Joint Fixation • Bladder • Pubic Symphysis Fixation Hardware • Large Pelvic Hematoma – Hardware Hyperdense (Acute) 12.3 x • Pelvic Hematoma 11.5 x 10.8cm (Hyperdense Acute) • Psoas Hematoma Resolving

McGovern Medical School CT Abdomen and Pelvis with Contrast - Delayed • 10/25/19: CT Abdomen Pelvis w/contrast

Image 85 - Delayed • Bladder with Contrast layering • Pelvis Hematoma • Active Extravasation of contrast into Hematoma 1.7 x 3.2 cm

McGovern Medical School Splenic Laceration • 10/25/19: CT Abdomen Pelvis w/ contrast

Image 43 • Right Kidney • Liver • Hypodensity in caudal spleen, likely representing resolving laceration in setting of recent trauma • Aorta • IVC

McGovern Medical School Summary of Key Imaging Findings

• Patient PMH: HTN, Auto Ped s/p ORIF Pelvis • Patient CC: abdominal pain, distension, clicking sound, urinary urgency • Imaging findings: • Hardware failure at pubis symphysis with 1 cm diastasis • Intact hardware at right sacroiliac joint • Large pelvis hematoma extending from bladder - anterior to pubis symphysis • Resolving psoas hematoma • Resolving Splenic Laceration

McGovern Medical School Differential Diagnosis: Pelvic Hematoma

• Hematoma – hyperdense if acute/subacute, active extravasation of contrast with continued bleeding specific for hematoma2 • Abscess – would typically see rim enhancement, thick walls, septation, gas/fluid levels. Consider in postoperative patients. 3 • Perforated Viscus – would see free air and dilated bowel loops4

McGovern Medical School Final Diagnosis: Pelvis Hematoma – Venous Bleed and Soft Tissue Injury • Most likely secondary hardware failure at pubic symphysis • 90% of bleeds after pelvic fixation are venous bleeds from the plexus5 • Soft tissue injuries found during surgical washout and hardware removal

McGovern Medical School Treatment Options: Abdominal Washout Removal of Fractured Hardware

• Patient was taken to surgery for multiple washouts, removal of hardware and placement of wound vacuum • If hematoma source had been arterial then IR could have embolized the bleeding artery endovascularly aka Transcather Arterial Embolization.6 • Soft tissue injuries required washouts to remove bony fragments and foreign materials and wound vacuum application to allow healing via secondary intention7 • If bowel had been injured a diverting colostomy would have been performed8

McGovern Medical School Cost of Imaging at Memorial Hermann

• CT Abdomen Pelvis W/ Contrast9 • Insured: charged $7,998, patient owes $480 • Uninsured: patient owes $2,879

McGovern Medical School Take Home Points

• Abdominal pain in postoperative patient warrants computed tomography of abdomen and pelvis with contrast • Contrast shows active extravasation in bleeding hematomas • Hematomas are hyperdense if acute • Hardware failure causing soft tissue injury requires removal of hardware and washout • The appearance of blood at CT depends on window width, hematocrit, physical state of blood, use of intravenous contrast material, and attenuation of adjacent organs. Rapid infusion of contrast material improves visualization of hematoma.10

McGovern Medical School References 1) ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain https://acsearch.acr.org/docs/69467/Narrative/ 2) Shanmuganathan K, Mirvis SE, Sover ER. Value of contrast-enhanced CT in detecting active hemorrhage in patients with blunt abdominal or pelvic trauma. AJR Am J Roentgenol 1993; 161:65-69. Crossref, Medline, Google Scholar 3) Daffner, H., Richard et al. “Computed Tomography in the Diagnosis of Intra-Abdominal Abscesses.” Annals of Surgery 189.1 (1979): 29–33. Web. 4) Evaluation of bowel and mesenteric blunt trauma with multidetector CT.Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F Radiographics. 2006 Jul-Aug; 26(4):1119-31. 5) Gansslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care. 2003;9:515–523. doi: 10.1097/00075198-200312000-00009. 6) Management of acute and chronic open wounds: the importance of moist environment in optimal wound healing.AUAtiyeh BS, Ioannovich J, Al-Amm CA, El-Musa KA SOCurr Pharm Biotechnol. 2002;3(3):179. 7) Percutaneous transcatheter embolization for massive bleeding from pelvic fractures.AUPanetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW SOJ Trauma. 1985;25(11):1021. 8) Open pelvic fracture: an injury for trauma centers.AUSinnott R, Rhodes M, Brader A SOAm J Surg. 1992;163(3):283. 9) Cost of Imaging at Memorial Hermann. Website URL: https://www.memorialhermann.org/patients-caregivers/pricing- estimates-and-information/ 10) CT in abdominal and pelvic trauma. J L Roberts, K Dalen, C M Bosanko, S Z Jafir https://doi.org/10.1148/radiographics.13.4.8356265

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