Imaging Visceral Trauma in Abuse

Katherine Nimkin, MD Division of Pediatric Imaging Massachusetts General Hospital

Assistant Professor of Radiology Harvard Medical School Boston, MA Objectives

• Summary of recent retrospective reviews

• Imaging of specific of the neck, chest and abdomen in abused children

• Imaging strategies

• Conclusions Disclosures

• No relevant financial disclosures Retrospective Reviews Presentation: Accidental vs Abusive

Study Percentage Comments

The abused children were younger and DiScala et al 10% due to abuse had a worse outcome compared to (2000) in children <5 years accidentally injured children.

Abuse was most common cause of Trokel et al 16% blunt trauma due to abuse in children less than 2 years and abused (2004) In children <5years children had higher mortality.

Abused children were younger, more severely injured, had more bowel Wood et al 11% abdominal injuries due to abuse injuries and had delay in seeking care. (2005) Solid organ injury predominated in all groups. Retrospective Reviews Abused Children Presentation: Prevalence of Abdominal Injuries

Study Percentage Comments

10 were stable enough for CT; most common in this group. Sivit et al First larger review using CT. 14/69 (20%) 4 were too unstable for CT; (1989) abused children had visceral injuries. intestinal/mesenteric injuries were most common.

Abused children with visceral injuries Roaten et al 24/265 (9%) abused children had visceral had more severe injuries and were more (2005) injuries. likely to need surgery.

60% had significant abdominal clinical Hilmes et al 35/84 (42%) abused children <5 years had findings. Liver and bowel were most (2010) abdominal injuries on CT. commonly injured. 9 required surgery; 9 died (all from ).

11/68 (16%) children >3 years old with Multiple abnormal physical and Trout et al suspected abuse had positive findings on laboratory abnormalities were associated (2011) abdominal CT. with positive CT. Visceral Injury in Abuse

• Visceral injury in abused children is uncommon

• 2.33 cases/million children/year in children <5 years (Barnes 2005)

• Increased prevalence in children with clinical or laboratory findings suggesting abdominal injury

• True prevalence is likely underestimated

• Up to 16% abdominal injuries in young children are due to abuse

• Second most common cause of death from abuse after brain injury Visceral Injury in Abuse

• Usually younger than 3 years

• Delay in seeking care

• Multiple and severe injuries

• Due to direct blow to the abdomen and shearing forces

• Mortality rate up to 53%, likely partly due to delay

• Average age of fatal injury around 2 years Visceral Injury in Abuse

• Solid organ injuries (liver) most common • Hollow viscus injuries/pancreatic injuries have strongest association with abuse and more often require surgery • Clinical presentation similar to that seen with accidental trauma-distension, pain, vomiting • Bruising often absent

LIVER

• Most commonly injured organ with inflicted abdominal injury • Elevated transaminases have high specificity and sensitivity for hepatic injury • Hepatic transaminases rise rapidly after uncomplicated blunt liver injury and fall predictably • ALT >AST indicates subacute injury

LIVER

• Injuries to left lobe in abuse-compressed against spine

• US and CT

• Periportal tracking, laceration, hematoma

• Portal venous gas, vascular injury, avulsion of bile duct

Pneumatosis (white arrows) and portal venous gas (black arrows) in abused 2 year old with duodenal and colonic hematoma.

Mueller GP, Cassady CI, Dietrich RB, Pais MJ, Warden MJ (1994) Pediatric case of the day. Occult abuse (manifesting with pneumatosis intestinalis and portal venous gas). RadioGraphics 14:928–930. 8 month old with bruising and elevated transaminases. T12-L4 compression fractures and left liver laceration (arrow). 5 month old with head and skeletal injuries. Left liver laceration (arrow) on CT and MRI (cor STIR). 7 month old with grade IV liver laceration and left 12th posterior rib fracture. Hollow Viscus Injury

• Injury to mesentery, bowel perforation or bowel hematoma • Usually duodenum and jejunum • These injuries are more common with abuse than accidental injury • Shearing forces generated by a direct blow or sudden deceleration lead to intestinal-mesenteric injuries

Hollow Viscus Injury

• CT findings- free air or contrast, bowel wall thickening or defect, pneumatosis, mesenteric stranding, free fluid • May overlap with hypoperfusion complex • Fractures of lower anterior ribs associated with bowel injury • Intestinal strictures may develop later Hollow Viscus Injury Perforation

• MVA less likely to cause perforation

• Falls on stairs rarely cause bowel perforation

• Perforation-usually near ligament of Treitz: jejunum>duodenum>ileum

• Gastric perforation rare

• Free air seen in only one third of perforations

• Most frequent CT findings with bowel rupture is unexplained free fluid

36 month old abused boy with jejunal perforation. Free air (black arrows) small bowel wall thickening (white arrow) and free fluid.

Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD (2011) Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use? Pediatr Radiol;41(1):92-8. Hollow Viscus Injury Hematoma

• Partial thickness tear and subserosal bleeding • Duodenal hematoma is the most common bowel injury in abuse • Ultrasound may detect the bowel hematoma- echogenic or hypoechogenic • UGI series to confirm or follow duodenal hematoma- ”coiled spring” appearance, intramural mass or focal mural thickening • CT- hyper or hypodense mass

Duodenal and jejunal hematomas in a 2 1/2-year-old abused infant with multiple bruises and no history of trauma.

Radkowski MA, Merten DF, Leonidas JC (1983)The abused child: criteria for the radiologic diagnosis. RadioGraphics; 3:262–297. 3 year old abused child with chylous ascites and duodenal hematoma.

3 weeks later

Kleinman PK, Brill P, Winchester P: The resolving duodenal-jejunal hematoma in abused children, Radiology 160:747–750, 198. TRV PANC SAG GB TRV GB

2 year old abused infant, elevated transaminases and pancreatic enzymes Vomiting, diarrhea, bruises on face and abdomen Duodenal hematoma (arrows) Edema pancreatic head

21 month old with vomiting and elevated transaminases Duodenal hematoma PANCREAS

• Most common cause of pancreatitis in children is trauma • 8.6% of abusive abdominal injuries (Trokel 2006) • Elevated amylase/lipase not reliable indicators of injury and do not correlate with grade of injury • Edema, laceration, hematoma

PANCREAS

• Thin section CT for subtle injuries

• CT findings-pancreatic enlargement, peri- pancreatic fluid, linear or rounded hypodensity in gland, fluid between splenic vein and pancreas, pseudocyst

• Osseous changes due to fat necrosis-lytic bone lesions, lower extremities 24 month old girl with lethargy, abdominal distension and pain. Contrast-opacified loops of bowel (arrow) are interposed between the head and tail of the pancreas (arrowheads). Pancreatic transection

Hilmes MA, Hernanz-Schulman M, Greeley CS, Piercey LM, Yu C, Kan JH (2011) CT identification of abdominal injuries in abused pre-school-age children. Pediatr Radiol;41(5):643-51. 3 year old boy without a history of trauma exhibits a thick wall pseudocyst (c), transection through the pancreatic body (t) and blurring of the peripancreatic fat (arrowheads).

Raissaki M, Veyrac C, Blondiaux E, Hadjigeorgi C (2011) Abdominal imaging in child abuse. Pediatr Radiol;41(1):4-16. Permeative changes due to pancreatitis Pancreatic enzymes cause medullary fat necrosis and osteolysis

Servaes S, Haller JO (2003) Characteristic pancreatic injuries secondary to child abuse. Emerg Radiol;10(2):90-3. SPLEEN

• Less commonly injured than liver with inflicted injury

• Massive bleeding may cause hypoperfusion complex ADRENAL

• Adrenal hemorrhage is a marker of significant blunt trauma to the abdomen

• Seen with inflicted injury associated with other visceral injuries

• More common on right 3 month old bruising and elevated transaminases. Right adrenal hematoma, bilateral rib fractures,right liver laceration and periportal tracking. Right adrenal hemorrhage in 4 month old abused infant

T1

Hyperdense on CT T2

Nimkin K, Teeger S, Wallach MT, DuVally JC, Spevak MR, Kleinman PK (1994) Adrenal hemorrhage in abused children: imaging and postmortem findings. AJR 162:661–663. URINARY TRACT

• Renal injuries less common in abuse

• Use of microscopic hematuria as a screening tool for renal injury is controversial

• Bone scans may detect renal injuries

• Bladder injuries rarely occur-blunt trauma when bladder is full-perforation at dome of bladder

• CT of bladder perforation-unexplained ascites Follow-up images

3 year old abused by babysitter Large right renal laceration with development of urinomas

Bone scan- Abnormal tracer Courtesy of Dr. Ilse Castro-Aragon accumulation right kidney 4 year old abused child with intraperitoneal bladder rupture. Air-fluid level in bladder and free fluid with no solid organ injury. Stepmother confessed to forcibly pulling child into her knee.

Lautz T, Leonhardt D, Rowell E, Reynolds M (2009) Intraperitoneal bladder rupture as an isolated manifestation of nonaccidental trauma in a child. Pediatr Emerg Care;25(4):260-2. URINARY TRACT

• from soft tissue injuries can lead to myoglobinuria and acute renal failure

• Dark urine with positive dipstick for blood without significant RBCs

• IV contrast is contraindicated 4 hour delayed film from IVP Renal failure due to probable myoglobinuria in an abused child

Rosenberg HK, Gefter WB, Lebowitz RL, Mahboubi S, Rosenberg H (1983) Prolonged dense nephrograms in battered children. Urology 21:325–330. ANOGENITAL INJURIES

• May mimic injuries seen with accidental injury

• Trauma due to foreign bodies and sexual abuse

• Scrotal bruising and hematoma

Forced insertion of battery into vagina of 3 year old girl Tear in hymen and acid on cervix and upper vagina

Courtesy of Dr. Alice Newton 2 month old boy with distal bowel obstruction. Mass in the distal colon (arrows) initially felt to represent stool. At laparotomy, a carrot was found in the descending colon, presumably forcibly inserted into the rectum. Aprile A, Cesca E, Cecchetto G, Viel G, Mognato G, Gamba P (2009) Partial bowel obstruction in a 2 month-old child. A delayed diagnosis of anal abuse. Forensic Sci Int Nov 20;192(1-3):e7-9 CHYLOUS ASCITES

• May be seen with abuse

• Traumatic disruption of lymphatic drainage

• May be associated with chylothorax, skeletal and other abdominal injuries Transection neck of pancreas (white arrow) with chylous ascites. Pancreatic duct (black arrow).

Hilfer CL, Holgersen LO (1995) Massive chylous ascites and transected pancreas secondary to child abuse: successful non-surgical management. Pediatr Radiol;25(2):117-9. CHEST

• Thoracic injuries 3x more common with abuse than accidental injury

• , , , rib fractures, chylothorax

• Rib fractures may be absent with significant due to pliable rib cage in young children CHEST

• Pulmonary contusion most common injury in children with chest trauma

• Non-cardiogenic pulmonary edema due to upper airway obstruction (suffocation) or neurogenic cause (head trauma)

• in neonate

• Foreign bodies forced into airway and aspirated

• Vascular injuries rare

3 month old baby-PCP noted crepitus over chest. Multiple bilateral rib fractures and moderate right hemothorax. CARDIOVASCULAR

• Intracardiac needle

• Traumatic VSD, LV aneurysm

• Commotio cordis (cardiac concussion)-blow to the chest causes dysrhythmia and cardiac arrest

• Vascular injuries rare in abuse

• False aneurysm left gastric artery-mimicked liver mass

• Abdominal aortic transection-one case associated with L2-3 fracture-dislocation 3 month old with needle in right ventricle

Sola JE, Cateriano JH, Thompson WR, Neville HL (2008) Pediatric penetrating cardiac injury from abuse: a case report. Pediatr Surg Int;24(4):495-7. NECK

• Pharyngeal, hypopharyngeal and esophageal perforations-forced insertion of objects, sexual abuse, blunt or penetrating external trauma • Usually seen in infancy- stridor, respiratory problems • , pneumomediastinum, retropharyngeal abscess • Foreign body may migrate into mediastinum

3 week old with inflicted hypopharyngeal perforation

Kleinman PK (1998) editor. Diagnostic imaging of child abuse. 2nd ed. Mosby, St. Louis. 2 month old abused infant with extensive cervical and mediastinal emphysema and hypopharyngeal perforation.

Kleinman PK (1998) editor. Diagnostic imaging of child abuse. 2nd ed. Mosby, St. Louis 7 month old Marble in soft tissues of neck Perforated esophagus with migration into neck Forced in mouth by mother

Bakshi J, Verma RK, Karuppiah S (2009) Migratory foreign body of neck in a battered baby: a case report. Int J Pediatr Otorhinolaryngol;73(12):1814-6. Who Should Be Imaged?

• Significant clinical findings suggesting blunt abdominal trauma- especially young children with abdominal bruising and distension • Elevated transaminases, gross hematuria, elevated amylase/lipase, and falling hematocrit in the setting of suspected abuse

Who Should Be Imaged? Screening Tests

• Coant (1992)-49 abused kids without clinical signs of abdominal trauma, 4 had elevated transaminases, 3/4 had liver laceration on CT

• Lindberg et al (2009)-suggest imaging abused children when AST/ALT>80 IU/L or when bruising, distention or tenderness

• Lane et al (2009)-findings support screening with liver and pancreatic enzymes for physically abused children

Who Should Be Imaged? Selective imaging

• Trout et el (2011)- found CT abdomen positive in only 16% of cases of suspected abuse • They recommend CT with absent/hypoactive bowel sounds, LFTs greater than twice normal and >2 abnormal labs or physical exam findings • Should CT be performed in children with lower anterior rib fractures? • Should forensic value be considered?

Visceral Imaging Approach Abdominal Injury

• Supine and upright radiographs of the abdomen • Ultrasound to assess for free abdominal fluid but not adequate to evaluate for visceral injury-may detect duodenal hematoma • Abdominal CT with IV contrast with delayed images of the bladder (oral contrast optional) • Pediatric CT protocols should utilize all available dose reduction techniques Visceral Imaging Approach Abdominal Injury

• UGI series and/or ultrasound to follow or diagnose suspected duodenal hematoma • Consider repeat abdominal CT with oral and IV contrast if bowel injury suspected and not seen on prior exam • Chest CT in selected cases only • Contrast enhanced ultrasound and whole body MRI may show future promise Visceral Imaging Approach Neck and Chest

• Neck and chest radiographs

• Non-ionic contrast swallowing study in suspected pharyngeal perforation and/or CT neck with contrast Conclusions

• Visceral injuries in abused children are relatively uncommon but second only to head trauma as a cause of death with abuse • When present, visceral injuries are usually multiple and severe • A delay in seeking care and no history of trauma are typical

Conclusions

• Hepatic injury is the most common visceral injury with abuse; bowel and pancreatic injuries are strongly associated with abuse

• Imaging should be performed when clinical and/or laboratory findings are suggestive of inflicted visceral injury

• Documentation of clinically insignificant visceral injury made have significant medico- legal implications References

1. Bakshi J, Verma RK, Karuppiah S (2009) Migratory foreign body of neck in a battered baby: a case report. Int J Pediatr Otorhinolaryngol;73(12):1814-6. 2. Barnes PM, Norton CM, Dunstan FD, Kemp AM, Yates DW, Sibert JR (2005) Abdominal injury due to child abuse. Lancet;366(9481):234-5. 3. DiScala C, Sege R, Li G, Reece RM (2000) Child abuse and unintentional injuries: a 10-year retrospective. Arch Pediatr Adolesc Med;154(1):16-22. 4. Hilfer CL, Holgersen LO (1995) Massive chylous ascites and transected pancreas secondary to child abuse: successful non- surgical management. Pediatr Radiol;25(2):117-9. 5. Hilmes MA, Hernanz-Schulman M, Greeley CS, Piercey LM, Yu C, Kan JH (2011) CT identification of abdominal injuries in abused pre-school-age children. Pediatr Radiol;41(5):643-51. 6. Kleinman PK (1998) editor. Diagnostic imaging of child abuse. 2nd ed. Mosby, St. Louis. 7. Lane WG, Dubowitz H, Langenberg P (2009) Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics;124(6):1595-602. 8. Lautz T, Leonhardt D, Rowell E, Reynolds M (2009) Intraperitoneal bladder rupture as an isolated manifestation of nonaccidental trauma in a child. Pediatr Emerg Care;25(4):260-2. 9. Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K, et al. (2009) Utility of hepatic transaminases to recognize abuse in children. Pediatrics;124(2):509-16. 10. Mueller GP, Cassady CI, Dietrich RB, Pais MJ, Warden MJ (1994) Pediatric case of the day. Occult child abuse (manifesting with pneumatosis intestinalis and portal venous gas). RadioGraphics 14:928–930. 11. Ng CS, Hall CM (1998) Costochondral junction fractures and intra-abdominal trauma in non-accidental injury (child abuse). Pediatr Radiol;28(9):671-6.

References

12. Nimkin K, Teeger S, Wallach MT, DuVally JC, Spevak MR, Kleinman PK (1994) Adrenal hemorrhage in abused children: imaging and postmortem findings. AJR 162:661–663. 13. Radkowski MA, Merten DF, Leonidas JC (1983)The abused child: criteria for the radiologic diagnosis. RadioGraphics; 3:262–297. 14. Raissaki M, Veyrac C, Blondiaux E, Hadjigeorgi C (2011) Abdominal imaging in child abuse. Pediatr Radiol;41(1):4-16. 15. Roaten JB, Partrick DA, Bensard DD, Hendrickson RJ, Vertrees T, Sirotnak AP, et al. (2005) Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes. Am J Surg;190(6):827-9. 16. Rosenberg HK, Gefter WB, Lebowitz RL, Mahboubi S, Rosenberg H (1983) Prolonged dense nephrograms in battered children. Urology 21:325–330. 17. Servaes S, Haller JO (2003) Characteristic pancreatic injuries secondary to child abuse. Emerg Radiol;10(2):90-3. 18. Sivit CJ, Taylor GA, Eichelberger MR (1989) Visceral Injury in Battered Children: A Changing Perspective. Radiology; 173:659-661 19. Sola JE, Cateriano JH, Thompson WR, Neville HL (2008) Pediatric penetrating cardiac injury from abuse: a case report. Pediatr Surg Int;24(4):495-7. 20. Trokel M, DiScala C, Terrin NC, Sege RD (2004) Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes. Child Maltreat;9(1):111-7. 21. Trokel M, Discala C, Terrin NC, Sege RD (2006) Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care;22(10):700-4. 22. Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD (2011) Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use? Pediatr Radiol;41(1):92-8. 23. Wadhera R, Gulati SP, Garg A, Ghai A (2008) Bronchial foreign body: an unusual form of child abuse. Int J Pediatr Otorhinolaryngol;72(1):133-5. 24. Wood J, Rubin DM, Nance ML, Christian CW (2005) Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma;59(5):1203-8.