Case r -   Large hepatic contusions and active bleeding

There is hemoperitoneum around the liver, spleen, in the gall bladder fossa, and in the pelvis.  There are large contusions in the superior right lobe of the liver (Segment VII) with evidence of active bleeding (1 and 2).  There is an additional linear laceration in the posterior-inferior right lobe.  Two more rounded, hypoattenuating lesions in the liver probably represent cysts and not trauma.  Lastly, there is a right adrenal hemorrhage.

The large contusions appear as amorphous areas of decreased enhancement within the liver (1 and 2). Each contusion contains extravascular contrast which is as bright as the contrast within the arteries (1 and 2).  Delayed images were obtained and you can see that in both regions the extravasated contrast diffuses into the surrounding hematoma (1 and 2).  The contrast has become less dense and has spread to cover a larger area.  This is exactly the appearance of active bleeding.  This patient had an urgent hepatic angiogram which shows bleeding near the liver dome.  The bleeding resolved after embolization with gelfoam.

The lesion in the inferior right liver is hypoattenuating.  However, it has smooth round margins like a cyst.  Additionally, it is lower density than the hemorrhage seen elsewhere.  Compare to the intraperitoneal hemorrhage and to the density of the contusions.  Also, the internal high density is not as bright as the contrast in the arteries.  On the delayed images the internal density is unchanged.  This appearance is most consistent with a cyst.  The internal density may be old hemorrhage but it does not represent active bleeding.  The angiogram shows no bleeding in this area.  Also, there is a simple cyst in the left lobe of the liver, seen on arterial and delayed images.  If there were no history of trauma you would call this a cyst, which is what it is.

Lastly, notice the hyperdense mass in the right adrenal gland.  This is what an adrenal hemorrhage looks like.  The hemorrhage actually splays the left and right arms of the gland.  It is not possible to exclude an adrenal tumor but given the severe hepatic injuries an adrenal hematoma is most likely.  This can be proven on a follow-up exam if necessary.  On follow-up exams the hemorrhage will decrease in size.  A neoplasm will either remain unchanged or grow.  It is very difficult to definitively exclude hemorrhage within an adrenal neoplasm.

Did you notice the gallstone?

Take home points:

• AActive bleeding looks like extravascular contrast (as bright as the contrast in the arteries) surrounded by hematoma which diffuses into the hematoma on delayed imaging.
• Appearance of adrenal hematoma which can look like a hyperdense adrenal mass.
• Trauma patients can have hepatic cysts or hemangiomas which should not be confused with acute injury.