Case z -  Stab wound to abdomen with active bleeding

There is hemoperitoneum.  Hemorrhage is seen around the liver anteriorly (1, 2), inferiorly, and in the pelvis.  There is a round but irregular focus of decreased enhancement within the right anterior liver.  Within this area is a central focus of enhancement that is as bright as the arteries.  Superficial to this area are two foci of air within the skin and abdominal wall musculature.  There is no air seen within the abdomen.

In the setting of trauma a focus of decreased enhancement within the liver is concerning for laceration or contusion.  The central enhancement equal to that of the arteries is concerning for active arterial extravasation surrounded by hematoma.  Delayed images were obtained.  The central enhancement dissipates.  The findings are more conspicuous on the liver windows (bottom row). The subcutaneous and abdominal wall air likely represent the patient's reported stab wound.  These are located immediately superficial to the hepatic abnormality.

The patient was stable.  The trauma resident did not believe my interpretation of the CT scan and performed a deep peritoneal lavage (DPL).  The DPL yielded bright red blood.  The patient went to the OR and there was a right anterior and superficial hepatic laceration with active arterial bleeding which was stopped with the argon laser.

In cases of blunt injury you are looking for evidence of aortic or intra-abdominal injury, usually to the solid organs.  Since most surgeons treat hemoperitoneum conservatively, you are most concerned about active bleeding or suspected bowel injury.  Penetrating trauma is a slightly different story.  Your primary goal is to look for evidence of peritoneal penetration: i.e. intraperitoneal air or hemorrhage.  At my previous hospital all penetrating injuries with intraperitoneal extent warranted surgical exploration.  Different hospitals practice differently.  In this case, the fact that there was active bleeding is a nice bonus find.  The presence of hemoperitoneum means that the knife entered the abdomen.  That alone should have pressed our surgeons.  The following day the Trauma Attending informed me that the patient should have proceeded to the OR without a DPL.

Review the schematic for active bleeding.  Active bleeding is extraluminal contrast as bright as the artery which diffuses into a surrounding hematoma on delayed images.

Take home point

• In penetrating trauma look for evidence of peritoneal extension: i.e. pneumoperitionem and hemoperitoneum.  In most centers this will prompt surgical exploration.