Monday, June 9, 2014

55-year-old man undergoing cystography after motor vehicle collision

Cystogram image is shown below
There is contrast in the bladder.

There is contrast in the perivesical space.

There is contrast in the peritoneal cavity.

CT images of the abdomen and pelvis
Images from unenhanced CT the abdomen and pelvis performed immediately after cystogram are shown below

What is the final diagnosis?
 Ureteral injury
 Extraperitoneal bladder rupture
 Collecting system injury
 Intraperitoneal bladder rupture

What is the next step in management? 
 Additional imaging to evaluate the bladder.
 Transurethral Foley catheter drainage
 Suprapubic catheter drainage
 Operative management

Findings and diagnosis

  • Cystogram
    • Extravasation from the urinary bladder into the peritoneal cavity, with contrast extending into the paracolic gutters
    • Metallic density in the left pelvis, consistent with shrapnel
  • Unenhanced CT of the abdomen and pelvis, performed immediately after cystogram
    • Large amount of intraperitoneal high-density fluid in the subhepatic space, paracolic gutters and within the peritoneal cavity, representing contrast from cystogram performed prior to the CT scan
Differential diagnosis
  • Intraperitoneal bladder rupture
  • Extraperitoneal bladder rupture
  • Ureteral injury
  • Collecting system injury
Diagnosis: Intraperitoneal bladder rupture
  • Etiology
    • Bladder injury is most commonly seen in the setting of motor vehicle collisions.
    • Bladder trauma occurs from blunt injury and penetrating or iatrogenic trauma.
    • Often associated with pelvic fractures.
  • Classification of bladder injury
    • Type 1: Simple bladder contusion is a mucosal injury and does not have detectable abnormalities on imaging studies.
    • Type 2: Intraperitoneal rupture is the result of a direct blow to an already distended bladder, which increases intraluminal pressure and causes rupture of the dome of the bladder. Intraperitoneal bladder injury accounts for about one-third of all major bladder injuries.
    • Type 3: Interstitial injury is an intramural or partial thickness laceration with an intact serosa. This type of injury is rare and would be difficult to recognize on imaging studies.
    • Type 4: Extraperitoneal rupture is the most common type of bladder injury, and accounts for approximately 60% of major bladder injuries.
      • Type 4A: Simple extraperitoneal rupture has extravasation limited to the perivesical space.
      • Type 4B: Complicated extraperitoneal rupture has extravasation beyond the perivesical space.
    • Type 5: Combined injury is a combination of intraperitoneal and extraperitoneal injury, and accounts for 5% of all bladder injuries.
  • Clinical presentation
    • Gross hematuria
    • Suprapubic pain
    • Anuria
    • Decreased bowel sounds (with intraperitoneal injury)
    • Acute abdomen (with intraperitoneal injury)
  • Laboratory findings
    • Urinanalysis will demonstrate hematuria.
    • Peritoneal lavage fluid will be consistent with urine.
  • Imaging recommendations
    • Cystography -- CT or conventional (equal sensitivity).
    • Exclude urethral injury in males before performing cystography.
    • Check postdrainage films to identify extravasation that was hidden by contrast.
  • Radiographic findings
    • Cystography
      • Bladder contusion: Usually not recognized by imaging, but may have teardrop appearance of bladder due to extrinsic compression of bladder by bladder hematoma.
      • Intraperitoneal: Extravasation of contrast around bowel loops, paracolic gutters, pouch of Douglas, and intraperitoneal viscera.
      • Interstitial injury: Focal defect along the wall of the bladder may be seen, but is difficult to recognize on imaging.
      • Extraperitoneal:
        • Simple: Extravasation around the bladder.
        • Complex: Extravasation extends beyond the pelvis.
      • Combined: Findings of both intraperitoneal and extraperitoneal rupture.
    • CT cystography
      • Contusion: Normal appearance.
      • Intraperitoneal: Same findings as conventional cystogram.
      • Interstitial: Extravasation of contrast intramurally and submucosally without transmural extension, but difficult to recognize on imaging.
      • Extraperitoneal rupture:
        • Simple: Contrast is confined to perivesical space.
        • Complex: Contrast extends beyond the perivesical space.
        • "Molar tooth" sign -- rounded superiorly with pointed inferior contours.
    • Ultrasound
      • Fluid around the bladder
      • Hematoma within bladder wall
  • Complications include fistulas, abscess, sepsis, hematoma, and hemorrhage.
  • Management is determined by classification of injury.
    • Contusions and interstitial injuries are managed conservatively with Foley catheterization.
    • Intraperitoneal injury requires laparotomy and surgical repair of bladder injury.
    • Extraperitoneal injury is usually treated with catheter drainage. If there is complicated extraperitoneal rupture, then surgical repair may be necessary.
  • Follow-up: Perform cystography 10 days after initiation of treatment.
1.     Chan DP, Abujudeh HH, Cushing GL Jr, Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: Experience in 234 cases. AJR Am J Roentgenol. 2006:187(5);1296-1302.
2.     Ramchandani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol. 2009;192(6):1514-23..
Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics.2000;20(5):1373-1381.



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