Skip to main content
SpringerLink
Log in

CT of acute abdominopelvic hemorrhage: protocols, pearls, and pitfalls

  • Review
  • Published:
Abdominal Radiology Aims and scope Submit manuscript

Abstract

Abdominal and pelvic hemorrhage may be secondary to a number of causes and is often a medical emergency. Patient presentation ranges from obvious trauma with evidence of hemodynamic instability to vague symptoms. CT has become the imaging modality of choice for identifying abdominopelvic hemorrhage. Recognizing acute hemorrhage as well as identifying its location and severity are key to expediting management. In the Emergency Department, ultrasound often used in the initial evaluation of trauma patients, but is not sensitive for subtle bleeds or injuries. CT is the best first-line imaging tool to identify abdominal hemorrhage and, compared with angiography, has been shown to be superior in detecting intra-abdominal bleeding, especially when the bleeding rate is low. Depending on location and etiology, abdominopelvic hemorrhage may have a characteristic appearance, such as the “sentinel clot” sign associated with blunt trauma to the solid organs or the “triangle sign” of a mesenteric bleed. The following pictorial essay reviews CT technique, study interpretation, and interpretative pearls and pitfalls in the recognition of acute abdominopelvic hemorrhage.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17

Similar content being viewed by others

Data availability

All data and materials support the published claims and comply with field standards.

Code availability

Not applicable.

References

  1. Kim YJ, Kim JS, Cho SH, et al. Characteristics of computed tomography in hemodynamically unstable blunt trauma patients: Experience at a tertiary care center. Medicine (Baltimore). 2017;96(49):e9168.

  2. Tasu JP, Vesselle G, Herpe G, et al. Postoperative abdominal bleeding. Diagn Interv Imaging. 2015;96(7-8):823-831.

    Article  PubMed  Google Scholar 

  3. Kendall JL, Faragher J, Hewitt GJ, Burcham G, Haukoos JS. Emergency department ultrasound is not a sensitive detector of solid organ injury. Western Journal of Emergency Medicine. 2009;10(1):1-5.

    PubMed  PubMed Central  Google Scholar 

  4. Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology. 2003 Sep;228(3):743-52.

    Article  PubMed  Google Scholar 

  5. Lee CH, Goo JM, Ye HJ, Ye SJ, Park CM, Chun EJ, Im JG. Radiation dose modulation techniques in the multidetector CT era: from basics to practice. Radiographics. 2008 Sep-Oct;28(5):1451–9. doi: https://doi.org/10.1148/rg.285075075. PMID: 18794318.

  6. Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology. 2010 Jul;256(1):32-61. doi: https://doi.org/10.1148/radiol.10090908. PMID: 20574084.

    Article  PubMed  Google Scholar 

  7. Steiner K et al. Acute gastrointestinal bleeding: CT angiography with multi-planar reformatting. Abdominal Imaging 2011.36: 115-125.

    Article  PubMed  Google Scholar 

  8. Geffroy Y et al. Multidetector CT angiography in acute gastrointestinal bleeding: why, when and how. Radiographics 2011. 31:35-E47.

    Article  Google Scholar 

  9. Katz DS, Lane MJ, Mindelzun RE Unenhanced CT of abdominal and pelvic hemorrhage. Seminars in Ultrasound, CT, and MRI, Vol 20, No 2 (April),1999:pp 94–107.

  10. Furlan A, Fakhran S, Federle MP. Spontaneous abdominal hemorrhage: causes, CT findings and clinical implications. AJR:193, October 2009. 1077–1087.

  11. Federle MP, Pan K, Pealer KM. CT criteria for differentiating abdominal hemorrhage: anticoagulation or aortic aneurysm rupture? AJR (2007); 188: 1324-1330.

    Article  PubMed  Google Scholar 

  12. Naulet P, Wassel J, Gervaise A, Blum A. Evaluation of the value of abdominopelvic acquisition without contrast injection when performing a whole body CT scan in a patient who may have multiple trauma. Diagnostic and Interventional Imaging. 2013;94(4):410-417.

    Article  CAS  PubMed  Google Scholar 

  13. Lane MJ et al. Active arterial contrast extravasation on helical CT of the abdomen, pelvis and chest. AJR:171,September 1998, 679–685.

  14. 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 Jul;161(1):65-9.

    Article  CAS  PubMed  Google Scholar 

  15. Lubner M, Menias C, Rucker C, Bhalla S, Peterson CM, Wang L, Gratz B. Blood in the belly: CT findings of hemoperitoneum. Radiographics. 2007 Jan-Feb;27(1):109–25.

  16. Wu C et al. Contrast-Enhanced Multiphasic Computed Tomography for Identifying Life-Threatening Mesenteric Hemorrhage and Transmural Bowel Injuries. J Trauma. 2011;71: 543–548.

    PubMed  Google Scholar 

  17. Murakami AM et al. Active extravasation of the abdomen and pelvis in trauma using 64MDCT. Emerg Radiol (2009) 16:375–382. DOI https://doi.org/10.1007/s10140-009-0802-1

    Article  PubMed  Google Scholar 

  18. Anderson SW et al. 64 MDCT in multiple trauma patients: imaging manifestations and clinical implications of active extravasation. Emerg Radiol (2007) 14:151–159. DOI https://doi.org/10.1007/s10140-007-0600-6

    Article  PubMed  Google Scholar 

  19. Wortman JR, Uyeda JW, Fulwadhva UP, Sodickson AD. Dual-energy CT for abdominal and pelvic trauma. Radiographics. 2018;38(2):586-602. doi: https://doi.org/10.1148/rg.2018170058.

    Article  PubMed  Google Scholar 

  20. Trabzonlu TA, Mozaffary A, Kim D et al. Dual-energy CT evaluation of gastrointestinal bleeding. Abdom Radiol 45, 1–14 (2020). https://doiorg.proxy1.library.jhu.edu/https://doi.org/10.1007/s00261-019-02226-6

  21. Mitchell CH, Fishman EK, Johnson PT. Nuances of the unenhanced abdominal CT: careful inspection discloses critical findings. Abdom Imaging. 2015 Oct;40(7):2883-93. doi: https://doi.org/10.1007/s00261-015-0422-z.

    Article  PubMed  Google Scholar 

  22. Stuber T et al. Pitfalls in detection of acute gastrointestinal bleeding with multi-detector row helical CT. Abdominal Imaging 2009. 34:476-482.

    Article  CAS  PubMed  Google Scholar 

  23. Sin FN, Tsang JP, Siu KL, Ma JK, Yung AW. Medications as causes of intraluminal hyperdensities: what radiologists need to know. Eur J Radiol. 2012 Jul;81(7):1652-6. doi: https://doi.org/10.1016/j.ejrad.2011.03.010. Epub 2011 Apr 3. PMID: 21459531.

    Article  PubMed  Google Scholar 

  24. Benedetti N, Aslam R, Wang ZJ, et al. Delayed enhancement of ascites after IV contrast material administration at CT: Time course and clinical correlation. American Journal of Roentgenology. 2009;193(3):732-737.

    Article  PubMed  Google Scholar 

  25. Alarhayem AQ, Myers JG, Dent D, et al. "Blush at first sight": Significance of computed tomographic and angiographic discrepancy in patients with blunt abdominal trauma. American journal of surgery. 2015;210(6):1104.

    Article  PubMed  Google Scholar 

  26. Raman SP, Horton KM, Fishman EK. MDCT and CT angiography evaluation of rectal bleeding: the role of volume visualization. AJR Am J Roentgenol. 2013 Sep;201(3):589-97. doi: https://doi.org/10.2214/AJR.12.10357.

    Article  PubMed  Google Scholar 

Download references

Funding

Not applicable.

Author information

Authors and Affiliations

  1. The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Erin Gomez, Karen Horton, Elliot K. Fishman & Pamela T. Johnson

  2. 600 N. Wolfe St., MRI Building 143, Baltimore, MD, 21287, USA

    Erin Gomez

Authors
  1. Erin Gomez
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Karen Horton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Elliot K. Fishman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pamela T. Johnson
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation and image collection were performed by EG and PTJ. The first draft of the manuscript was written by EG and PTJ and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Erin Gomez.

Ethics declarations

Conflict of interest

None to disclose.

Ethical approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gomez, E., Horton, K., Fishman, E.K. et al. CT of acute abdominopelvic hemorrhage: protocols, pearls, and pitfalls. Abdom Radiol 47, 475–484 (2022). https://doi.org/10.1007/s00261-021-03336-w

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00261-021-03336-w

Keywords

Search

Navigation