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The diagnostic impact of computed tomography in blunt abdominal trauma
ClinicalRadiology (1983) 34,261-265 © 1983 Royal College of Radiologists
0009-9260/83/00680261502.00
The Diagnostic Impact of Computed Tomography in Blunt Abdominal Trauma W. A. FUCHS and G. ROBOTTI Department o f Diagnostic Radiology, University Hospital, Berne, Switzerland Sixty patients with blunt abdominal trauma were investigated by computed tomography, 21 within 48 h of injury, 39 within days and weeks. Organ laceration of the spleen, fiver, pancreas and kidney and haematoma formation were comprehensively demonstrated and post-operative complications readily identified. Computed tomography is currently the radiological method of choice to evaluate injuries to abdominal organs.
Abdominal trauma may cause multiple injuries to intraperitoneal and retroperitoneal viscera. Comprehensive imaging by computed tomography (CT) seems to be ideally suited to depict such traumatic sequelae (Druy and Rubin, 1979; Haertel and Fuchs, 1979; Berger and Kuhn, 1981; Federle et al., 1981a; Feuerbach et al., 1981). This report describes the CT findings in abdominal trauma and assesses the current role of CT in the management of abdominal injuries. PATIENTS AND INVESTIGATION TECHNIQUE Sixty patients with abdominal trauma (48 males and 12 females, age 9 - 7 4 years, mean 35 years) were examined. Twenty-one patients were investigated in the acute phase, that is, within 48 h, and 49 CT studies were done in 39 patients within days or weeks following injury. Scans were generally obtained after oral and intravenous contrast media. All studies were performed on a fan-beam, whole-body scanner with a scanning speed of 4 s.* Images were mainly obtained at 1 6 m m intmvals, although contiguous 8 r a m sections were done for more detailed evaluation of specific regions.
and abscesses. In eight patients the post-operative follow-up studies were normal (Table 2).
Hepatic Injury Twenty-two patients with hepatic injuries were investigated and in 17 of these operative verification of the CT findings was available. Of the six acute CT scans showing laceration of the liver parenchyma with intrahepatic haematoma, the lesion was found in the dorso,zranial aspect of the right liver lobe (Fig. 1) in five cases and in the left lobe in one case. Irregular areas of low density showing reduced contrast enhancement and loci of increased attenuation representing freshly clotted blood were thought to be Table 1 - Acute injury of abdominal parenchymatous organs: 21 patients, 21 CT investigations
Liver Spleen Pancreas Kidney Liver + spleen Spleen + kidney Liver + pancreas + kidney
4 4 1 9 1 1 1
RESULTS Acute CT studies following blunt abdominal trauma showed lesions of the liver and spleen with approximately equal frequency, whereas kidney injuries and traumatic pancreatitis were more often observed later. In three patients parenchymal damage to two or three organs simultaneously was seen (Table 1). Abnormal findings on follow-up studies included traumatic sequelae within the liver and kidney, as well as infected subphrenic haematomas * Somatom SF, Siemens-Erlangen, FRG.
Table 2 - Post-traumatic abnormalities of abdominal parenchymatous organs
Liver Spleen Pancreas Kidney Normal post-operative findings
Patients (n = 39)
CT investigations (n = 49)
16 1 5 9 8
25 1 6 9 8
262
CLINICAL RADIOLOGY
Fig. 1 - Laceration of the dorso-cranial aspect of the right liver lobe with extensive intrahepatic and peritoneal haematoma.
Fig. 3 - Infected subhepatic h a e m a t o m a 3 m o n t h s after surgical suturing of liver laceration.
~tll~
Fig. 2 tissue.
Subcapsular h a e m a t o m a compressing the hepatic
typical findings. A lenticular fluid collection compressing the underlying hepatic tissue was interpreted in one patient as a subcapsular haematoma (Fig. 2). Perihepatic haematomas with bleeding into the peritoneal cavity occurred in four cases (Fig. 1). In 16 patients the CT investigations were performed at a later stage, usually for post-operative evaluation. Subphrenic perihepatic infected haematomas presenting as hypodense fluid collections (Fig. 3), as well as biliary leakage, were identified in nine patients. Liver necrosis after operative ligation of right hepatic-artery branches appeared in three cases as areas of marked decrease in density, particularly following contrast enhancement (Fig. 4). Posttraumatic scar tissue of decreased density following contrast enhancement was the main finding in four patients.
Splenic Injury There were two patients with splenic lacerations and three with secondary rapture of a subcapsular
~
v
Fig. 4 - Liver necrosis following hepatic artery ligation showing decreased tissue density following contrast enhancement.
haematoma, findings which were all confimaed by surgery. One case with minimal l~ceration and limited perisplenic haematoma was followed by CT and not operated upon. Computed tomographic findings of splenic laceration included an irregular organ contour, fracture planes through the splenic parenchyma (Figs 5 and 10) perisplenic haematoma and free intraperitoneal blood (Fig. 5). Damaged parenchyma showed inhomogeneous contrast enhancement and haematomas were more apparent since they did not enhance.
Pancreatic Injury Acute pancreatic lesions in two patients showed enlargement of the organ and exudation into the anterior pararenal space, with obliteration of the pancreatic contour (Fig. 6). Exudates and pseudocyst formation were identified in three cases (Fig. 7).
DIAGNOSTIC
IMPACT
O F C T IN B L U N T
r
ABDOMINAL
v
TRAUMA
263
•
v
v ~
Fig. 7 - Post-traumatic pancreatic pseudocyst formanon 4 months after trauma.
Fig. 5 - Splenic laceration with extensive perisplenic haematoma and free intraperltoneal blood.
v
Fig. 6 - Acute pancreatic injury with fragmentation, exudation and bleeding within the pancreatic body and tail.
Fig. 8 Laceration of renal parenchyma and perirenal haematoma with urinary leakage.
Renal Injury
Subcapsular haematoma presenting as a biconvex fluid collection within the kidney was identified twice. Perirenal haematoma following laceration of the renal capsule limited by intact Gerota's fascia (Fig. 8) was observed in 17 cases. Bleeding into the pararenal space due to laceration of Gerota's fascia was present in six cases, more often in the anterior pararenal space (Fig. 10). In one case, extension of the haemorrhage to the opposite side was found.
Renal lesions were identified in 20 patients, of whom 11 were investigated within 2 4 h of the accident. Fragmentation of the kidney due to massive organ laceration was observed in nine cases (Fig. 8). Laceration of the renal artery, shown by grossly reduced renal contrast enhancement on CT, was confirmed by angiography in two patients (Fig. 9).
264
CLINICAL RADIOLOGY
splenic capsule. Rupture of the organ and intraabdominal bleeding may then occur at a later stage. Because of its ease of performance and accuracy in the demonstration of splenic injury, CT could replace arteriography, sonography and scintigraphy (Mall and Kaiser, 1980; Jeffrey et al., 1981). Management of splenic injuries is becoming less aggressive. Minor subcapsular and perirenal haematomas and small lacerations may be managed conservatively or with suture repair and then followed up by CT investigations (Goodman and Federle, 1980). Injury to the liver results in great morbidity and mortality. Immediate surgical intervention is often Fig. 9 - Markedly reduced and trregular renal contrast e n h a n c e m e n t due to complete laceration of the left main necessary to stop bleeding. Post-operative CT studies have proved to be particularly valuable in this group renal artery. of patients. Accurate assessment of the size of the haematoma, and the demonstration of associated parenchymal laceration, by CT is important, since limited injuries may be best managed conservatively. In the acute stage, differentiation between lacerated tissue and normal liver parenchyma is difficult owing to the small density difference which is, however, enhanced by intravenous contrast injection. With increasing time after injury the density ofhaematomas and necrotic sequestrated tissue decreases because of haemoglobin catabolism, and demarcation of the usually rounded parenchymal lesions becomes clearer (Haertel and Fuchs, 1979; Federle et al., 1981a). Biliary leakage may be identified if there are lowdensity fluid collections within the liver hilus, but injuries to the biliary system may be missed in the presence of parenchymal liver lesions and bleeding. Pancreatic injuries are frequently associated with traumatic laceration of adjacent organs. Blunt trauma to the pancreas leading to contusion, and even disruption, of the organ results in bleeding and exudation into the anterior pararenal space and the lesser sac Fig. 10 - Extensive perirenal and anterior pararenal haema(Haertel and Fuchs, 1979). Pancreatic abscesses and t o m a due to laceration of the kidney and Gerota's capsule. pseudocysts may eventually develop as traumatic F r a g m e n t a t i o n of t h e spleen. sequelae (Federle et al., 1981a). Computed tomography easily demonstrates these pathological conditions, which are otherwise difficult to identify. In renal injury, CT has proved to be a very accurate Leakage of contrast material was identified in nine cases. Injury to a kidney containing large cysts means of assessing parenchymal damage and haemaresulted in leakage of contrast material from the toma formation (Schaner et al., 1977; Braedel et al., renal pelvis into ruptured cystic structures. A post- 1980; Federle et al., 1981b; Fretz and Haertel, 1981; traumatic urinoma was diagnosed in one patient. In Sandler and Toombs, 1981). In case of complete late follow-up studies parenchymal scarring was seen laceration and vascular pedicle injuries, CT helps to in three cases. predict the necessity of complete nephrectomy or the possibility of surgical repair. Computed tomography also permits more confident non-surgical therapy, DISCUSSION demonstrating whether perirenal and pararenal Abdominal injury may cause laceration of the haematomas are enlarging or resolving. Angiography spleen or may produce parenchymatous contusion, becomes necessary when laceration of the main renal resulting in a subcapsular haematoma limited by the artery is suspected on the basis of markedly reduced
D I A G N O S T I C IMPACT OF CT IN B L U N T A B D O M I N A L T R A U M A
enhancement of the kidney parenchyma following intravenous bolus injection of contrast material. Further indications for renal angiography include suspicion of traumatic arteriovenous fistula or traumatic renal aneurism. CONCLUSIONS Computed tomography is recognised as the radiological method of choice in patients with positive findings on peritoneal lavage or abnormal abdominal radiographs following the injection of urographic contrast material. In acute haemorrhagic shock due to massive bleeding the patient must be operated upon immediately in order to localise and ligate the site of vascular leakage. Post-operative follow-up studies by CT are then of particular value. Computed tomography has limited angiography to the demonstration of major vascular injury and has confined exploratory laparotomy to a selected number of patients in haemorrhagic shock. REFERENCES
Berger, P. E. & Kuhn, J. P. (1981). CT of blunt abdominal trauma in childhood. American Journal of Roentgenology, 136,105-110. Braedel, H. U., Rzehak, L., Schindler, E., Posky, M. S. & Dbhring, W. (1980). Computertomographische Untersuchungen bei Nierenverletzungen. Fortschritte auf dem Gebiete der R6ntgenstrahlen und der Nuklearmedizin, 132, 4 9 - 5 4 .
265
Druy, E. M. & Rubin, B. E. (1979). Computed tomography in the evaluation of abdominal trauma. Journal of Computer Assisted Tomography, 3, 4 0 - 44. Federle, M. P., Goldberg, H. I., Kaiser, J. A., Moss, A. A., Jeffrey, R. B. & Mall, J. C. (1981a). Evaluation of abdominal trauma by computed tomography. Radiology, 138,637-644. Federle, M. P., Kaiser, J. A., McAninch, J. W., Jeffrey, R. B. & Mall, J. C. (1981b). The role of computed tomography in renal trauma. Radiology, 141,455 460. Feuerbach, St., Gullotta, U., Reiser, M., Allgayer, B. & Ingianni, G. (1981). Computertomographische Symptomatologie des B e c k e n - u n d Bauchtraumas. Fortsehritte auf dem Gebiete der Rdntgenstrahlen und der Nuklearmedizin, 134,293 296. Fretz, Ch. & Haertel, M. (1981). Computertomographie nach Nierentrauma. Fortsehritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 135, 6 5 3 - 6 5 6 . Goodman, P. C. & Federle, M. P. (1980). Splenorrhaphy: CT appearance. Journal of Computer Assisted Tomography, 4, 2 5 1 - 2 5 2 . Haertel, M. & Fuchs, W. A. (1979). Computertomographie nach stumpfem Abdominaltrauma. Fortsehritte calfdem Gebiete der R6ntgenstrahlen und der Nuklearmedizin, 131,487-492. Jeffrey, R. B., Laing, F. C., Federle, M. P. & Goodman, P. C. (1981). Computed tomography of splenic trauma. Radiology, 1 4 1 , 7 2 9 - 7 3 2 . Mall, J. C. & Kaiser, J. A. (1980). CT diagnosis of splenic laceration. American Journal of Roentgenology, 134, 265-269. Sandler, C. M. & Toombs, B. D. (1981). Computed tomographic evaluation of blunt renal injuries. Radiology, 141, 461-466. Schaner, G. E., Balow, J. E. & Doppman, J. L. (1977). Computed tomography in the diagnosis of subcapsular and perirenal haematoma. American Journal of Roentgenology, 129, 8 3 - 8 8 .
0009-9260/83/00680261502.00
The Diagnostic Impact of Computed Tomography in Blunt Abdominal Trauma W. A. FUCHS and G. ROBOTTI Department o f Diagnostic Radiology, University Hospital, Berne, Switzerland Sixty patients with blunt abdominal trauma were investigated by computed tomography, 21 within 48 h of injury, 39 within days and weeks. Organ laceration of the spleen, fiver, pancreas and kidney and haematoma formation were comprehensively demonstrated and post-operative complications readily identified. Computed tomography is currently the radiological method of choice to evaluate injuries to abdominal organs.
Abdominal trauma may cause multiple injuries to intraperitoneal and retroperitoneal viscera. Comprehensive imaging by computed tomography (CT) seems to be ideally suited to depict such traumatic sequelae (Druy and Rubin, 1979; Haertel and Fuchs, 1979; Berger and Kuhn, 1981; Federle et al., 1981a; Feuerbach et al., 1981). This report describes the CT findings in abdominal trauma and assesses the current role of CT in the management of abdominal injuries. PATIENTS AND INVESTIGATION TECHNIQUE Sixty patients with abdominal trauma (48 males and 12 females, age 9 - 7 4 years, mean 35 years) were examined. Twenty-one patients were investigated in the acute phase, that is, within 48 h, and 49 CT studies were done in 39 patients within days or weeks following injury. Scans were generally obtained after oral and intravenous contrast media. All studies were performed on a fan-beam, whole-body scanner with a scanning speed of 4 s.* Images were mainly obtained at 1 6 m m intmvals, although contiguous 8 r a m sections were done for more detailed evaluation of specific regions.
and abscesses. In eight patients the post-operative follow-up studies were normal (Table 2).
Hepatic Injury Twenty-two patients with hepatic injuries were investigated and in 17 of these operative verification of the CT findings was available. Of the six acute CT scans showing laceration of the liver parenchyma with intrahepatic haematoma, the lesion was found in the dorso,zranial aspect of the right liver lobe (Fig. 1) in five cases and in the left lobe in one case. Irregular areas of low density showing reduced contrast enhancement and loci of increased attenuation representing freshly clotted blood were thought to be Table 1 - Acute injury of abdominal parenchymatous organs: 21 patients, 21 CT investigations
Liver Spleen Pancreas Kidney Liver + spleen Spleen + kidney Liver + pancreas + kidney
4 4 1 9 1 1 1
RESULTS Acute CT studies following blunt abdominal trauma showed lesions of the liver and spleen with approximately equal frequency, whereas kidney injuries and traumatic pancreatitis were more often observed later. In three patients parenchymal damage to two or three organs simultaneously was seen (Table 1). Abnormal findings on follow-up studies included traumatic sequelae within the liver and kidney, as well as infected subphrenic haematomas * Somatom SF, Siemens-Erlangen, FRG.
Table 2 - Post-traumatic abnormalities of abdominal parenchymatous organs
Liver Spleen Pancreas Kidney Normal post-operative findings
Patients (n = 39)
CT investigations (n = 49)
16 1 5 9 8
25 1 6 9 8
262
CLINICAL RADIOLOGY
Fig. 1 - Laceration of the dorso-cranial aspect of the right liver lobe with extensive intrahepatic and peritoneal haematoma.
Fig. 3 - Infected subhepatic h a e m a t o m a 3 m o n t h s after surgical suturing of liver laceration.
~tll~
Fig. 2 tissue.
Subcapsular h a e m a t o m a compressing the hepatic
typical findings. A lenticular fluid collection compressing the underlying hepatic tissue was interpreted in one patient as a subcapsular haematoma (Fig. 2). Perihepatic haematomas with bleeding into the peritoneal cavity occurred in four cases (Fig. 1). In 16 patients the CT investigations were performed at a later stage, usually for post-operative evaluation. Subphrenic perihepatic infected haematomas presenting as hypodense fluid collections (Fig. 3), as well as biliary leakage, were identified in nine patients. Liver necrosis after operative ligation of right hepatic-artery branches appeared in three cases as areas of marked decrease in density, particularly following contrast enhancement (Fig. 4). Posttraumatic scar tissue of decreased density following contrast enhancement was the main finding in four patients.
Splenic Injury There were two patients with splenic lacerations and three with secondary rapture of a subcapsular
~
v
Fig. 4 - Liver necrosis following hepatic artery ligation showing decreased tissue density following contrast enhancement.
haematoma, findings which were all confimaed by surgery. One case with minimal l~ceration and limited perisplenic haematoma was followed by CT and not operated upon. Computed tomographic findings of splenic laceration included an irregular organ contour, fracture planes through the splenic parenchyma (Figs 5 and 10) perisplenic haematoma and free intraperitoneal blood (Fig. 5). Damaged parenchyma showed inhomogeneous contrast enhancement and haematomas were more apparent since they did not enhance.
Pancreatic Injury Acute pancreatic lesions in two patients showed enlargement of the organ and exudation into the anterior pararenal space, with obliteration of the pancreatic contour (Fig. 6). Exudates and pseudocyst formation were identified in three cases (Fig. 7).
DIAGNOSTIC
IMPACT
O F C T IN B L U N T
r
ABDOMINAL
v
TRAUMA
263
•
v
v ~
Fig. 7 - Post-traumatic pancreatic pseudocyst formanon 4 months after trauma.
Fig. 5 - Splenic laceration with extensive perisplenic haematoma and free intraperltoneal blood.
v
Fig. 6 - Acute pancreatic injury with fragmentation, exudation and bleeding within the pancreatic body and tail.
Fig. 8 Laceration of renal parenchyma and perirenal haematoma with urinary leakage.
Renal Injury
Subcapsular haematoma presenting as a biconvex fluid collection within the kidney was identified twice. Perirenal haematoma following laceration of the renal capsule limited by intact Gerota's fascia (Fig. 8) was observed in 17 cases. Bleeding into the pararenal space due to laceration of Gerota's fascia was present in six cases, more often in the anterior pararenal space (Fig. 10). In one case, extension of the haemorrhage to the opposite side was found.
Renal lesions were identified in 20 patients, of whom 11 were investigated within 2 4 h of the accident. Fragmentation of the kidney due to massive organ laceration was observed in nine cases (Fig. 8). Laceration of the renal artery, shown by grossly reduced renal contrast enhancement on CT, was confirmed by angiography in two patients (Fig. 9).
264
CLINICAL RADIOLOGY
splenic capsule. Rupture of the organ and intraabdominal bleeding may then occur at a later stage. Because of its ease of performance and accuracy in the demonstration of splenic injury, CT could replace arteriography, sonography and scintigraphy (Mall and Kaiser, 1980; Jeffrey et al., 1981). Management of splenic injuries is becoming less aggressive. Minor subcapsular and perirenal haematomas and small lacerations may be managed conservatively or with suture repair and then followed up by CT investigations (Goodman and Federle, 1980). Injury to the liver results in great morbidity and mortality. Immediate surgical intervention is often Fig. 9 - Markedly reduced and trregular renal contrast e n h a n c e m e n t due to complete laceration of the left main necessary to stop bleeding. Post-operative CT studies have proved to be particularly valuable in this group renal artery. of patients. Accurate assessment of the size of the haematoma, and the demonstration of associated parenchymal laceration, by CT is important, since limited injuries may be best managed conservatively. In the acute stage, differentiation between lacerated tissue and normal liver parenchyma is difficult owing to the small density difference which is, however, enhanced by intravenous contrast injection. With increasing time after injury the density ofhaematomas and necrotic sequestrated tissue decreases because of haemoglobin catabolism, and demarcation of the usually rounded parenchymal lesions becomes clearer (Haertel and Fuchs, 1979; Federle et al., 1981a). Biliary leakage may be identified if there are lowdensity fluid collections within the liver hilus, but injuries to the biliary system may be missed in the presence of parenchymal liver lesions and bleeding. Pancreatic injuries are frequently associated with traumatic laceration of adjacent organs. Blunt trauma to the pancreas leading to contusion, and even disruption, of the organ results in bleeding and exudation into the anterior pararenal space and the lesser sac Fig. 10 - Extensive perirenal and anterior pararenal haema(Haertel and Fuchs, 1979). Pancreatic abscesses and t o m a due to laceration of the kidney and Gerota's capsule. pseudocysts may eventually develop as traumatic F r a g m e n t a t i o n of t h e spleen. sequelae (Federle et al., 1981a). Computed tomography easily demonstrates these pathological conditions, which are otherwise difficult to identify. In renal injury, CT has proved to be a very accurate Leakage of contrast material was identified in nine cases. Injury to a kidney containing large cysts means of assessing parenchymal damage and haemaresulted in leakage of contrast material from the toma formation (Schaner et al., 1977; Braedel et al., renal pelvis into ruptured cystic structures. A post- 1980; Federle et al., 1981b; Fretz and Haertel, 1981; traumatic urinoma was diagnosed in one patient. In Sandler and Toombs, 1981). In case of complete late follow-up studies parenchymal scarring was seen laceration and vascular pedicle injuries, CT helps to in three cases. predict the necessity of complete nephrectomy or the possibility of surgical repair. Computed tomography also permits more confident non-surgical therapy, DISCUSSION demonstrating whether perirenal and pararenal Abdominal injury may cause laceration of the haematomas are enlarging or resolving. Angiography spleen or may produce parenchymatous contusion, becomes necessary when laceration of the main renal resulting in a subcapsular haematoma limited by the artery is suspected on the basis of markedly reduced
D I A G N O S T I C IMPACT OF CT IN B L U N T A B D O M I N A L T R A U M A
enhancement of the kidney parenchyma following intravenous bolus injection of contrast material. Further indications for renal angiography include suspicion of traumatic arteriovenous fistula or traumatic renal aneurism. CONCLUSIONS Computed tomography is recognised as the radiological method of choice in patients with positive findings on peritoneal lavage or abnormal abdominal radiographs following the injection of urographic contrast material. In acute haemorrhagic shock due to massive bleeding the patient must be operated upon immediately in order to localise and ligate the site of vascular leakage. Post-operative follow-up studies by CT are then of particular value. Computed tomography has limited angiography to the demonstration of major vascular injury and has confined exploratory laparotomy to a selected number of patients in haemorrhagic shock. REFERENCES
Berger, P. E. & Kuhn, J. P. (1981). CT of blunt abdominal trauma in childhood. American Journal of Roentgenology, 136,105-110. Braedel, H. U., Rzehak, L., Schindler, E., Posky, M. S. & Dbhring, W. (1980). Computertomographische Untersuchungen bei Nierenverletzungen. Fortschritte auf dem Gebiete der R6ntgenstrahlen und der Nuklearmedizin, 132, 4 9 - 5 4 .
265
Druy, E. M. & Rubin, B. E. (1979). Computed tomography in the evaluation of abdominal trauma. Journal of Computer Assisted Tomography, 3, 4 0 - 44. Federle, M. P., Goldberg, H. I., Kaiser, J. A., Moss, A. A., Jeffrey, R. B. & Mall, J. C. (1981a). Evaluation of abdominal trauma by computed tomography. Radiology, 138,637-644. Federle, M. P., Kaiser, J. A., McAninch, J. W., Jeffrey, R. B. & Mall, J. C. (1981b). The role of computed tomography in renal trauma. Radiology, 141,455 460. Feuerbach, St., Gullotta, U., Reiser, M., Allgayer, B. & Ingianni, G. (1981). Computertomographische Symptomatologie des B e c k e n - u n d Bauchtraumas. Fortsehritte auf dem Gebiete der Rdntgenstrahlen und der Nuklearmedizin, 134,293 296. Fretz, Ch. & Haertel, M. (1981). Computertomographie nach Nierentrauma. Fortsehritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 135, 6 5 3 - 6 5 6 . Goodman, P. C. & Federle, M. P. (1980). Splenorrhaphy: CT appearance. Journal of Computer Assisted Tomography, 4, 2 5 1 - 2 5 2 . Haertel, M. & Fuchs, W. A. (1979). Computertomographie nach stumpfem Abdominaltrauma. Fortsehritte calfdem Gebiete der R6ntgenstrahlen und der Nuklearmedizin, 131,487-492. Jeffrey, R. B., Laing, F. C., Federle, M. P. & Goodman, P. C. (1981). Computed tomography of splenic trauma. Radiology, 1 4 1 , 7 2 9 - 7 3 2 . Mall, J. C. & Kaiser, J. A. (1980). CT diagnosis of splenic laceration. American Journal of Roentgenology, 134, 265-269. Sandler, C. M. & Toombs, B. D. (1981). Computed tomographic evaluation of blunt renal injuries. Radiology, 141, 461-466. Schaner, G. E., Balow, J. E. & Doppman, J. L. (1977). Computed tomography in the diagnosis of subcapsular and perirenal haematoma. American Journal of Roentgenology, 129, 8 3 - 8 8 .