Tümör ilişkili intraabdominal kanama

Özet

Bilinen ya da henüz tanınmamış hepatoselüler karsinom, renal hücreli karsinom, anjiyomiyolipom veya adrenal neoplazm, akut intratümöral kanama ve rüptürle akut karın ya da hemorajik şoka yol açabilir. BT; tümör içindeki kanı, kapsül bütünlüğünü, hemoperitoneumu ve aktif arteriyel ekstravazasyonu birlikte haritalar. Kontrastsız ve kontrastlı fazların karşılaştırılması, pıhtıyı canlı tümör dokusundan ve aktif kanamayı yalnızca yüksek dansiteli sıvıdan ayırır. Rüptür noktası ve aktif ekstravazyonun doğru tanımlanması, hemorajinin kaynağının belirlenmesi ve uygun acil müdahalinin planlanması açısından kritiktir.

Faz ve pencere

Kontrastsız tanısal

Tümör içinde yeni gelişmiş hiperdens kan/pıhtı ve perihepatik, perirenal ya da periadrenal yüksek atenüasyonlu hematom aranır; serbest sıvının dansitesi kanama lehine olabilir.

Arteriyel tanısal

Tümör içi veya çevresindeki arterlerden kaynaklanan kontrast yoğunluğunda odak, damar lümeniyle süreklilik ve ekstravazasyon odağının çevre hematoma yayılımı değerlendirilir.

Portal tanısal

Arteriyel fazda görülen ekstravazasyon odağının büyümesi veya şekil değiştirmesi aktif kanamayı; hemoperitoneumun dağılımı ve organ yüzeyindeki tümör rüptürü de kanama kaynağını destekler.

Önerilen pencereler: Batın (G 400 / M 50), Karaciğer (G 150 / M 30), Anjiyo (G 600 / M 150).

BT bulguları

• Hepatoselüler karsinom ve renal hücreli karsinom yüksek damarlanma nedeniyle spontan intratümöral kanama ve rüptür gösterebilir; anjiyomiyolipom da kanayabilir. Periferik veya subkapsüler hepatoselüler karsinomda rüptür ve hemoperitoneum olasılığı artar.
• Tümör içi kanama, kontrastsız BT'de hiperdens intratümöral veya peritümöral sıvı olarak görülebilir; organ çevresindeki hematom kanama odağını destekler.
• Tümör konturunda düzensizlik, kapsül kesintisi ya da komşu hematom içine açılan defekt rüptür odağını işaret eder.
• Perihepatik, perirenal veya adrenal yatak hematomu kanama kaynağı olan organın çevresinde yoğunlaşabilir.
• Yüksek atenüasyonlu intraperitoneal sıvı hemoperitoneumu gösterir; sıvı genellikle Morrison poşu ve pelvis gibi bağımlı alanlarda birikir.
• Arteriyel kontrast ekstravazasyonu damar dışına taşan kontrast yoğunluğunda odak olarak görülür; sonraki fazda yayılması aktif kanama lehinedir.
• Tümörün kontrastlanan solid bölümü ile kontrastlanmayan pıhtı aynı kitle içinde yan yana bulunabilir; önceki BT varsa yeni kanama değişikliğiyle kıyaslanır.

Normalde

Normal adrenal bezler BT'de bilateral lambdoid yapıda görünür; sol adrenal bez sağa göre daha kalın olabilir. Aynı düzeyde tümör içi hiperdens pıhtının çevre parankimden ayrılıp ayrılmadığına, organ kapsülünün sürekliliğine ve serbest sıvının anatomik ceplerdeki dağılımına bakılır.

Ayırıcı tanı

Rüptüre abdominal aort anevrizması

retroperitoneal hematom aorta çevresinden yayılır; tümör içi kanama odağı eşlik etmez.

Abdominal aort anevrizma rüptürü

retroperitoneal hematom aorta çevresinde yoğunlaşır ve kontrastlı BT'de aktif ekstravazyon veya intimal flap görülebilir.

Dalak yaralanması

kanama odağı dalak parankim yırtığı ya da subkapsüler hematomla ilişkilidir ve travma bağlamı destekleyebilir.

Adrenal kanama

adrenal yatakta bez yapısını bozan hematom gözlenir; spontan kanamalarda altta yatan neoplastik kökeni saptamak zordur ve tüm olgularda primer adrenal kitle açıkça görülmez.

Dalak rüptürü

perisplenik hematom ve serbest karın içi kanama ile seyreder; travma veya enfeksiyon (CMV gibi) bağlı spontan rüptür de görülebilir.

Tuzaklar

• Kontrastsız inceleme olmadan tümör içindeki hiperdens pıhtı ile kontrastlanan tümör dokusu karışabilir; mümkünse fazları aynı odak üzerinde karşılaştır.
• Tek fazda damar kesitine denk gelen parlak odak aktif ekstravazasyon sanılabilir; aktif kaçakta kontrast ilerleyen fazlarda yayılır veya büyür, pseudoanevrizma ise sınırlı damar benzeri şeklini ve damar benzeri kontrastlanmasını korur.
• Küçük miktarda pelvik hemoperitoneum üst abdomen dışındaki kaynaklardan da gelebilir; karaciğer, böbrek ve adrenal bezleri hematomla birlikte incele.
• Tümör rüptürü bulunması aktif kanamanın hâlen sürdüğünü tek başına kanıtlamaz; ekstravazasyon ile yalnızca pıhtı/hematom ayrımını raporda koru.

Kendini dene

1. Hipotansif hastada ekzofitik karaciğer kitlesi, yüksek atenüasyonlu perihepatik sıvı ve portal fazda genişleyen kontrast odağı görülüyor. En olası durum?

   • Rüptüre hepatik tümör
   • Hemorajik basit kist
   • Dalak laserasyonu
   • Aort anevrizma rüptürü
   Cevabı göster

   Rüptüre hepatik tümör. Tümör yüzeyindeki kanama ve fazlar arasında yayılan ekstravazasyon, tümör rüptürünü ve aktif kanamayı destekler. Hemorajik kistte odak kist içinde kalır; dalak yaralanması dalak parankim defekti, aort rüptürü ise aorta çevresi hematomla açıklanır.

2. Arteriyel fazda sınırlı bir odak olarak görülen ve portal/late fazlarda boyut ve yoğunlukça artarak çevreye yayılan bulgunun en olası nedeni nedir?

   • Aktif kontrast ekstravazasyonu
   • Pseudoanevrizma
   • Organize pıhtı
   • Kistik duvar kalsifikasyonu
   Cevabı göster

   Aktif kontrast ekstravazasyonu. Kaynaklara göre aktif kanama odakları kontrastlı BT fazları arasında belirgin şekilde büyür ve şekil değiştirir; bu davranış pseudoanevrizma veya stabil kistik yapıların aksinedir.

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 7 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez. İçerik yapay zekâ destekli bir süreçle güncel literatüre göre cümle cümle kaynaklarla karşılaştırıldı, ancak uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.