Hemoperitoneum ve retroperitoneal kanama

Özet

Künt veya penetran karın travmasında intraperitoneal kanama karaciğer, dalak, mezenter ya da pelvis kaynaklı olabilir; retroperitoneal kanama ise böbrek, damar, pankreas-duodenum çevresi veya pelvis yaralanmasını gösterebilir. Kontrastlı BT, kanın dağılımını ve eşlik eden organ hasarını haritalarken arteriyel faz aktif ekstravazasyonu, portal faz parankim ve venöz yaralanma bulgularını gösterir. En yoğun pıhtının komşu olduğu yapı olası kanama odağını işaret eder, ancak kan kompartımanlar boyunca yayılabilir. Kaynağın veya aktif kanamanın atlanması hızla kötüleşen kan kaybı ve gizli retroperitoneal yaralanmanın tanınmasını geciktirebilir.

Faz ve pencere

Kontrastsız tanısal

Peritoneal veya retroperitoneal sıvının kanla uyumlu yüksek atenüasyonu ve yaralanan organa komşu daha yoğun sentinel pıhtı görülebilir; ölçülen atenüasyon hematokrit ve pıhtılaşmaya göre değiştiğinden tek başına eşik kullanılmaz.

Arteriyel tanısal

Arteriyel kanama, arter komşuluğunda lümenle benzer yoğunlukta kontrast odağı olarak görülür; aktif ekstravazasyon damar sınırları içinde kalmaz ve fazlar arasında büyüyebilir ya da şekil değiştirebilir.

Portal tanısal

Hemoperitoneumun perihepatik, perisplenik, parakolik oluk ve pelvisteki dağılımı; organ laserasyonu ve portal/venöz kaynaklı kanama değerlendirilir. Retroperitoneal kanın perirenal, anterior/pararenal veya psoas çevresindeki yerleşimi olası kaynağı sınırlar.

Önerilen pencereler: Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Hemoperitoneum — serbest sıvı Morrison poşu, perisplenik alan, parakolik oluklar ve pelviste birikir; bu boşluklardaki sıvı izlenmesi kanamanın varlığını ve hacmini gösterir.
• Sentinel pıhtı — komşu serbest kana göre daha yüksek atenüasyonlu sınırlı pıhtı, kanama odağının yakınındaki yaralı organı düşündürür.
• Aktif kontrast ekstravazasyonu — damar lümeninden dışarı uzanan kontrast odağı, devam eden kanamayı gösterir; arteriyel görüntüde yakalanıp portal fazda yayılımı artabilir.
• Perirenal hematom — Gerota fasyası içinde böbreği çevreleyen kanama renal yaralanma veya damar hasarı yönünden araştırılır.
• Psoas veya pararenal hematom — retroperitoneal fasya planlarını dolduran kan, duodenum-pankreas, böbrek, lomber damar veya vertebra yaralanmasına eşlik edebilir.
• Büyük damar çevresi hematom — aorta veya vena kava komşuluğunda kanama, damar duvarı düzensizliği, lümen içi trombüs ve ekstravazasyonla birlikte aranır.
• Pelvik retroperitoneal hematom — pelvis kırığına eşlik edebilir; kanama içilak arterler, venöz pleksus veya kemik kaynaklı olup bazen aktif ekstravazasyon olmadan da görülebilir.

Normalde

Normal BT'de Morrison ve perisplenik boşluklar, parakolik oluklar, pararenal yağ planları ve psoas kasları arasında serbest sıvı ya da kitle etkili kan ürünü bulunmaz. Sağ-sol retroperitoneal planları karşılaştırırken Gerota fasyası, böbrek konturu, psoas hacmi ve damar çevresi yağın silinip silinmediğine; peritoneal sıvıda ise bağımlı alanlardaki dağılım ve komşu en yoğun pıhtıya bakılır.

Ayırıcı tanı

Basit asit

homojen düşük atenüasyonlu serbest sıvı iken, hemoperitoneumda komşu pıhtıda daha yüksek atenüasyon ve travmatik organ laserasyonu izlenir.

İdrar kaçağı

perirenal/retroperitoneal sıvı üriner sistem yaralanmasıyla ilişkili olabilir; gecikmiş fazda kontrastlı idrarın koleksiyona dolması ayırıcıdır.

Yağ dokusu infiltrasyonu (stranding)

Mezenterik veya perirenal bölgede görülebilir; sıklıkla serbest sıvı bulgusuyla birlikte değerlendirilir.

İntraperitoneal oral kontrast

bağırsak lümeni dışındaki kontrast ekstraluminal kaçak olabilir; damar fazlarıyla ve lümen devamlılığıyla ayrıştırılır.

Tuzaklar

• Serbest sıvının yalnızca miktarına bakıp kaynağı varsayma; pıhtının en yoğun bölümünü ve komşu organın kapsül/parankim bütünlüğünü izle.
• Aktif ekstravazasyonu sabit bir damar kesiti sanma; ardışık arteriyel ve portal fazlarda odağın damar sınırına bağlı kalıp kalmadığını kontrol et.
• Retroperitoneal hematomu yalnızca pelvis kırığına bağlama; renal hilus, psoas, pankreas-duodenum komşuluğu ve büyük damar çevresini ayrı ayrı tara.

Kendini dene

1. Portal fazda perirenal hematom içinde böbrek laserasyonuna komşu, çevre kandan daha yoğun bir pıhtı görülüyor. Olası odağı en iyi gösteren işaret hangisidir?

   • Sentinel pıhtı
   • İdrar kaçağı
   • Basit asit
   • Şok barsağı
   Cevabı göster

   Sentinel pıhtı. Sentinel pıhtı, en yoğun kan ürününün yakındaki yaralanma kaynağını işaret etmesidir. İdrar kaçağı gecikmiş fazda kontrastlı idrarla doğrulanır; basit asit yaygın düşük atenüasyonlu sıvıdır; şok barsağı bağırsak duvarı kontrastlanma paternidir.

2. Arteriyel fazda iliak arter yanındaki kontrast odağı portal fazda büyüyerek retroperitoneal hematoma karışıyor. En uygun yorum hangisidir?

   • Aktif arteriyel ekstravazasyon
   • Sabit flebolit
   • Perirenal kist
   • Serbest hava
   Cevabı göster

   Aktif arteriyel ekstravazasyon. Fazlar arasında damar dışına yayılan ve büyüyen kontrast aktif kanamayı destekler. Flebolit damar içinde sabit kalsifik odaktır; kist sıvı dansitelidir; serbest hava gaz atenüasyonunda görülür.

Bu konunun yer aldığı turlar

• Politravma (tüm gövde) BT'si

İlgili konular

• Mezenter yaralanması
• Künt barsak yaralanması
• Duodenal ve retroperitoneal yaralanma
• Delici/kesici yaralanma ve yara yolu

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 3 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.