The liver is the most common solid organ injured in cases of inflicted intra-abdominal injury, likely attributed to its size and anatomic location [9, 11]. Nationally, liver injuries account for 64% of all abdominal visceral injuries in hospitalized children with suspected physical abuse, with liver lacerations representing the most commonly identified injury [7, 11]. Single-institution publications report that liver injuries represent 33% to 42.9% of intra-abdominal injuries in children diagnosed with physical abuse [9, 10, 13]. Liver injuries include contusions, lacerations, and subcapsular hematomas; rarely, diffuse organ disruption may result in cases of severe injury, and injuries may be associated with vascular and biliary complications [5, 14] (see Figs. 1, 2, and 3). On CT, contusions present as ill-defined hypodense areas, and lacerations appear as irregular, hypodense defects that traverse the parenchyma to the capsular surface [39]. Subcapsular hematomas are collections of blood deep to the capsule and appear as lens-shaped, frequently hypodense compared to the liver parenchyma, which can often be compressed by this collection. Sometimes subcapsular collections have scattered hyperdense areas, which are more likely to represent clotted blood than active extravasation, but delayed phase imaging can be helpful to look for contrast pooling to identify active bleeding [40]. The AAST grading severity increases with the depth of lacerations and the size of hematoma [41]. Congenital fissures or clefts and diaphragmatic indentations or slips may mimic hepatic injuries on CT imaging [42]. While complications can occur with more severe injuries to the liver, including arterial pseudoaneurysm, delayed hemorrhage, and biliary leak, most inflicted liver injuries are managed conservatively [5, 9, 10, 40, 43].

An 18-month-old male presented with lethargy and markedly elevated liver enzymes. Caregiver confessed to multiple blows to the epigastrium. a Coronal image of a post-contrast CT abdomen and pelvis in portal venous phase demonstrates extensive liver lacerations and a large volume complex peritoneal fluid (white arrows) with a higher density than the bladder. b Axial CT image from the same study shows two separate renal lacerations in the upper pole of the right kidney (white and black arrows). c Coronal image from the same study shows a post-traumatic right renal vein thrombus (white arrow)

2-year-old male found unresponsive with chest wall bruising and elevated liver enzymes. Findings elicited concern for physical abuse. CT of the abdomen and pelvis in portal venous phase was obtained. a Axial image shows splenic (white arrow) and liver (black arrow) lacerations each consistent with grade II injuries and a healing rib fracture (black open circle). b Axial image of the same study at a slightly more caudal level shows multiple branching liver lacerations (black arrows) consistent with a grade II liver injury. c Axial CT image in bone algorithm at the level of the splenic laceration better delineates the healing left rib fracture (white arrow) and an anterior right rib fracture (black arrow)

A 17-month-old male presented with lethargy, vomiting, extensive facial and neck bruising, and subconjunctival hemorrhages, concerning for physical abuse. a CT abdomen pelvis in portal venous phase shows grade II splenic (white arrowheads) and liver (white arrow) lacerations. b Axial image demonstrates a right renal laceration (white arrow). c Coronal image of the same study shows segmental devascularization injury of the renal lower pole (white arrowhead). Ascites as well as previously noted hepatic and splenic lacerations are also visible in the image (unmarked)

In cases of inflicted intra-abdominal injuries, splenic injuries are less common than liver injuries. Nationally, splenic injuries reportedly account for 9% of all injuries in hospitalized children with suspected physical abuse [7]. Single-institution publications report that splenic injuries represent 13.4% to 21% of intra-abdominal injuries in children diagnosed with physical abuse [9, 10, 13].

As with liver injuries, splenic injuries also include contusions, lacerations, and subcapsular hematomas, where the AAST grading severity increases with the depth of lacerations and the size of hematoma [41] (see Figs. 2 and 3). Higher grades are assigned to splenic injuries when the injury extends into the hilum due to a higher risk of hemorrhage. A splenic laceration involving two surfaces is referred to as a “fractured” spleen, and when multiple splenic parenchymal fractures are present, the spleen is termed “shattered” [40]. Congenital fissures or clefts and diaphragmatic indentations or slips may also mimic splenic injuries on CT imaging, as seen with liver injuries [42]. Most inflicted spleen injuries are managed conservatively [5, 9, 10, 42, 43]. In rare cases where splenic injuries result in hemodynamic instability and require intervention, vascular embolization is being increasingly utilized over intra-abdominal surgery [44].

Nationally, pancreatic injuries account for 7.3% of all abdominal injuries in hospitalized children with suspected physical abuse [7]. Single-institution publications report that pancreatic injuries represent 9.8% to 16.7% of intra-abdominal injuries among children with physical abuse [9, 10, 13]. Pancreatic injuries are overrepresented in cases of inflicted intra-abdominal injury [6, 7, 10]. Pancreatic injuries related to physical abuse can be seen with hollow viscus injuries and may have a delayed presentation with pancreatic pseudocysts.

On CT, pancreatic injuries can present as focal gland enlargement, ill-defined, hypodense parenchymal contusions, lacerations, full-thickness gland transections, and pancreatic pseudocysts [5, 12, 14] (see Figs. 4 and 5). It should be noted that the diagnostic accuracy of CT for pancreatic injury in pediatric patients is limited. This is, in part, due to the relative paucity of fat in children, which limits peripancreatic fat stranding as a marker of injury, and due to some post-traumatic findings, such as fluid in the lesser sac, peripancreatic edema, and peripancreatic fluid, taking up to 24 h to manifest [14, 45, 46].

A 3-year-old female with multiple abdominal injuries from physical abuse including grade II left hepatic lobe lacerations, right adrenal hematoma, and a pancreatic contusion with elevated serum lipase. CT of the abdomen and pelvis with IV contrast was obtained in the portal venous phase. a Axial image at the level of the pancreas shows focal pancreatic body contusion (white arrow). b Coronal image shows the pancreatic body contusion (white arrow)

A 3-year-old male with a history of developmental delay presented with a new onset of repeated vomiting after feeds and on further evaluation was found to be in an abusive home environment. CT of the abdomen and pelvis with IV contrast in portal venous phase was obtained. a Axial image shows a deep laceration through the pancreas (white arrow) and a pancreatic pseudocyst anterior to the pancreatic tail (black arrow) and posterior to the stomach, which is partially compressed and anteriorly displaced by the pancreatic pseudocyst. b Coronal image shows a deep laceration through the pancreas (white arrow) which appears to communicate with a pancreatic pseudocyst (black arrow). c Coronal 3D thin slice MRCP image shows partial visualization of the main pancreatic duct in the pancreatic tail (white arrow) and a pancreatic laceration which communicates with the pancreatic pseudocyst near the main pancreatic duct course (white double arrow) concerning for a ductal tear. d Coned image from an ERCP with contrast injection into the main pancreatic duct shows a focal amorphous region of contrast extravasation (black arrow) in the region of the superiorly positioned pseudocyst confirming a tear of the main pancreatic duct which communicates with the pseudocyst

The integrity of the main pancreatic duct is the most important factor in determining whether emergent intervention is warranted for management of a pancreatic injury. Imaging findings of complete pancreatic transection, large lacerations exceeding 50% of the gland thickness, or a large amount of peripancreatic fluid on CT raise concerns about the integrity of the main pancreatic duct. These findings warrant further assessment with an MRCP [47, 48]. CT has limited sensitivity for detecting main pancreatic duct injury even when pancreatic parenchymal lacerations exceed 50% of the thickness of the gland [45, 46]. There is a paucity of information regarding the sensitivity and specificity of CT for identifying pancreatic duct injuries in children, but in adults, the reported CT detection rate for pancreatic duct injury is low, approximating 43% [45, 46]. Either MRCP or ERCP can be used to evaluate main pancreatic duct injury [45, 46]. In clinical practice, MRCP is typically preferred in the initial workup of pediatric patients with suspected main pancreatic duct injuries, as ERCP requires sedation and endoscopy, and thus, is reserved for complex cases needing further clarification.

Typically, distal pancreatectomies or, less commonly, pancreatic duct stenting are the interventions performed in children with main pancreatic duct injuries. However, there is a growing body of literature advocating for non-operative management in this setting [45, 47].

Nationally, renal injuries account for 19.2% of all abdominal injuries in hospitalized children with suspected physical abuse [7]. Single-institution publications report that renal injuries represent 7.3% to 20% of intra-abdominal injuries among children diagnosed with physical abuse [9, 10, 13]. Renal injuries include renal contusions and lacerations, perinephric hematomas, and renal vascular injury (see Figs. 1 and 3).

CT of the abdomen and pelvis with IV contrast in both portal venous and excretory phases is the recommended modality to diagnose injury to the renal parenchyma and collecting system [25]. The routine use of excretory phase is not recommended for trauma workup and should only be used in select cases where renal or genitourinary tract injury is suspected. Hematuria is not a reliable predictor for renal injury, but the presence of gross hematuria or microscopic hematuria with > 50 RBC/hpf, with associated flank ecchymosis, rib fractures, or drop in hematocrit raises suspicion for renal or urinary tract injury [49]. CT can reliably depict renal contusions, depth of renal lacerations, perinephric hemorrhage, and major renal vascular injury or parenchymal devascularization. Renal contusions represent small intrarenal hematomas and appear as ill-defined, focal hypodense areas on CT. Excretory phase CT imaging depicts injury to the collecting system in the form of urinary contrast extravasation. In addition, the excretory phase can be useful to differentiate perinephric hematomas and urinomas and to diagnose urine leak in the setting of significant unexplained free intraperitoneal free fluid [49].

Bladder injury is an uncommon occurrence with abdominal trauma. There are several case reports of bladder rupture from inflicted trauma [50, 51]. The mechanism of injury is hypothesized to be blunt trauma on a full urinary bladder causing intraperitoneal bladder rupture, typically at the dome of the bladder, which is the weakest part covered by the peritoneum. Spillage of urine into the peritoneal cavity can lead to peritonitis. If the bladder rupture has occurred more than 24 h prior to presentation, patients can present with electrolyte imbalance and azotemia from peritoneal absorption of urine, mimicking renal failure [50, 51]. This is particularly relevant in cases where there may be a delay in seeking medical care. Bladder rupture can present as non-specific intraperitoneal free fluid on US and portal venous phase CT without other intra-abdominal organ injury. An excretory-phase CT can indicate a bladder rupture with the presence of free extravasated contrast in the pelvis (see Fig. 6). Though bladder rupture may be identified on excretory phase CT imaging, a cystogram is the preferred approach to allow for adequate bladder distension resulting in a more thorough evaluation for intraperitoneal or extra-peritoneal bladder rupture. Intraperitoneal bladder rupture generally requires operative repair, but there are reports of successful conservative management with bladder catheterization and peritoneal drainage [50].

A 2-year-old female presented with abdominal bruising, abdominal pain, and acute renal failure without a history of trauma. Findings elicited concern for physical abuse. a Axial image at the level of the bladder in routine portal venous phase shows low-density fluid in the cul-de-sac (white asterisk). Air in the bladder from a recent Foley catheter placement is also visible (unmarked). b Axial CT image at the level of the bladder in excretory phase demonstrates contrast opacifying the cul-de-sac fluid consistent with urine leak (white arrow). c Axial CT image of the same study in excretory phase at a more cephalad location from the bladder shows contrast extravasation into peritoneum (white arrow). d Cystogram performed on the same patient through a Foley catheter shows contrast leakage from the bladder revealing an intraperitoneal bladder rupture (white asterisk)

Adrenal injuries are rarely reported in isolation in the context of physical abuse. When present, they often occur with multiple co-existing intra-abdominal and extra-abdominal injuries [9, 52]. Single-institution publications report that adrenal injuries represent 4.9% to 16.6% of intra-abdominal injuries among children with diagnosed physical abuse [9, 10, 13]. Adrenal hematomas are the most common type of injury and tend to involve the right side more frequently [53, 54] (see Fig. 7). Adrenal lacerations have been reported, albeit rarely, in the setting of fatal physical abuse and are also more likely to be right-sided [52]. The proximity of the right adrenal gland to the spine makes it more susceptible to compression during trauma, and its injury is often accompanied by ipsilateral visceral injuries, particularly to the liver and right kidney [55]. On CT and US, adrenal hematomas typically appear as an oval, mass-like structure often splaying the limbs of the adrenal gland, while MRI performed in the subacute phase reveals the presence of subacute blood products [54]. Over time, the hematoma undergoes characteristic changes, usually resolving completely, though residual calcifications may occasionally persist [56].

A 5-month-old male who was brought to the emergency department by his aunt for sleepiness and bruising over face, neck, chest, abdomen, and thighs. Further workup revealed bilateral rib fractures of different ages and elevated liver enzymes. a Axial contrast-enhanced CT scan of the abdomen in portal venous phase shows an oval, hypodense right adrenal hematoma (white arrow). The liver shows an area of branching lacerations, consistent with co-existing hepatic injury. b Coronal contrast-enhanced CT image of the same study shows the oval hypodense right adrenal hematoma (black arrow) which splays the adrenal limbs

Nationally, hollow viscus injuries account for 12% of all abdominal injuries in hospitalized children with suspected physical abuse [7]. Although less frequent than solid organ injuries, hollow viscus injuries are overrepresented in cases of physical abuse and are more likely to require operative intervention [8, 10, 11]. Multiple sources report the small bowel, specifically the duodenum and proximal jejunum, as the most frequently injured hollow viscus organs in physical abuse [5, 6, 12, 17, 57]. Although less commonly encountered than small bowel injuries, the stomach and colon can also become injured from physical abuse [5, 58]. Acute hollow viscus injuries can range from mural hematomas to perforations, and long-term manifestations include bowel ischemia with associated luminal stenosis and strictures due to injuries of associated mesenteric vessels [5, 14].

In young children, duodenal injuries are strongly associated with abuse and have been the first recognizable sign of maltreatment in some reports [5, 12, 57,