Imaging colorectal trauma using 64-MDCT technology

Firearm injury to the left buttock with uterus penetrating trauma

A multispecialty trauma team must provide care for pelvic gunshot wounds (PGW) due to the high risk of associated morbidity and mortality, the high density of organs that might be wounded within the pelvis, and the potential consequences of these complicated injuries. We present a case of a 59-year-old woman hemodynamically stable with firearm injury to the left buttock. CT examination showed free air in the peritoneal cavity and in the retroperitoneum and a focal contrast extravasation within the uterine fundus. The patient underwent urgent laparotomy that revealed triple bowel perforation (sigmoid colon, medium rectum, ileum) and a laceration of the posterior and anterior uterine wall at level of the cervix with no signs of active bleeding. The bullet was lodged above the peritoneal reflection, in the right pelvis, and it was removed, and handed over to the judicial authority. The perforated bowel segments were resected with Hartmann's procedure and ileal anastomosis. The uterine laceration was repaired. Although all the viscera and the structures along the trajectory can be harmed, pelvic gunshot wounds have the potential to inflict serious injury. Nongravid uterine traumas are a unique occurrence, and proper care requires an understanding of lesion grading. Finding the gynecological lesion in female patients is essential to receiving the best care and protecting the reproductive system.

Can multidetector CT detect the site of gastrointestinal tract injury in trauma? - A retrospective study

PURPOSE

We aimed to assess the performance of computed tomography (CT) in localizing site of traumatic gastrointestinal tract (GIT) injury and determine the diagnostic value of CT signs in site localization.

METHODS

CT scans of 97 patients with surgically proven GIT or mesenteric injuries were retrospectively reviewed by radiologists blinded to surgical findings. Diagnosis of either GIT or mesenteric injuries was made. In patients with GIT injuries, site of injury and presence of CT signs such as focal bowel wall hyperenhancement, hypoenhancement, wall discontinuity, wall thickening, extramural air, intramural air, perivisceral infiltration, and active vascular contrast leak were evaluated.

RESULTS

Out of 97 patients, 90 had GIT injuries (70 single site injuries and 20 multiple site injuries) and seven had isolated mesenteric injury. The overall concordance between CT and operative findings for exact site localization was 67.8% (61/90), partial concordance rate was 11.1% (10/90), and discordance rate was 21.1% (19/90). For single site localization, concordance rate was 77.1% (54/70), discordance rate was 21.4% (15/70), and partial concordance rate was 1.4% (1/70). In multiple site injury, concordance rate for all sites of injury was 35% (7/20), partial concordance rate was 45% (9/20), and discordance rate was 20% (4/20). For upper GIT injuries, wall discontinuity was the most accurate sign for localization. For small bowel injury, intramural air and hyperenhancement were the most specific signs for site localization, while for large bowel injury, wall discontinuity and hypoenhancement were the most specific signs.

CONCLUSION

CT performs better in diagnosing small bowel injury compared with large bowel injury. CT can well predict the presence of multiple site injury but has limited performance in exact localization of all injury sites.

Role of Multidetector Computed Tomography in the Diagnosis of Colorectal Perforations

Colonic perforations can be classified into perforations that occur at the site of a localized pathologic process and cecal perforations that occur secondary to distal colonic obstructions. Rectal perforations may result from foreign bodies inserted into the rectum; moreover, deep rectal biopsies, polypectomy, improper cleansing enema, or thermometer placement may also lead to rectal perforation. Correct identification of the cause and site of the perforation is crucial for appropriate management and surgical planning. Multidetector row computed tomography has a pivot role in planning the type of operative treatment, the prognosis, and in assessing those patients who have clinical symptoms of peritonitis but no radiographic signs of perforation.

Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries in Patients with Blunt Chest and Abdominal Trauma

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma.

Bowel and mesenteric injuries from blunt abdominal trauma: a review

The bowel and the mesentery represent the third most frequently involved structures in blunt abdominal trauma after the liver and the spleen. Clinical assessment alone in patients with suspected intestinal and/or mesenteric injury from blunt abdominal trauma is associated with unacceptable diagnostic delays. Multi-detector computed tomography, thanks to its high spatial, time and contrast resolutions, allows a prompt identification and proper classification of such conditions. The radiologist, in fact, is asked not only to identify the signs of trauma but also to provide an indication of their clinical significance, suggesting the chance of conservative treatment in the cases of mild and moderate, non-complicated or self-limiting injuries and focusing on life-threatening conditions which may benefit from immediate surgical or interventional procedures. Specific and non-specific CT signs of bowel and mesenteric injuries from blunt abdominal trauma are reviewed in this paper.

Mechanisms of injury and CT findings in bowel and mesenteric trauma

Bowel and mesenteric injuries are relatively uncommon but associated with significant morbidity and mortality. Early recognition is crucial, and multidetector computed tomography (MDCT) now has a central role in the evaluation of patients with a history of trauma. In this review, we describe the MDCT appearances of bowel and mesenteric injuries with reference to findings at surgery. Emphasis is placed on the importance of an understanding of mechanism of injury when interpreting CT findings following abdominal trauma.

Penetrating wounds to the torso: evaluation with triple-contrast multidetector CT

Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.

Rectal trauma in adults

Rectal trauma is associated with high rates of morbidity and mortality and generally affects young males due to its aetiology of violent crime and vehicular collision. Historically, management has followed principles derived from military practice, with faecal diversion, pre-sacral drainage and distal washout being mandatory. Civilian trauma studies examining management of colon and rectum injuries from the early 1950s identified major differences in the level of energy transfer between civilian and military wounds, given that the vast majority are penetrating in nature. This led to a re-evaluation of the necessity for these interventions for all rectal injuries. Current management depends on whether the injury is intra- or extraperitoneal, with those above the peritoneal reflection being readily accessible and amenable to treatment as for colon injury. Extraperitoneal injuries remain difficult to access and direct repair is usually impossible; the mainstay of treatment in most instances remains faecal diversion. The role of pre-sacral drainage and distal washout remains contentious in the realms of civilian rectal injury but retains a place in battlefield or other high-energy transfer rectal injuries where aggressive early management reduces septic complications. This article reviews the historical and current evidence for the management of both civilian and military extraperitoneal rectal injuries.