Small mesenteric hematoma following blunt abdominal trauma as early sign in computed tomography of occult small bowel perforation—report of 2 cases

A clinician's perspective on the new organ mesentery and non-vascular mesenteropathies

Mesentery was discovered as a new organ in 2017. It is a continuous membranous tissue from the duodenojejunal flexure to the anorectal junction. It has distinct anatomy, physiology, and disease states. Primary mesenteropathies include vascular and non-vascular diseases. Some of them are common, and some of them are rarely seen in clinical practice. Secondary mesenteropathies occur when infection or malignancy in another organ spreads to the mesentery. Each entity has specific diagnostic and treatment protocols. Increased awareness of different mesenteropathies and an understanding of their various presentations at different stages of life can help in early diagnosis and improved clinical outcomes.

Spontaneous mesenteric hematoma: Case report and review literature of a rare clinical entity

Spontaneous mesenteric hematomas (SMH) are not a common entity. Here we describe a case of 64 year old woman who presented with a vague abdominal pain and diffuse tenderness. Her CT abdomen revealed an ill-defined hyperdense mass like lesion in the mesentery and she underwent exploratory laparotomy which revealed a large hematoma in the mesentery with inflammation of the adjoining small bowel loop. Histopathology revealed findings consistent with hematoma with no evidence of neoplastic lesion.

Successful conservative management of a large traumatic mesenteric hematoma: A case report

INTRODUCTION AND IMPORTANCE

In blunt abdominal trauma, small bowel and mesentery injury (SBMI) is the third most common organ injury with an estimated incidence of 1-5%. Traumatic mesenteric injuries are difficult to diagnose and their undiagnosed complications are severe with high mortality rates.

CASE PRESENTATION

A 21-year-old male presented to the emergency room with severe colicky pain in the right-hypochondrium 2 h after dinner. He gave history of nausea, vomiting and diarrhea after dinner and before the pain started. The morning after admission, a Contrast Enhanced Computed Tomography (CECT) scan was done which showed a large mesenteric hematoma. On subsequent questioning, the patient then recalled a blow to the abdomen while playing basketball two days ago. Since the patient was hemodynamically stable, non-operative management (NOM) was chosen with close monitoring. Regular follow-up ultrasonography (USG) scans showed progressive spontaneous resolution of the hematoma.

CLINICAL DISCUSSION

Nonspecific symptoms of mesenteric hematoma make it difficult to reach a diagnosis. It is usually identified by history or medical imaging. Mesenteric hematoma can be managed conservatively if there is no active bleeding. In stable patients, selective visceral angiography should be performed and bleeding vessels should be embolized where possible.

CONCLUSION

This case highlights a successful conservative management of a large traumatic mesenteric hematoma. It also emphasizes the importance of eliciting a detailed history of major or minor trauma for any patient with abdominal pain. Previous cases have also highlighted the importance of non-operative management and avoidance of emergency laparotomy in stable patients.

Magnetic Resonance Imaging, the Virtual Biopsy of Mesenteric Masses

ABSTRACT

The mesentery may be affected by multiple disease processes. Magnetic resonance imaging aids as a virtual pathological biopsy tool in the assessment of mesenteric masses because of superior soft tissue contrast and characterization. In this comprehensive review, we describe in detail the magnetic resonance imaging features of some solid and cystic mesenteric masses, with an emphasis on lesion-specific signal characteristics on T1- and T2-weighted images, diffusion-weighted imaging, and enhancement features on the dynamic postcontrast phase that aid in narrowing the differential diagnosis.

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

A case of spontaneous mesenteric hematoma with diagnostic difficulty

Background

Spontaneous mesenteric hematoma (SMH) is a rare condition characterized by intraperitoneal hemorrhage of unknown etiology. SMH without worsening of general status allows conservative management; however, patients showing chronological changes on imaging require surgical intervention to rule out possible malignancy.

Case presentation

A 69-year-old man was referred to our hospital to evaluate an abdominal mass with no associated clinical symptoms. He had a history of chronic hepatitis C and diabetes mellitus. Six months earlier, computed tomography (CT) revealed a 75-mm tumor arising from the jejunum, suspected to be a gastrointestinal stromal tumor (GIST) of the small intestine. Following a further 6 months of observation, the patient was referred to our hospital. Abdominal contrast-enhanced CT revealed a well-defined heterogeneous round tumor with a maximum diameter of 75 mm adjacent to the upper jejunum. The tumor was accompanied by calcification at the periphery, with no evidence of augmentation over the prior 6 months. Diffuse lymphadenopathy was observed around the aorta and splenic artery. Under the diagnosis of GIST arising from small intestine, the patient underwent elective surgery. The resection revealed an elastic soft tumor at the mesentery adjacent to the upper jejunum with severe adhesion between the tumor and jejunum. The tumor origin was unclear; thus, we performed mesenteric excision and partial enterectomy without lymph node dissection.

The tumor was surrounded by fibrous capsular tissue containing massive hemosiderin deposits and cholesterol crystals showing partial calcification, resulting in a diagnosis of spontaneous hematoma of the mesentery.

Conclusions

We report a case of SMH mimicking small intestinal GIST. It is difficult to diagnose long-established SMH because its radiological features change with time, and more case reports are needed to improve the accuracy of diagnosis.

A case of spontaneous mesenteric hematoma successfully diagnosed and treated with aggressive imaging

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Spontaneous mesenteric hematoma is an uncommon syndrome, and often misdiagnosed as other non-hemorrhagic acute abdomen.

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Close monitoring for any signs of further deterioration, as well as aggressive imaging diagnosis, enabled us to make early diagnosis and treatment.

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Sharing our experience may help physicians initiate treatment of mesenteric hematomas early to prevent life-threatening adverse events.

Introduction

Spontaneous mesenteric hematoma is an uncommon syndrome triggered by bleeding localized in the mesenteric vascular tree of a bowel segment for no apparent underlying reason. We herein report a surgical patient with an extremely rapidly growing spontaneous mesenteric hematoma that we successfully diagnosed using careful radiologic examination.

Presentation of case

A 56-year-old old male presenting sudden onset lower abdominal pain was referred to our emergency department. At the time of admission, his physical examination revealed stable vital signs without radiological abnormality. On the following day, the patient suddenly presented hypotension, tachycardia, and increased abdominal pain. Contrast-enhanced computed tomography examination showed a mass with both high- and low-density areas with a 130 mm maximum diameter bordering the transverse colon. Since interventional radiologists were not available, we decided to perform emergency exploratory laparotomy. On laparotomy, a 13 × 8 cm hematoma was found in the mesentery of the transverse colon. As bleeding was noted from the branches of the middle colic artery and gastrocolic artery, these responsible vessels were ligated. The patient was finally given the diagnosis of spontaneous mesenteric hematoma.

Discussion and conclusion

The present case, initially diagnosed as enterocolitis, suddenly manifested hypovolemic shock. Close monitoring for any signs of further deterioration, as well as aggressive imaging diagnosis, enabled us to avoid delays in treatment. Early diagnosis and treatment of mesenteric hematomas are essential to prevent them from rupturing and triggering life-threatening adverse events.

A spontaneous mesenteric hematoma with a fistula between the transverse colon resected by laparoscopic surgery: A case report

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A mesenteric hematoma with a fistula to the colon is very rare, and the etiology remains unclear.

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The patients with mesenteric hematoma who are stable can opt for the non-operative treatment.

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Laparoscopic surgery may be a useful treatment option compared to open surgery with respect to postoperative recovery.

Introduction

A spontaneous mesenteric hematoma is rare, and its etiology is unclear. We present a very rare case of spontaneous mesenteric hematoma with a fistula to the transverse colon.

Presentation of case

A 90-year-old male visited our hospital because of lower abdominal pain. The physical examination revealed tenderness in the lower abdomen. The laboratory data revealed anemia and low estimated glomerular filtration rate (eGFR). The abdominal contrast-enhanced computerized tomography (CT) indicated a mass with coexisting low- and high-density areas adjacent to the transverse colon. The mass was diagnosed as a mesenteric hematoma. We selected conservative therapy, because the patient’s condition was stable. After 15 days from discharge, he was admitted to the hospital again for the complaint of bloody stool. A fistula with blood flowing out at the splenic flexure was reported on colonoscopy. In the laparoscopic operative findings, the hematoma adhered to the stomach, pancreas and omentum. A hand-assisted laparoscopic transverse colectomy including hematoma in the mesentery was successful. The pathological reports revealed that a spontaneous mesenteric hematoma formed the fistula to the colon. The patient was discharged without any postoperative complication on day 10.

Discussion

Generally, laparotomy is often chosen for the treatment of mesenteric hematoma. The laparoscopic approach for mesenteric hematoma is useful under the specific condition that the preoperative patient’s condition is stable.

Conclusions

This is the first case of a spontaneous mesenteric hematoma with a fistula to the colon resected safely by laparoscopic surgery.

Large mesenteric hematoma after extracorporeal shock wave lithotripsy for pancreatic stones: A case report

RATIONALE

Mesenteric hematoma after extracorporeal shock wave lithotripsy (ESWL) for pancreatic stones is a very rare complication which has never been reported before.

PRESENTING CONCERNS

We reported a case of a 36-year-old male diagnosed as chronic pancreatitis with pancreatic stones and a large pancreatic pseudocyst. He underwent 3 repeated sessions of pancreatic ESWL (P-ESWL). After the last session of P-ESWL, he complained of dizziness. Physical examination revealed a large mass in the right abdomen.

DIAGNOSIS

Emergent upper abdominal computerized tomography (CT) revealed this mass is a mesenteric hematoma with the size of 8.2 cm × 11.7 cm in the right abdominal cavity after P-ESWL and there was no sign of intestinal obstruction.

INTERVENTIONS

With close monitoring of vital signs, the patient received conservative treatment for several days. Dynamic abdominal ultrasound monitoring revealed the mesenteric hematoma had organized.

OUTCOMES

Vital signs of the patient were stable after fluid transfusion. Three-month follow-up CT showed the mesenteric hematoma had absorbed completely.

LESSONS

Mesenteric hematoma rarely occurs after P-ESWL and it alerts us the importance of considering uncommon complications after P-ESWL. If mesenteric hematoma occurs after P-ESWL, conservative treatment could be the first choice while surgery can also be considered.

Report of a case with a spontaneous mesenteric hematoma that ruptured into the small intestine

INTRODUCTION

A spontaneous mesenteric hematoma is a rare condition. Furthermore, it is extremely rare that the mesenteric hematoma caused gastrointestinal bleeding with an unknown etiology. We experienced a case with a spontaneous mesenteric hematoma that ruptured into the jejunum.

PRESENTATION OF CASE

A 75-year-old man was referred to our hospital because of anal bleeding and anemia. Abdominal computed tomography (CT) showed a low density mass measuring 3.0cm in diameter, including an enhanced spot. This finding suggested that a pseudo-aneurysm or mesenteric hematoma caused active bleeding into the jejunum. He underwent emergent laparotomy and partial resection of the jejunum and the mesentery including the tumor. A histological examination of the jejunum indicated no pathogenic findings causing active bleeding. And there were no findings suggesting the mesenteric aneurysm had developed. The patient had no history related to the development of a mesenteric hematoma, such as trauma, labor, surgery, or anticoagulant treatment. Therefore, we finally diagnosed that a spontaneous mesenteric hematoma had ruptured into the jejunum.

DISCUSSION AND CONCLUSION

We reported extremely rare condition that the mesenteric hematoma was developed and ruptured into the jejunum without definitive etiology.

Mesenteric Hematoma: Is there a Role for Selective Management?

Mesenteric hematomas may present as a radiologic finding after blunt abdominal trauma that may be associated with surgically significant mesenteric and/or bowel injury. The question of whether to operate or not to operate on patients with mesenteric hematoma remains a topic of debate, especially with the improved imaging technology. This study sought to identify clinical and radiological characteristics for patient selection for operative management (OM) of mesenteric hematoma. A retrospective review of 33 adults with blunt abdominal trauma and mesenteric hematoma on CT scan (2009–2012) was performed. Patients with other intra-abdominal injuries, penetrating trauma, isolated gastric hematoma, contrast extravasation, extraluminal air, and Glasgow Coma Scale < 14 were excluded. Patients requiring surgical treatment within 24 hours of admission were compared with those who did not using chi-squared test, Fisher's exact test, and t test. Parameters included age, gender, race, Glasgow Coma Scale, vital signs, pain, tenderness, ecchymosis, Injury Severity Score, length of stay, and inhospital mortality. Logistic regression was used to determine positive associations with OM. Of the 33 patients, 19 underwent OM and 14 did not. Both groups were similar at baseline. Regression analysis revealed association for pain [odds ratio (OR) = 9.6, confidence interval (CI) = 1.8–49.9, P < 0.01], tenderness (OR = 32, CI = 4.6–222.2, P < 0.01), and free fluid (OR = 10.3, CI = 1.8–60, P < 0.01) with need for operative intervention. Nonoperative management patients had 100 per cent success rate. Of the OM patients, 100 per cent underwent therapeutic laparotomies. Findings of mesenteric hematoma on CT scan in examinable patients with no abdominal pain, tenderness, or free fluid predict successful nonoperative management.