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

Dual-Energy CT in the Acute Setting: Bowel Trauma

Traumatic bowel and mesenteric injuries (TBMI) have significant morbidity and mortality. The physical examination is often limited and sometimes not feasible in the trauma patient. Multidetector CT (MDCT) detection of TBMI is challenging and can be life-saving. Dual-energy CT (DECT) utilizes iodine overlay, monoenergetic imaging, and metal artifact reduction to enhance the conspicuity of TBMI. DECT may improve the conspicuity of TBMI leading to increased diagnostic accuracy and confidence. The aim of the article is to review the state of the art and applications of DECT in bowel trauma.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.

Perspectives and Management Strategies for Acute Colonic Intramural Hematoma

Acute intramural hematoma of the colon is a rarely encountered clinical condition with diverse precipitating factors. Different acute and chronic complications emerge following hematoma formation, mandating high clinical suspicion for early diagnosis and optimum management. CECT represents the cornerstone for the proper demonstration of colonic hematomas and possible detection of complications as well as the underlying etiology. There are multiple strategies for management of intramural hematoma and treatment should be tailored according to the etiology and the clinical condition of the patient, reserving surgical intervention for unstable or complicated cases. Endoscopic management of colonic hematomas offers a promising minimally invasive modality with potential safety and efficacy.

Iliac ecchymosis, a valuable sign for hollow viscus injuries in blunt pelvic trauma patients

PURPOSE

Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities.

METHODS

We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted.

RESULTS

In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p < 0.001).

CONCLUSION

IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.

Delayed presentation of intramural cecal hematoma with challenges in the treatment. A case report and review of the literature

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Intramural cecal hematoma is a rare condition with only 14 reported cases.

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It can mimic acute appendicitis.

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A history of trauma, if present, may offer a pointer to the diagnosis.

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Conservative treatment is the first choice in management. However, surgery still has a role.

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Evacuation of cecal hematoma can preserve the colon in selected patients.

Introduction

Intramural cecal hematomas are rarely encountered clinical entities with only 14 cases reported in our literature. It is usually reported after blunt external trauma, endoscopy-related trauma, coagulopathies, and occasionally spontaneous. Most cases presented acutely after primary insult; however, a delayed presentation rarely can occur.

Case presentation

Herein we describe an 8-year-old male patient who presented to the emergency department with an appendicitis-like picture six weeks after a history of falling. Intraoperatively, the patient was found to have a normal appendix. However, a large intramural cecal hematoma contains black blood with many clots was found. The patient was treated by hematoma evacuation with preservation of the cecum and colon and he was discharged with uneventful recovery. During two years follow up there was no history of complications or recurrence.

Discussion

Intramural cecal hematoma could be presented with various symptoms that range from mild abdominal pain to severe abdominal pain with vomiting, intestinal obstruction, bowel perforation, and hemoperitoneum. Diagnosis is challenging, and CT scan is the key for diagnosis. Although Conservative therapy is the first-line treatment; however, surgery still has a role in selected cases.

Conclusion

The authors report the first case of cecal hematomas with a delayed presentation. The optimal treatment should be individualized according to different etiologies, the patient's stability, and the presence of complications.

Diagnostic options for blunt abdominal trauma

PURPOSE

Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature.

METHODS

We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm.

RESULTS

A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries.

CONCLUSIONS

MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient's injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

[Value of laparoscopy in blunt and penetrating abdominal trauma-a systematic review]

BACKGROUND

The range of indications for laparoscopic procedures has been continuously widened in recent years. At the same time, however, the diagnostic and therapeutic role of laparoscopy in the management of blunt and penetrating abdominal trauma remains controversial.

METHODS

A systematic literature search was carried out in PubMed from 2008 to 2019 on the use of laparoscopy in blunt and penetrating abdominal trauma. Studies were analyzed in terms of relevant operative and perioperative event rates (rate of missed injuries, conversion rate, postoperative complication rate). On the basis of this analysis, an algorithm for the use of laparoscopy in abdominal trauma was developed for clinical practice.

RESULTS

A total of 15 full texts with 5869 patients were found. With a rate of 1.4%, laparoscopically missed injuries were very rare for both penetrating and blunt abdominal trauma. Of all trauma laparoscopies 29.3% were converted to open surgery (laparotomy). Among the non-converted laparoscopies 60.5% were therapeutic. Complications occurred after trauma laparoscopy in 8.6% of cases.

CONCLUSION

By means of systematic laparoscopic exploration, missed injuries in abdominal trauma are extremely rare, so that concerns in this respect no longer seem justified. A large proportion of intra-abdominal injuries can be treated using laparoscopy or laparoscopically assisted procedures.

Intramural hematoma of colon: Case report of 2 cases

INTRODUCTION

Colonic intramural hematomas are rarely encountered clinical entity. Colonic intramural hematomas are frequently associated with blunt trauma, and they could occur spontaneously in patients under anticoagulant therapy or with bleeding diathesis. There were few reports on synchronous colon cancer and intramural hematoma. Intramural hematomas of gastrointestinal tract in those patients undergoing anticoagulation treatment often occurred at the esophagus, duodenum, and small intestine, while colon was rarely affected site. Clinical symptoms of colonic intramural hematomas may include abdominal pain, lower gastrointestinal bleeding, and occasionally bowel obstruction.

PATIENT CONCERNS

We herein report 2 cases of colonic intramural hematomas. Case 1 presented with abdominal pain and decreased defecation. Colonoscopy and contrast-enhanced computed tomography (CT) revealed intramural hematoma proximal to the neoplasm at ascending colon. Case 2 was a patient under regular anticoagulation therapy after coronary arterial stent implantation. His chief complaints were intermittent abdominal pain and distension. Colonoscopy and contrast-enhanced CT demonstrated intramural hematoma at sigmoid colon.

DIAGNOSIS

Case 1 was diagnosed synchronous colonic intramural hematoma and colon cancer at ascending colon via surgery. Case 2 was diagnosed intramural hematoma of sigmoid colon through colonoscopy and follow-up CT.

INTERVENTIONS

Case 1 underwent right hemicolectomy. Case 2 received conservative treatment including anticoagulation discontinuation, total parenteral nutrition, and intravenous hydration.

OUTCOMES

They both had a good recovery.

CONCLUSION

Colonoscopy and CT are useful in diagnosing colonic intramural hematoma. The optimal treatment should be individualized according to different etiologies causing hematoma.

Nonsurgical management of traumatic pneumoperitoneum in a cat

OBJECTIVE

To describe the nonsurgical management of a cat with traumatic pneumoperitoneum.

CASE SERIES SUMMARY

A 4-year-old cat was presented following vehicular polytrauma. Thoracic radiographs revealed 4 rib fractures, a scapular fracture, and pneumothorax. Abdominal ultrasound revealed a small volume of free abdominal fluid. Computed tomography showed a mild pneumoretroperitoneum and a pneumoperitoneum in the region of the porta hepatis. The cat was managed conservatively with close monitoring. Exploratory laparotomy was not pursued given patient stability and static serial imaging studies revealing no indications for surgical intervention. After 6 days, the pneumoperitoneum was no longer detectable.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first report of successful nonsurgical management of traumatic pneumoperitoneum in a cat.

Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: A systematic literature review

BACKGROUND

Computed tomography (CT) diagnostic accuracy for blunt bowel and mesenteric injuries (BBMI) is controversial.

DATA SOURCES

A literature review to compute aggregate CT performance and individual CT sign sensitivity, specificity, and positive predictive value (PPV) for operative BBMI.

CONCLUSIONS

Sensitivity, specificity, and PPV were: overall CT performance 85.3%, 96.1%, 51.4%; abnormal wall enhancement 30.1%, 95.7%, 64.0%; bowel wall discontinuity 22.3%, 99.0%, 87.9%; bowel wall hematoma 22.5%, 100%, 19.5%; bowel wall thickening 35.2%, 96.5%, 32.1%; free air 32.0%, 98.7%, 57.1%; free fluid 65.6%, 85.0%, 25.5%; mesenteric air 27.6%, 99.1%, 85.3%; mesenteric extravasation 22.9%, 99.6%, 73.9%; mesenteric hematoma/fluid 33.9%, 98.7%, 52.8%; mesenteric stranding/streaking 34.3%, 91.8%, 31.6%; mesenteric vessel beading 32.1%, 97.2%, 60.4%; mesenteric vessel termination 31.6%, 97.2%, 63.5%; oral contrast extravasation 10.0%, 100%, 100%; retroperitoneal air 9.4%, 94.9%, 55.6%; and retroperitoneal fluid 44.2%, 49.4%, 38.5%. Sensitivity, specificity, and PPV vary substantially among known signs. Other clinical factors are necessary for comprehensive BBMI identification.