The pathophysiology and management of bowel and mesenteric injuries due to blunt trauma

Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study

BACKGROUND

Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury.

METHODS

Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R.

RESULTS

AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged.

CONCLUSION

BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.

Bucket-handle mesenteric tear and traumatic abdominal wall hernia following bicycle handlebar injury in an adult: A 'case report'

INTRODUCTION AND IMPORTANCE

Bucket-handle mesenteric tear (BHMT) is a type of intestinal mesenteric injury where the intestine separates from its mesentery resulting in ischemia and perforation. Traumatic abdominal wall hernia (TAWH) is a disruption of the abdominal wall muscles and fascia in the presence of intact skin. BHMT and TAWH following bicycle handlebar injury in adults are rare. TAWH and generalized abdominal tenderness led to emergent surgical treatment in our patient. I aim to report these rare clinical entities in an adult patient with the management. This case report can create awareness among primary care physicians to decide on early referral and surgeons on early treatment.

CASE PRESENTATION

A 55y man presented 4 h after a bicycle handlebar injury to the abdomen. He had generalized abdominal pain but no history of vomiting, smoking, diabetes, or hypertension. Lab results were insignificant. TAWH and generalized tenderness led to the additional diagnosis of hollow-viscus perforation, but laparotomy revealed BHMT of the ileum and transverse colon. We did TAWH repair, bowel resection, and end-to-end anastomosis with excellent results.

CLINICAL DISCUSSION

BHMT following bicycle handlebar injury is rare in adults, with few case reports. Imaging is less sensitive, and surgery is the definitive diagnosis of BHMT.TAWH in adults after bicycle handlebar injury is rare and can be a sign of serious-intraabdominal injuries, and surgical repair is the treatment.

CONCLUSION

BHMT and TAWH following bicycle handlebar injury are rare in adults. BHMT can be life-threatening if not detected and treated early.

Abdominal trauma

Traumatic injuries are the leading cause of death in people aged<45 years, and abdominal trauma is a source of significant morbidity and mortality and high economic costs. Imaging has a fundamental role in abdominal trauma, where CT is a fundamental tool for rapid, accurate diagnosis that will be key for patients' clinical outcomes.

CT-based diagnostic algorithm to identify bowel and/or mesenteric injury in patients with blunt abdominal trauma

OBJECTIVES

To develop a CT-based algorithm and evaluate its performance for the diagnosis of blunt bowel and/or mesenteric injury (BBMI) in patients with blunt abdominal trauma.

METHODS

This retrospective study included a training cohort of 79 patients (29 with BBMI and 50 patients with blunt abdominal trauma without BBMI) and a validation cohort of 37 patients (13 patients with BBMI and 24 patients with blunt abdominal trauma without BBMI). CT examinations were blindly analyzed by two independent radiologists. For each CT sign, the kappa value, sensitivity, specificity, and accuracy were calculated. A diagnostic algorithm was built using a recursive partitioning model on the training cohort, and its performances were assessed on the validation cohort.

RESULTS

CT signs with kappa value > 0.6 were extraluminal gas, hemoperitoneum, no or moderate bowel wall enhancement, and solid organ injury. CT signs yielding best accuracies in the training cohort were extraluminal gas (98%; 95% CI: 91-100), bowel wall defect (97%; 95% CI: 91-100), irregularity of mesenteric vessels (97%; 95% CI: 90-99), and mesenteric vessel extravasation (97%; 95% CI: 90-99). Using a recursive partitioning model, a decision tree algorithm including extraluminal gas and no/moderate bowel wall enhancement was built, achieving 86% sensitivity (95% CI: 74-99) and 96% specificity (95% CI: 91-100) in the training cohort and 92% sensitivity (95% CI: 78-97) and 88% specificity (95% CI: 74-100) in the validation cohort for the diagnosis of BBMI.

CONCLUSIONS

An effective diagnostic algorithm was built to identify BBMI in patients with blunt abdominal trauma using only extraluminal gas and no/moderate bowel wall enhancement on CT examination.

KEY POINTS

• A CT diagnostic algorithm that included extraluminal gas and no/moderate bowel wall enhancement was built for the diagnosis of surgical blunt bowel and/or mesenteric injury. • A decision tree combining only two reproducible CT signs has high diagnostic performance for the diagnosis of surgical blunt bowel and/or mesenteric injury.

Isolated superior mesenteric artery rupture caused by abdominal trauma

The superior mesenteric artery (SMA) is one of the visceral branches of the abdominal aorta. It has multiple branches to supply blood and nutrition to the intestinal segment, and these form an anastomosis with each other. SMA injuries are usually classified as major visceral artery injuries, and have an incidence of <1%. The clinical manifestations of patients with SMA injuries include intra-abdominal bleeding and peritoneal irritation. The compromised blood supply can lead to intestinal ischemia and perforation. These injuries are often not diagnosed in time and have significant mortality rates of 25%‍-‍68% due to the lack of specific features (Maithel et al., 2020). Not only that, but patients with less severe trauma or no visible damage on initial examination may still have clinically significant intra-abdominal injuries (Nishijima et al., 2012). Emergency departments often encounter multiple cases that require urgent diagnosis and treatment (Li et al., 2021; Zhang et al., 2021; Zhou et al., 2021), and therefore, it is imperative to diagnose and manage these rare injuries expeditiously.

A Case of Delayed Cecal Perforation After Abdominal (Seat Belt) Injury

Seatbelts have reduced the number of fatal head, facial, and chest injuries. They have, however, introduced a set of injuries comprising abdominal wall bruising, Intra-abdominal injuries, and lumbar spine fractures collectively termed the seat belt syndrome. Surgical repair is the treatment for encountered bowel injuries. We present a case of delayed bowel perforation following presentation with signs of seat belt trauma identifying a decisional dilemma in the surgical management of serosal tears with no apparent signs of perforation.

A Study on Trauma Mechanisms and Injury Sites in Patients with Blunt Abdominal Trauma

Background

Although blunt abdominal trauma is sometimes readily identified in patients with trauma, its diagnosis and treatment can be delayed due to various limitations including unconsciousness or unstable vital functions, which may cause shock due to blood loss and sepsis. Confirming the correlation between the specific damage of the abdominal organ and the recommended surgical intervention will allow for predicting abdominal damage based on the specific underlying trauma mechanisms.

Objectives

This study aimed to assess the proportion of patients with blunt trauma resulting from intraabdominal injury who received surgical intervention (surgery and angioembolization [A/E]), stratified by trauma mechanism and to examine which organs were damaged per different trauma incident.

Methods

We retrospectively analyzed the clinical characteristics of 2,291 patients in a tertiary trauma center. Clinical characteristics included age, sex, injury severity score, trauma mechanism (car, motorcycle, pedestrian, bicycle, ship or train accident, fall, slipping or rolling down, bumping, crush injury, explosion burn, and others), abdominal surgical intervention, damaged organ, and A/E site.

Results

One-fourth of the patients with blunt trauma required surgical intervention in the abdomen. In particular, the mesentery or bowel was the main injured area for abdominal surgery in all mechanisms, and the spleen or liver was the main damaged organ subjected to A/E. Therefore, we should consider that a substantial proportion of patients with trauma do require abdominal surgery. In particular, repeated physical examination and imaging tests are necessary when the patients are unconscious or their vital functions are unstable for accurate confirmation of injury.

Vascular bowel and mesenteric injury in blunt abdominal trauma: a single centre experience

AIM

To establish common patterns of injury in vascular bowel and mesenteric injury (VBMI) and to identify any factors that may lead to delayed treatment.

METHODS AND MATERIALS

Forty-one patients with blunt VBMI presented to the level 1 trauma centre of the The Royal London Hospital over 5 years. Computed tomography (CT) images were reviewed to identify the specific location of injury and additional features such as seatbelt bruising and lumbar hernias. Surgical reports were reviewed to record any pertinent surgical findings at laparotomy.

RESULTS

The commonest mechanism of injury was a restrained car occupant involved in a road traffic collision (49%, n=20). The ileocaecal mesenteric vasculature was most frequently injured (41.5%, n=17), followed by the mid ileum (17.1%, n=7). Seatbelt bruising was identified in 80% of restrained car occupants and lumbar hernias in 22% of all patients with VBMI.

CONCLUSION

Restrained car occupants involved in road traffic collisions are at increased risk of VBMI with particular susceptibility of the ileocaecal mesentery. This has implications for the reporting radiologist and trauma surgeon in deciding which patients require careful monitoring for the development of delayed bowel ischaemia.

Laparoscopic treatment of mesenteric avulsion and intestinal perforation after blunt abdominal trauma: A report of a case

•

Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen.

•

The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

•

We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion treated with laparoscopic approach.

•

Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment.

•

The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Introduction

Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen. The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

Case report

We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion. Since the patient was hemodynamically stable, a laparoscopic approach was carried on.

Discussion

Blunt abdominal trauma are responsible of 6–14.9% of all traumatic injuries (Galia et al., 2017). The frequency of small bowel lesions ranges from 5% to 15%, while small bowel mesenteric injuries are approximately found in 5% of patients after blunt abdominal trauma. There are different biomechanical reasons explaining how a blunt trauma can cause damages to small bowel and its mesentery. Clinical diagnosis of small bowel perforation after blunt abdominal trauma is often challenging for non-specific objective clinical signs and because peritoneal irritation symptoms are present only in collaborative patients.

Conclusion

Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment. The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Mesenteric Vascular Injury in Trauma: An NTDB Study

BACKGROUND

Although abdominal trauma remains a major cause of morbidity and mortality, there has not been a large-scale multicenter study regarding outcomes in patients who incur mesenteric vascular injuries. The goal of this retrospective analysis was to investigate the factors associated with outcomes in patients with trauma diagnosed with mesenteric vascular injuries.

METHODS

A retrospective database analysis was performed on patients who sustained a mesenteric vascular injury (MVI, ICD-9 902.20-902.29) identified by the 2012 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, emergency room (ER) and final hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score (ISS), and injury type (blunt or penetrating).

RESULTS

Of the 1,133 total patients included, blunt trauma accounted for 740 (65%) of the injuries, whereas penetrating trauma accounted for 364 of the injuries (32%). Patients with penetrating injuries were 1.43 times more likely to die from their injuries than those suffering from blunt trauma (95% CI 1.04-1.98, P < 0.05). Patients with a higher ISS (>16) were 5.39 times more likely to die from their injuries than those with a lower ISS (95% CI 1.89-15.4, P = 0.002); if ISS was >25, the patient was 15.1 times more likely to die (95% CI 5.5-41.7, P < 0.001). Men were more likely to suffer from penetrating injuries than women (37% vs. 13%, P < 0.001), and African Americans were nearly 4 times more likely to present with penetrating injuries (69% vs 17%, P < 0.001). Age was also associated with mortality as patients >65 years and between 21 and 44 years were more likely to die from their injuries than patients in other age categories. Of the 740 patients with blunt MVIs, 326 (44%) were taken directly from the ER to the operating room (OR) and 306 (41%) to the intensive care unit (ICU), whereas with penetrating MVIs, 311 (85%) were taken to the OR from the emergency department and 18 (5%) to the intensive care unit. Of the 740 blunt MVIs, 115 died (16%), compared with 76 (21%) of the penetrating MVIs (P < 0.001). Injuries to the hepatic and superior mesenteric arteries were associated with higher mortality, with OR 2.03 and 3.03, respectively (P < 0.001).

CONCLUSIONS

The presence of mesenteric arterial injury warrants rapid identification and management as these injuries are associated with significant morbidity and mortality, with penetrating mechanism, injury to large mesenteric vessels, and increased ISS associated with increased mortality.

Evaluation of Bowel and Mesentery in Abdominal Trauma

Since the advent of multidetecter computed tomography (CT), radiologist sensitivity in detection of traumatic bowel and mesenteric abnormalities has significantly improved. Although several CT signs have been described to identify intestinal injury, accurate interpretation of these findings can remain challenging. Early detection of bowel and mesenteric injury is important as it alters patient management, disposition, and follow-up. This article reviews the common imaging findings of traumatic small bowel and mesenteric injury.

Imaging of blunt bowel and mesenteric injuries: Current status

Blunt abdominal trauma often presents a diagnostic challenge. Clinical examination demonstrates low reliability in detecting abdominal injury (16 %) when there is a history of head injury or loss of consciousness. This can prove detrimental, as delays in the diagnosis of traumatic bowel injury of 8 h or less can result in increased morbidity and mortality, as well as prolonged hospitalization. Although hemodynamically unstable patients will require an urgent laparotomy following clinical assessment, MDCT is the modality of choice for comprehensive imaging of blunt abdominal trauma in hemodynamically stable patients. Despite the use of MDCT, blunt injury to the bowel and mesentery, which accounts for up to 5% of injuries in cases of trauma, may be difficult to detect. The use of a constellation of direct and indirect signs on MDCT can help make the diagnosis and guide clinical management. Direct signs on MDCT, such as bowel wall discontinuity, and extraluminal gas may assist in the diagnosis of traumatic bowel injury. However, these signs are not sensitive. Therefore, the astute radiologist may have to rely on indirect signs of injury, such as free fluid, bowel wall thickening, and abnormal bowel wall enhancement to make the diagnosis. This review will focus on MDCT imaging findings of bowel and mesenteric injuries secondary to blunt abdominal trauma.

Evaluation and Management of Traumatic Conditions in the Athlete

The athletic training room is filled with a multitude of conditions encompassing many different specialties of medicine. When it comes to traumatic injuries in the training room, many of them are not musculoskeletal in nature. Ultrasound in the training room can help identify serious and subtle solid-organ injury and small pneumothoraces. The discussion of these conditions follows a simple outline that helps identify injury/conditions through a proper history and physical. Evidence-based treatment/management/return to play guidelines are discussed.

Surgical intervention for blunt bowel and mesenteric injury: indications and time intervals

PURPOSE

Decision making in management of blunt bowel and mesenteric injury (BBMI) is difficult. This study aimed to identify indicators for laparotomy and appropriate time intervals to surgery.

METHODS

We retrospectively reviewed our hospital's trauma registry to identify patients with a diagnosis of BBMI from February 2011 to July 2017. Patients requiring therapeutic surgical treatment (OM group) were compared with those who did not (NOM group). Preoperative risk factors for surgery (with p < 0.1 by univariate analysis) were integrated in a multivariate logistic regression model. In the OM group, we identified relevant factors for time intervals to surgical interventions.

RESULTS

Among 2808 trauma patients admitted to our hospital, 83 (3.0%) had bowel and mesenteric injury; 6 patients with penetrating trauma, 2 lethal, untreated cases, and 2 patients who underwent exploratory laparotomy were excluded. Finally, 73 patients (47 males), with a mean Injury Severity Score (ISS) of 23, were included. Results from univariate analysis identified three relevant factors between the OM and NOM groups: ISS score (p = 0.036), hemodynamic instability (p = 0.041), and free air (p = 0.0018). Multivariate analysis revealed one relevant factor, free air (p = 0.0002). Short intervals between hospital admission and intervention were associated with 7-day mortality (p = 0.029), hemodynamic instability (p = 0.0009), focused assessment with sonography for trauma positive (p < 0.0001), and mesenteric extravasation (p = 0.012).

CONCLUSIONS

Early surgical intervention is essential in cases of hemodynamically unstable BBMI and bowel perforation with free air; nevertheless, it is associated with high mortality. We suggest that prompt transport along with early intervention could significantly lessen mortality.

[Acute abdominal trauma]

BACKGROUND

In patients with multiple trauma, abdominal involvement is a particularly relevant injury pattern. Depending on the intensity and manner of injury, heterogeneous but often typical organ manifestations result. Knowledge of these injury patterns is essential for targeted diagnostics and treatment.

OBJECTIVE

This review provides a presentation of typical forms of abdominal injury with appropriate radiological techniques and where applicable treatment.

MATERIAL AND METHODS

Experiences and case examples from a supraregional trauma center are presented and discussed with the results of a Medline literature search and relevant parts of the german S3 guidelines on polytrauma.

RESULTS

Traumatic abdominal injuries are subdivided into blunt and penetrating injuries. Among these groups, blunt trauma with splenic injury being most frequent followed by liver and kidney involvement. In penetrating abdominal injuries hollow visceral organs are most frequently affected. For diagnosis, ultrasound and with escalating injury severity, multidetector computed tomography (MDCT) are the most important methods. For years there has been an ongoing trend towards conservative management and interventional hemorrhage control. This is driven by improvements in imaging that enable a more precise classification and indications for subsequent treatment.

CONCLUSION

Progress in radiology has led to an increasingly more important role for radiology in the management of traumatic abdominal injury. Therefore, it is crucial for the radiologist to gain interdisciplinary knowledge of the relevant trauma mechanisms and injury patterns of the severely injured patient in order to provide a treatment process that provides the optimal outcome.

Multiple isolated small bowel perforations following blunt abdominal trauma

INTRODUCTION

Small bowel injury is uncommon after blunt abdominal trauma. Repeated clinical assessment is important, especially when investigative imaging is negative.

CASE PRESENTATION

39-year-old male presented to the emergency department following a blunt abdominal trauma. No initial hemodynamic abnormalities were found. Abdominal CT scan was negative for small bowel perforation. Repeated clinical assessment revealed increasing abdominal pain with tachycardia, and an emergent laparotomy was undertaken. Four grade II and one grade I small bowel perforations were found, all repaired with interrupted sutures. Patient was discharged home on day 7.

DISCUSSION/CONCLUSION

The diagnosis of small bowel injury is difficult and a low threshold of suspicion is crucial to reduce morbidity and mortality. Hemodynamic instability or abdominal tenderness after blunt abdominal trauma are indications for immediate surgical exploration, despite negative imaging findings. Serial clinical assessment is the main decision tool to perform an abdominal exploration.

Ability of specific and nonspecific signs of multidetector computed tomography (MDCT) in the diagnosis of blunt surgically important bowel and mesenteric injuries

PURPOSE

To determine the accuracy of MDCT in the evaluation of blunt surgically relevant bowel and/or mesenteric injuries (BMIs) using single specific CT signs together with specific pairs of nonspecific signs.

METHODS

Fifty-four patients examined with MDCT were divided into two groups: a 'surgical' group of 20 patients-which underwent surgery for blunt BMIs-and a control group of 34 'nonsurgical' trauma patients. Two radiologists with different experience performed a double-blind retrospective evaluation of the images, classifying the patients in the two groups by using only single specific signs; then, the images were reviewed in consensus with a third radiologist and sensitivity and specificity were calculated. Subsequently, the frequency of every single sign and of every possible combination of nonspecific signs in the two groups was registered, to find combinations present only in the surgical group; sensitivity and specificity were calculated by using even those specific combinations.

RESULTS

At the first consensual evaluation, sensitivity and specificity were 75 and 100%, respectively. Two combinations of nonspecific signs (focal wall thickening + extraluminal air; focal wall thickening + seat belt sign) were found only in surgical patients that did not present any single specific sign: Sensitivity calculated adding those two combinations was 95%, without a decrease in specificity.

CONCLUSIONS

MDCT is an accurate technique in the evaluation of blunt surgically relevant BMIs. The single specific CT signs were sufficient for the diagnosis in only 75% of the cases; adding the two specific combinations allowed an increase in sensitivity of 20%.

Emergency CT of blunt abdominal trauma: experience from a large urban hospital in Southern China

Trauma is one of the leading causes of death for men and women under the age of 45 years old, and abdominal injuries contribute to a large number of these deaths. Prompt diagnosis is very important for treatment decision making and can be life-saving. CT has become an essential imaging modality in emergency medicine. In this pictorial review, we present our experience of CT in blunt abdominal trauma and describe CT findings of common injuries, including hemoperitoneum, solid viscera, hollow viscera, mesenteric and diaphragmatic injuries. Unenhanced CT is routinely used, tailored protocols should be reserved for patients with questionable or subtle findings at unenhanced CT, especially for bowel and mesenteric injuries. The decision can be made by radiologists based on initial findings or by referring clinicians based by clinical presentations or deterioration of patients' condition.

Biomechanical analysis of traumatic mesenteric avulsion

Mesenteric avulsion, corresponding to a tearing of intestine's root, generally results from high deceleration in road accidents. The biomechanical analysis of bowel and mesenteric injuries is a major challenge for injury prevention, particularly because seat belt restraint may paradoxically increase their risk of occurrence. The aim of this study was to identify the biomechanical behavior of mesentery and small bowel (MSB) tissue samples under dynamical loading conditions. A dedicated test bench was designed in order to perform tensile tests on fresh MSB porcine specimens, with quasi-static (1 mm/s) and dynamic (100 mm/s) loading conditions. The mechanical behavior of MSB specimens was investigated and compared to isolated mesenteric and isolated small bowel specimens. The results show a high sensitivity of MSB stiffness (1.0 ± 0.2 and 1.3 ± 0.3 N/mm at 1 and 100 mm/s, p = 0.001) and ultimate force (22 ± 5 and 35 ± 8 N at 1 and 100 mm/s, p = 0.001) to the loading rate but not for the displacement at failure. This leads to postulate on a failure criteria based on strain level regardless of the strain rate. These experimental results could be further used to develop refined finite element models and to further investigate on injury mechanisms associated to seat belt restraints, as well as to evaluate and improve protective devices.

BWH emergency radiology-surgical correlation: omental hematoma with active extravasation: a rare diagnosis

We describe the radiological and intraoperative correlation of a large omental hematoma with active intra-abdominal bleeding secondary to omental lacerations in a 75-year-old man following blunt trauma from a motor vehicle accident. The purpose of this article is to emphasize the importance of recognizing omental and mesenteric injuries in trauma patients, as these injuries are rare and can be overlooked on CT.

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.

Blunt bowel and mesenteric injuries detected on CT scan: who is really eligible for surgery?

BACKGROUND

There is no consensually accepted approach to the management of blunt bowel and mesenteric injuries. Surgery is required urgently in the case of bowel perforation or haemodynamic instability, but several patients can be treated non-operatively. This study aimed to identify the risk factors for surgery in an initial assessment.

METHODS

We retrospectively reviewed the medical charts and computed tomography (CT) scans of adult patients presenting with a blunt abdominal trauma to our centre between the years 2004 and 2011. We included only patients with a CT scan showing suspected injury to the mesentery or bowel.

RESULTS

There were 43 patients (33 males and 10 females), with a mean Injury Severity Score (ISS) of 22. The most frequently suspected injuries based on a CT scan were mesenteric infiltrations in 40 (93 %) patients and bowel wall thickening in 22 (51 %) patients. Surgical therapy was required for 23 (54 %) patients. Four factors were independently associated with surgical treatment: a free-fluid peritoneal effusion without solid organ injury [adjusted odds ratio (OR) = 14.4, 95 % confidence interval (CI) [1.9-111]; p = 0.015], a beaded appearance of the mesenteric vessels (OR = 9 [1.3-63]; p = 0.027), female gender (OR = 14.2 [1.3-159]; p = 0.031) and ISS >15 (OR = 6.9 [1.1-44]; p = 0.041). Surgery was prescribed immediately for 11 (26 %) patients and with delay, after the failure of initially conservative treatment, for 12 (28 %) patients. The presence of a free-fluid peritoneal effusion without solid organ injury was also an independent risk factor for delayed surgery (OR = 9.8 [1-95]; p = 0.048).

CONCLUSIONS

In blunt abdominal trauma, the association of a bowel and/or mesenteric injury with a peritoneal effusion without solid organ injury on an initial CT scan should raise the suspicion of an injury requiring surgical treatment. Additionally, this finding should lead to a clinical discussion of the benefit of explorative laparotomy to prevent delayed surgery. However, these findings need validation by larger studies.

Multidetector CT findings of bowel transection in blunt abdominal trauma

Objective

Though a number of CT findings of bowel and mesenteric injuries in blunt abdominal trauma are described in literature, no studies on the specific CT signs of a transected bowel have been published. In the present study we describe the incidence and new CT signs of bowel transection in blunt abdominal trauma.

Materials and Methods

We investigated the incidence of bowel transection in 513 patients admitted for blunt abdominal trauma who underwent multidetector CT (MDCT). The MDCT findings of 8 patients with a surgically proven complete bowel transection were assessed retrospectively. We report novel CT signs that are unique for transection, such as complete cutoff sign (transection of bowel loop), Janus sign (abnormal dual bowel wall enhancement, both increased and decreased), and fecal spillage.

Results

The incidence of bowel transection in blunt abdominal trauma was 1.56%. In eight cases of bowel transection, percentage of CT signs unique for bowel transection were as follows: complete cutoff in 8 (100%), Janus sign in 6 (100%, excluding duodenal injury), and fecal spillage in 2 (25%). The combination of complete cutoff and Janus sign were highly specific findings in patients with bowel transection.

Conclusion

Complete cut off and Janus sign are the unique CT findings to help detect bowel transection in blunt abdominal trauma and recognition of these findings enables an accurate and prompt diagnosis for emergency laparotomy leading to reduced mortality and morbidity.

Multidetector CT of blunt abdominal trauma

The morbidity, mortality, and economic costs resulting from trauma in general, and blunt abdominal trauma in particular, are substantial. The "panscan" (computed tomographic [CT] examination of the head, neck, chest, abdomen, and pelvis) has become an essential element in the early evaluation and decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma. CT has virtually replaced diagnostic peritoneal lavage for the detection of important injuries. Over the past decade, substantial hardware and software developments in CT technology, especially the introduction and refinement of multidetector scanners, have expanded the versatility of CT for examination of the polytrauma patient in multiple facets: higher spatial resolution, faster image acquisition and reconstruction, and improved patient safety (optimization of radiation delivery methods). In this article, the authors review the elements of multidetector CT technique that are currently relevant for evaluating blunt abdominal trauma and describe the most important CT signs of trauma in the various organs. Because conservative nonsurgical therapy is preferred for all but the most severe injuries affecting the solid viscera, the authors emphasize the CT findings that are indications for direct therapeutic intervention.

Biomechanical characterisation of fresh and cadaverous human small intestine: applications for abdominal trauma

Intestinal injuries are responsible for significant morbidity and mortality arising from trauma to the abdomen. The biomechanical characterisation of the small intestine allows for the understanding of the pathophysiological mechanisms responsible for these injuries. Studies reported in the literature focus principally on quasi-static tests, which do not take into account the stresses experienced during high kinetic trauma. In addition, the use of embalmed human tissue can alter the recorded response. The stress-strain curves from 43 tensile tests performed at 1 m/s were analysed. Samples were prepared from four fresh human intestines and from four embalmed cadaveric intestines. The data indicated a two-phase response, with each response consisting of a quasi-linear increase in the stress followed by an inflection in the curve before a peak preceding the loss of stress. The fresh tissue was more deformable than the embalmed tissue, and its first peak stress was lower (P = 0.034). A complementary histological analysis was performed. The results of the analysis enable an investigation of the response of the intestinal wall layers to stress as a two-layer structure and highlight the high sensitivity of the structure's mechanical behaviour to the speed of loading and the method of preservation.

CT imaging of blunt traumatic bowel and mesenteric injuries

Delayed diagnosis of a bowel or mesenteric injury resulting in hollow viscus perforation leads to significant morbidity and mortality from hemorrhage, peritonitis, or abdominal sepsis. The timely diagnosis of bowel and mesenteric injuries requiring operative repair depends almost exclusively on their early detection by the radiologist on computed tomography examination, because the clinical signs and symptoms of these injuries are not specific and usually develop late. Therefore, the radiologist must be familiar with the often-subtle imaging findings of bowel and mesenteric injury that will allow for appropriate triage of a patient who has sustained blunt trauma to the abdomen or pelvis.

[Gastrointestinal and mesenteric injuries in the trauma patient: incidence, diagnosis delay and prognosis]

BACKGROUND

Gastrointestinal and mesenteric injuries (GIMI) are uncommon in trauma patients, and their diagnosis are often delayed. Our aims were to determine the reliability of CT scan in our centre, and to assess the clinical significance of a delayed diagnosis.

MATERIALS AND METHOD

Retrospective analysis of cases confirmed at laparotomy. Patients were identified at the Severe Trauma Registry of Gregorio Marañón University General Hospital, between 1993 and 2006.

RESULTS

We found 105 (16.6%) GIMI out of 632 patients with abdominal trauma, in a Registry with 1495 severe trauma cases included. A total of 46% had blunt injuries. The mean injury severity score (ISS) and new ISS (NISS) were 20 and 25, respectively. There were 9 (8.5%) deaths, 4 of which were unexpected. A CT scan was performed in 56 (53%) cases, and only in 37 there were signs suggestive of a GIMI. In another 43 (41%) patients an urgent laparotomy was indicated because of positive clinical findings or instability. Surgery was delayed for more than 8 hours in 21 (20%) patients, the most common reason being a false negative result in the CT scan.

CONCLUSIONS

The overall incidence of GIMI was high in our centre (31% due to penetration and 10.7% blunt trauma). Several factors, such as the initial lack of symptoms, a low diagnostic sensitivity of the CT scan (34% false negatives), and the non-surgical management of solid organ injuries, have contributed to a delayed diagnosis and treatment in one out of each five patients in our series, but this has not led to a significant increase in septic complications in this group.

Hollow viscus injury

BACKGROUND

Hollow viscus injuries are uncommon and occur in approximately 1% of all blunt trauma patients.

DISCUSSION

These injuries are often not suspected and are difficult to diagnosis. Morbidity and mortality are high, and a negative abdominal computed tomography is not sufficient to rule out these injuries in certain clinical scenarios.

CONCLUSION

Using a case-based approach, the epidemiology and diagnostic pathways to manage hollow viscus injuries are reviewed.

Blunt colon injury sustained during a kickboxing match

Emergency physicians routinely evaluate patients for injury from blunt abdominal trauma. Most serious injuries result from high energy mechanisms such as motor vehicle collisions. This case report describes a patient who sustained blunt trauma to the descending colon during a martial arts match, necessitating a hemicolectomy.

Evaluation of Bowel and Mesenteric Blunt Trauma with Multidetector CT

Bowel and mesenteric injuries are detected in 5% of blunt abdominal trauma patients at laparotomy. Computed tomography (CT) has been shown to be accurate for the diagnosis of bowel and mesenteric injuries and is the diagnostic test of choice in the evaluation of blunt abdominal trauma in hemodynamically stable patients. Specific CT findings of bowel and mesenteric injuries include bowel wall defect, intraperitoneal and mesenteric air, intraperitoneal extraluminal contrast material, extravasation of contrast material from mesenteric vessels, and evidence of bowel infarct. Specific signs of mesenteric injury are vascular beading and abrupt termination of mesenteric vessels. Less specific signs of bowel and mesenteric injuries include focal bowel wall thickening, mesenteric fat stranding with focal fluid and hematoma, and intraperitoneal or retroperitoneal fluid. When only nonspecific signs of bowel and mesenteric injuries are seen on CT images, correlation of CT features with clinical findings is necessary. A repeat CT examination after 6-8 hours if the patient's condition is stable may help determine the significance of these nonspecific findings.

The role of computed tomography in diagnosis of blunt intestinal and mesenteric trauma (BIMT)

Blunt intestinal mesenteric trauma (BIMT) is a rare injury with a high morbidity and mortality. It is a diagnostic dilemma for Trauma Surgeons and Emergency Physicians. This study was undertaken to assess the role of computed tomography (CT) in BIMT. Data were analyzed from 1995 to 2002. Thirty-six cases of BIMT were identified: 16 isolated and 20 non-isolated injuries. Initial CT scan was abnormal in 74% (17 out of 23), and 83% on retrospect (2 additional cases). CT scans were abnormal (initial and repeat) in 96% (22 out of 23). The most common abnormalities were free fluid (78%), mesenteric stranding or edema (39%), bowel wall hematoma, or edema (30%). Free air was seen in 31% and oral contrast extravasation in 15% of cases of bowel perforation. CT scan findings in BIMT can be subtle and non-specific. Suspicion of BIMT warrants close observation and probably further diagnostic testing.

Blunt injury to mesentery and small bowel:

Helical CT now allows rapid acquisition of sections through the abdomen and pelvis with optimal vascular opacification and minimal motion artifact. Oral contrast may aid in the identification of subtle bowel and mesenteric injuries and does not have any significant deleterious effects. CT findings of extraluminal enteric contrast, active hemorrhage, or free intraperitoneal-retroperitoneal air allow accurate diagnosis of SBMI in the setting of blunt abdominal trauma. Mesenteric hematoma in association with bowel wall thickening or the presence of significant amounts of free fluid without solid organ injury is highly suspicious for SBMI requiring laparotomy. CT alone or in concert with DPL and physical examination is a valuable tool in the timely diagnosis and treatment of bowel and mesenteric injury caused by blunt trauma.

Suboptimal restraint affects the pattern of abdominal injuries in children involved in motor vehicle crashes

BACKGROUND

Both solid and hollow visceral abdominal injuries have been associated with the use of seat belts in children involved in motor vehicle crashes. The relationship between the types of restraint used and the pattern of abdominal injury is unknown.

METHODS

A probability sample of restrained children involved in crashes was enrolled in an ongoing crash surveillance system (1998 through 2002) linking insurance claims data to telephone survey and crash investigation data. Significant abdominal injuries were considered when the Abbreviated Injury Scale (AIS) score was > or =2 and were defined as hollow visceral (HV; intestine, bladder), or solid visceral (liver, spleen, pancreas, kidney). Restraint type was categorized as optimal restraint (OR) or suboptimal restraint (S-OR) based on the child's age and size.

RESULTS

For the 33 months of review, interviews were obtained for 13,558 restrained children aged 0 to 15 years, of which, 56% were OR (n = 7,591) and 44% were S-OR (n = 5,967). A significant abdominal injury was recorded in 78 children. A hollow visceral injury was recorded in 38 (9 OR and 29 S-OR), and a solid visceral injury in 32 (18 OR and 14 S-OR). Both hollow and solid visceral injuries were present in 8 children (2 OR and 6 S-OR). Suboptimally restrained children had a higher risk for hollow visceral injury when compared with optimally restrained children (Odds Ratio, 4.14 [95% Confidence Interval 1.33 to 13.22, P <.01]).

CONCLUSIONS

Among restrained children with intraabdominal injuries, those who were suboptimally restrained were 4 times more likely to have a hollow visceral than a solid visceral injury when compared with those who were optimally restrained. This suggests that the mechanism of injury for hollow viscus may be directly related to the improper positioning of the restraint.