Index CT-Based Scoring Systems in Operative Blunt Bowel and Mesenteric Injury Identification

INTRODUCTION

Determining the need for surgical management of blunt bowel and mesenteric injury (BBMI) remains a clinical challenge. The Faget score and Bowel Injury Prediction Score (BIPS) have been suggested to address this issue. Their efficacy in determining the need for surgery was examined.

METHODS

A retrospective review of all adult blunt trauma patients hospitalized at a level 1 trauma center between January 2009 and August 2019 who had small bowel, colon, and/or mesenteric injury was conducted. We further analyzed those who underwent preoperative computed tomography (CT) scanning at our institution. Final index CT reports were retrospectively reviewed to calculate the Faget and BIPS CT scores. All images were also independently reviewed by an attending radiologist to determine the BIPS CT score.

RESULTS

During the study period, 14,897 blunt trauma patients were hospitalized, of which 91 had BBMI. Of these, 62 met inclusion criteria. Among patients previously identified as having BBMI in the registry, the retrospectively applied Faget score had a sensitivity of 39.1%, specificity of 81.2%, positive predictive value (PPV) of 85.7%, and negative predictive value (NPV) of 31.7% in identifying patients with operative BBMI. The retrospectively applied BIPS score had a sensitivity of 47.8%, specificity of 87.5%, PPV of 91.7%, and NPV of 36.8% in this cohort. When CT images were reviewed by an attending radiologist using the BIPS criteria, sensitivity was 56.5%, specificity 93.7%, PPV 96.3%, and NPV 42.8%.

CONCLUSIONS

Existing BBMI scoring systems had limited sensitivity but excellent PPV in predicting the need for operative intervention for BBMI. Attending radiologist review of CT images using the BIPS scoring system demonstrated improved accuracy as opposed to retrospective application of the BIPS score to radiology reports.

Delayed hollow viscus injury with an occult seatbelt abrasion presenting as a small bowel obstruction

We present the case of a previously healthy 29-year-old male who presented with a small bowel obstruction in the absence of previous abdominal surgery who was found to have evidence of an occult seatbeltabrasion and ultimately multifocal hollow viscus injury secondary to blunt abdominal trauma at the time of exploratory laparotomy. Hollow viscus injury is a rare, but potentially life-threatening, complication of blunt abdominal trauma. While cross-sectional imaging is an important diagnostic tool, results must be considered within a patient's clinical context as delays in surgical management can lead to significant morbidity and mortality.

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.

Blunt abdominal trauma managed with mesenteric embolization: case report

Blunt abdominal trauma occurs in 20% of polytraumatized patients, of which approximately 5% may have mesenteric lesions. We present a case of a woman suffering from a blunt abdominal trauma, who underwent computed tomography with evidence of hematoma on the right flank, which was controlled by angioembolization of the superior mesenteric artery. Treatment of mesenteric lesions will be determined according to the hemodynamic status of the patient, since in view of stability, a choice can be made between open surgery and embolization, but in case of instability, laparotomy is recommended.

Transcatheter arterial embolization in abdominal blunt trauma with active mesenteric bleeding: case series and review of literature

PURPOSE

To evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) in treating traumatic mesenteric injuries with active bleeding, to report the outcome in a case series, and to compare the results with the existing data.

METHODS

All consecutive patients with active mesenteric bleeding due to blunt abdominal trauma referred to a level-one Trauma Center and treated by TAE were included; the related demographic and medical data were retrospectively reported. A literature review was conducted; all reported cases were collected and analysed together with our case series. A univariate analysis of risk factors for TAE failure, bowel necrosis, complication and length of stay was performed.

RESULTS

Four consecutive patients were included. Technical success was 100%. One patient developed colon ischemia after the procedure and underwent surgical treatment; another presented transient mild renal failure and late respiratory failure. No 30-day mortality was reported. These results are consistent with those reported in literature. The analysis of our cases together with case collected from literature resulted in a case series of 25 patients. Univariate analysis showed colon as site of bleeding as a significant risk factor for bowel necrosis and older age as a significant risk factor for longer length of stay. TAE failure was not significantly associated neither with a higher complication rate nor with a higher length of stay.

CONCLUSION

TAE is a safe and effective procedure to control mesenteric bleeding, thus should be considered, in selected cases and in appropriate setting, as an alternative to emergency surgery.

Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score

PURPOSE

Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma.

METHODS

All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score.

RESULTS

151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91).

CONCLUSIONS

CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.

Defining an intra-operative blunt mesenteric injury grading system and its use as a tool for surgical-decision making

BACKGROUND

The mesentery may be injured in trauma and few grading systems describe mesenteric injury severity. We aimed to develop and validate an intra-operative mesenteric injury grading system.

METHODS

A modified Delphi technique was used to generate an intraoperative grading system for blunt mesenteric injury called the mesenteric injury score (MIS). We performed a retrospective review (2010-2016) of patients >15 years old with blunt abdominal trauma. Patient demographics, injury severity score (ISS) and mechanism, clinical, operative, and outcome data were abstracted. The intraoperative grading system was used to describe patient outcomes including duration of stay and management approach. We compared the correlation of abdominal abbreviated injury score, Blunt Injury Prediction Score (BIPS) and the MIS with clinical outcomes using Spearman's rho.

RESULTS

There were fifty-one patients of which 86% were male. Injury mechanisms included motor vehicle accidents (n = 37, 73%), pedestrian vehicle accidents (n = 7, 13%), assaults (n = 4, 8%), falls (n = 2, 4%), and a single airplane crash (2%). Median [IQR] ISS was 16 [10-25] and GCS at hospital admission was 15 [15-15]. The median [IQR] international normalized ratio was 1.2 [1.1-1.5], lactate was 2.7 [1.7-4.9], and hemoglobin was 11.4 [8.6-12.2]. The distributions of MIS included Grade I (3, 5%), Grade II (10, 20%), Grade III (10, 20%), Grade IV, 5 (10%), and Grade V (23, 45%). Increasing mesenteric injury grade was associated with longer duration of stay, need for bowel resection, and damage control laparotomy.

CONCLUSIONS

We developed an intra-operative mesenteric injury grading system (MIS) and provided an initial retrospective validation using a series of patients with blunt abdominal trauma. The proposed MIS corresponded with both the AIS and the BIPS. Future study comparing cross sectional imaging and operative findings based on MIS criteria is needed.

Isolated Mesenteric Injury causing Ileal Devascularisation with Uterine Perforation following Termination of Pregnancy; A Case Report and Literature Review

Surgical abortion is one of the leading causes of maternal mortality, constituting up to 20% of maternal deaths. Uterine perforation is a rare complication, accounting for4% of all the abortion related complications. Intestinal injury with uterine perforation following termination of pregnancy is even rare and is a potentially fatal complication with mortality of up to 10%. A 27-year-old G3P2L2 woman with 12 weeks of gestation referred to our hospital in hemorrhagic shock with a suspicion of uterine perforation following dilatation and curettage for termination of pregnancy. Patient underwent emergency laparotomy. She was found to have uterine perforation with mesenteric and ileal injuries intraoperatively. Perforation closure with ileoileal resection and anastomosis was done. Postoperatively the patient recovered completely. Prompt reporting/recognition of uterine perforation, preoperative resuscitation and early intervention are the most important steps in the management of patients with intestinal injury. Trauma surgeon should never hesitate or delay in considering an Emergency Laparotomy/laparoscopy in cases of suspected intestinal injury with uterine perforation. Emergency exploration decreases the morbidity and mortality to a great extent in patients with intestinal injury.

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.

Laparoscopy in Blunt Abdominal Trauma: for Whom? When?and Why?

The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.

Core curriculum illustration: blunt trauma to the bowel

This is the 22nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma

BACKGROUND

The diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high.

PATIENTS AND METHODS

Blunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR≥1. CT findings, DPL and surgery results, and global outcome were analyzed.

RESULTS

Thirty-seven were included in the study (27 males, median age of 30 years (range, 17-69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p=0.02) and small bowel wall abnormalities (p=0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59-100]) and 43% (CI 95% [25-63]). The sensitivity remained 100% (CI 95% [59-100]) when the ratio was ≥4 (n=10 patients), and the specificity reached 90% (CI 95% [73-98]).

CONCLUSION

DPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR≥1. Indications for exploratory laparotomy could be restricted to patients with a CCR≥4 to improve the specificity of diagnosis management.

Hollow viscus injury due to blunt trauma: A review

Blunt abdominal trauma results in injury to the bowel and mesenteries in 3-5% of cases. The injuries are polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small bowel and may result in bleeding and/or peritonitis. An urgent laparotomy is necessary if there is evidence of active bleeding or peritonitis at the initial examination, but these situations are uncommon. The main diagnostic challenge is to promptly and correctly identify lesions that require surgical repair. Diagnostic delay exceeding eight hours before surgical repair is associated with increased morbidity and probably with mortality. Because of this risk, the traditional therapeutic approach has been to operate on all patients with suspected bowel or mesenteric injury. However, this approach leads to a high rate of non-therapeutic laparotomy. A new approach of non-operative management (NOM) may be applicable to hemodynamically stable patients with no signs of perforation or peritonitis, and is being increasingly employed. This attitude has been described in several recent studies, and can be applied to nearly 40% of patients. However, there is no consensual agreement on which criteria or combination of clinical and radiological signs can insure the safety of NOM. When NOM is decided upon at the outset, very close monitoring is mandatory with repeated clinical examinations and interval computerized tomography (CT). Larger multicenter studies are needed to better define the selection criteria and modalities for NOM.

Seat belt syndrome: Delayed or missed intestinal injuries, a case report and review of literature

INTRODUCTION

Seat belt injuries are not uncommon. The use of seat belts is associated with a unique injury profile collectively termed "the seat belt syndrome". The aim is to aid in the early diagnosis of seat belt injuries.

CASE PRESENTATION

Two different patients presented to the emergency after sustaining a motor vehicle accident. Both were the drivers, restrained and had a frontal impact. On presentation they were hemodynamically stable with mild tenderness on the abdomen and the abdominal computed tomography (CT) did not show any signs of bowel or mesenteric injuries. The signs of peritonitis became obvious after 24h in one case and after 3 days in the other.

DISCUSSION

Early diagnosis provides better outcomes for patients with seat belt injuries, but this remains a challenge to trauma surgeons. The typical findings of peritonitis might not be present initially. The presence of abdominal wall ecchymosis (seat belt sign) increases the chance of intraabdominal injuries by eight folds.

CONCLUSION

Clinical signs of intestinal injuries might not be obvious on presentation. In the presence of seat belt sign the possibility of bowl injury must be suspected. Admit the patient for observation even if no clinical or radiological findings are present at presentation.

Small bowell perforation and mesentery injury after an unusual blunt abdominal trauma-Case report

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Blunt abdominal trauma after injury with a straw of bale in a rural hospital.

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Prompt evaluation with FAST and computed tomography did not show small bowell perforation.

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Despite this the patient went to surgery wich revealed jejunal perforation.

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Missed or another perforation needing re-surgery.

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Highly clinical suspicion depending on the mechanism of abdominal trauma.

Introduction

In blunt abdominal trauma, lesions of the small bowell and mesentery are often underdiagnosed; although unusual, they represent the third most injured organ, with increasing morbidity and mortality.

Presentation of case

The authors present the case of a 68 years old male, admitted to the emergency department after being hit by a bale of straw, weighing around 300 kg, in the abdomen. After successful ressuscitation, a CT scan was performed, suggesting hemoperitoneum because of vascular lesion of the right colon bleeding. An exploratory laparotomy was performed, confirming the presence of blood in the abdominal cavity and identifying jejunal perforation, an apparently innocent hematoma of the small bowel mesentery (beside the bowel wall) distally to the first lesion and a laceration of the sigmoid serosa; a segmental jejunal resection and suture of the colon serosa were performed. In the early post-operative period, an enteric discharge was noticed, mandating surgical reexploration; a previously unnoticed bowel perforation, in the mesenteric border where the hematoma was identified, justified an additional enterectomy, after what the patients recovery progressed uneventfully.

Discussion

In this case, a sudden increase in abdominal pressure could explain that missed rupture of the mesenteric border of the jejunum, also causing the mesenteric hematoma, or, in spite of that, a state of low perfusion could have lead to total wall ischemia of an already irrigation compromised segment.

Only noted after surgical exploration, despite prior evaluation with a computed tomography. Small bowell and mesenteric injuries are potentially missed due to decreased exploratory laparotomies for blunt abdominal trauma.

Conclusion

Although uncommon, small bowel and mesenteric injuries are associated with high morbidity and mortality. High clinical suspicion is essential for an early diagnosis

Double ischemic ileal stenosis secondary to mesenteric injury after blunt abdominal trauma

The authors describe a rare case in which blunt abdominal trauma resulted in mesenteric injury with delayed double ischemic ileal stenosis. Abdominal computed tomography demonstrated stenotic ileal loop with mural thickening. At surgery, a double stenotic bowel loop was found adjacent to a healed defect in the mesentery. Histological examination of the two resected segments showed fibrotic and ischemic lesions within the mesentery. Ischemic intestinal stenosis from mesenteric injury should be considered in the differential diagnosis in patients suffering from intestinal occlusion with a history of blunt abdominal trauma.