Blunt Injury of the Bowel and Mesentery

  • Matthew Dattwyler
  • Uttam K. Bodanapally
  • Kathirkamanathan Shanmuganathan
Emergency Radiology (J Yu, Section Editor)
  • 15 Downloads
Part of the following topical collections:
  1. Emergency Radiology

Abstract

Purpose of Review

Although not common, blunt bowel and mesenteric trauma requires prompt identification and intervention to avoid significant morbidity and mortality.

Recent Findings

Developments in MDCT technology especially with 64 and higher slice MDCT have improved image quality for better detection and depiction of bowel and mesenteric injury. Recent reports indicate that administration of oral contrast does not increase diagnostic accuracy, allowing for more rapid door to scan time. Dual-source CT (DS-CT) ability to generate iodine maps and virtual noncontrast images has the potential to increase conspicuity of bowel perfusion abnormalities, better distinguish hypo-perfused from nonperfused bowel, and reveal bowel wall hematoma obscured by mural enhancement.

Summary

This article will review the current state-of-the-art approach in using direct and indirect MDCT signs of bowel injury in an attempt to differentiate surgical from nonsurgical lesions, and discuss imaging protocols used at our institution for follow-up imaging in nonsurgical lesions. We will also demonstrate the potential utility of DS-CT in blunt bowel injury.

Keywords

Bowel injury Emergency radiology MDCT DS-CT Mesenteric trauma 

Notes

Compliance with Ethical Standards

Conflict of interest

Matthew Dattwyler and Kathirkamanathan Shanmuganathan each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Killeen KL, Shanmuganathan K, Poletti PA, Cooper C, Mirvis SE. Helical computed tomography of bowel and mesenteric injuries. J Trauma Acute Care Surg. 2001;51(1):26–36.CrossRefGoogle Scholar
  2. 2.
    Pande R, Saratzis A, Winter Beatty J, Doran C, Kirby R, Harmston C. Contemporary characteristics of blunt abdominal trauma in a regional series from the UK. Ann R Coll Surg Engl. 2017;99(1):82–7.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Watts DD, Fakhry SM, EAST Multi-Institutional HVI Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the East multi-institutional trial. J Trauma Acute Care Surg. 2003;54(2):289–94.CrossRefGoogle Scholar
  4. 4.
    Bodanapally UK, Shanmuganathan K. Bowel and mesenteric injury. In: Mirvis SE, Soto JA, Shanmuganathan K, Yu J, Kubal WS, editors. Problem Solving in Emergency Radiology. New York: Elsevier Health Sciences; 2014. p. 289–301.Google Scholar
  5. 5.
    Khan I, Bew D, Elias DA, Lewis D, Meacock LM. Mechanisms of injury and CT findings in bowel and mesenteric trauma. Clin Radiol. 2014; 69(6):639–47.CrossRefPubMedGoogle Scholar
  6. 6.
    Malinoski DJ, Patel MS, Yakar DO, Green D, Qureshi F, Inaba K, Salim A. A diagnostic delay of 5 hours increases the risk of death after blunt hollow viscus injury. J Trauma Acute Care Surg. 2010;69(1):84–7.CrossRefGoogle Scholar
  7. 7.
    Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D. Relatively short diagnostic delays (< 8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J. Trauma Acute Care Surg. 2000;48(3):408–15.CrossRefGoogle Scholar
  8. 8.
    Cho HS, Woo JY, Hong HS, Park MH, Ha HI, Yang I, Hwang JY. Multidetector CT findings of bowel transection in blunt abdominal trauma. Korean J Radiol. 2013;14(4):607–15.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Iaselli F, Mazzei MA, Firetto C, D’Elia D, Squitieri NC, Biondetti PR, Scaglione M. Bowel and mesenteric injuries from blunt abdominal trauma: a review. La Radiol Med. 2015;120(1):21–32.CrossRefGoogle Scholar
  10. 10.
    Scaglione M, di Castelguidone EDL, Scialpi M, Merola S, Diettrich AI, Lombardo P, Grassi R. Blunt trauma to the gastrointestinal tract and mesentery: is there a role for helical CT in the decision-making process? Eur J Radiol. 2004;50(1):67–73.CrossRefPubMedGoogle Scholar
  11. 11.
    Cox EF. Blunt abdominal trauma. A 5-year analysis of 870 patients requiring celiotomy. Ann Surg. 1984;199(4):467.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Hughes TMD, Elton C. The pathophysiology and management of bowel and mesenteric injuries due to blunt trauma. Injury. 2002;33(4):295–302.CrossRefPubMedGoogle Scholar
  13. 13.
    Jordan GL, Beall AC. Diagnosis and management of abdominal trauma. Curr Probl Surg. 1971;8(11):3–62.CrossRefGoogle Scholar
  14. 14.
    Hayes CW, Conway WF, Walsh JW, Coppage L, Gervin AS. Seat belt injuries: radiologic findings and clinical correlation. Radiographics. 1991;11(1):23–36.CrossRefPubMedGoogle Scholar
  15. 15.
    Williams JS, Lies JR, Bert A, Hale JR, Harry W. The automotive safety belt: in saving a life may produce intra-abdominal injuries. J Trauma Acute Care Surg. 1966;6(3):303–15.CrossRefGoogle Scholar
  16. 16.
    Miller LA, Shanmuganathan K. Multidetector CT evaluation of abdominal trauma. Radiol Clin North Am. 2005;43(6):1079–95.CrossRefPubMedGoogle Scholar
  17. 17.
    Malangoni MA, Condon RE. Traumatic abdominal wall hernia. J Trauma. 1983;23(4):356–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Borgialli DA, Ellison AM, Ehrlich P, Bonsu B, Menaker J, Wisner DH, Kuppermann N. Association between the seat belt sign and intra abdominal injuries in children with blunt torso trauma in motor vehicle collisions. Acad Emerg Med. 2014;21(11):1240–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Bosworth BM. Perforation of the small intestine from non-penetrating abdominal trauma. Am J Surg. 1948;76(5):472–82.CrossRefPubMedGoogle Scholar
  20. 20.
    Bège T, Ménard J, Tremblay J, Denis R, Arnoux PJ, Petit Y. Biomechanical analysis of traumatic mesenteric avulsion. Med Biol Eng Comput. 2015;53(2):187–94.CrossRefPubMedGoogle Scholar
  21. 21.
    Extein JE, Allen BC, Shapiro ML, Jaffe TA. CT findings of traumatic bucket-handle mesenteric injuries. Am J Roentgenol. 2017;209(6):W360–4.CrossRefGoogle Scholar
  22. 22.
    Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics. 2006;26(4):1119–31.CrossRefPubMedGoogle Scholar
  23. 23.
    Natarajan B, Gupta PK, Cemaj S, Sorensen M, Hatzoudis GI, Forse RA. FAST scan: is it worth doing in hemodynamically stable blunt trauma patients? Surgery. 2010;148(4):695–701.CrossRefPubMedGoogle Scholar
  24. 24.
    Farahmand N, Sirlin CB, Brown MA, Shragg GP, Fortlage D, Hoyt DB, Casola G. Hypotensive patients with blunt abdominal trauma: performance of screening US. Radiology. 2005;235(2):436–43.CrossRefPubMedGoogle Scholar
  25. 25.
    Bode PJ, Edwards MJ, Kruit MC, Van Vugt AB. Sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma. AJR Am J Roentgenol. 1999;172(4):905–11.CrossRefPubMedGoogle Scholar
  26. 26.
    Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MRI. 2004;25(2):180–204.CrossRefGoogle Scholar
  27. 27.
    Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology. 2012;265(3):678–93.CrossRefPubMedGoogle Scholar
  28. 28.
    Petrosoniak A, Engels PT, Hamilton P, Tien HC. Detection of significant bowel and mesenteric injuries in blunt abdominal trauma with 64-slice computed tomography. J Trauma Acute Care Surg. 2013;74(4):1081–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Allen TL, Mueller MT, Bonk RT, Harker CP, Duffy OH, Stevens MH. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma Acute Care Surg. 2004;56(2):314–22.CrossRefGoogle Scholar
  30. 30.
    Stuhlfaut JW, Soto JA, Lucey BC, Ulrich A, Rathlev NK, Burke PA, Hirsch EF. Blunt abdominal trauma: performance of CT without oral contrast material. Radiology. 2004;233(3):689–94.CrossRefPubMedGoogle Scholar
  31. 31.
    ∙ Lee CH, Haaland B, Earnest A, Tan CH. Use of positive oral contrast agents in abdominopelvic computed tomography for blunt abdominal injury: meta-analysis and systematic review. Eur Radiol 2013;23(9):2513–2521. This meta-analysis demonstrates non-inferiority of CT without oral contrast in the evaluation of blunt bowel injury compared to CT with positive oral contrast thereby allowing for more timely scanning of trauma patients and decreased aspiration risk without compromise of diagnostic accuracy. Google Scholar
  32. 32.
    Lee CH, Haaland B, Earnest A, Tan CH. Use of positive oral contrast agents in abdominopelvic computed tomography for blunt abdominal injury: meta-analysis and systematic review. Eur Radiol. 2013;23(9):2513–21.CrossRefPubMedGoogle Scholar
  33. 33.
    ∙ LeBedis CA, Anderson SW, Bates DD, Khalil R, Matherly D, Wing H, Soto JA. CT imaging signs of surgically proven bowel trauma. Emerg Radiol 2016;23(3), 213–219. This paper looks at incidence and inter-observer agreement of CT findings in patients who had surgically proven blunt bowel injury. Inter-observer agreement was strongest for the least sensitive findings of active IV contrast extravasation, free air, and bowel wall discontinuity with lower agreement for the more commonly encountered findings intraperitoneal fluid, mesenteric hematoma/fat stranding, bowel wall thickening/hematoma, and focal bowel hypoenhancement. There is still a high false negative rate (9.1%) despite utilizing more modern 64-slice MDCT.Google Scholar
  34. 34.
    Marek AP, Deisler RF, Sutherland JB, Punjabi G, Portillo A, Krook J, Ney AL. CT scan-detected pneumoperitoneum: an unreliable predictor of intra-abdominal injury in blunt trauma. Injury, 2014;45(1):116–121.Google Scholar
  35. 35.
    Drasin TE, Anderson SW, Asandra A, Rhea JT, Soto JA. MDCT evaluation of blunt abdominal trauma: clinical significance of free intraperitoneal fluid in males with absence of identifiable injury. AJR Am J Roentgenol. 2008;191(6):1821–6.CrossRefPubMedGoogle Scholar
  36. 36.
    Darras KE, McLaughlin PD, Kang H, et al. Virtual monoenergetic reconstruction of contrast-enhanced dual energy CT at 70 keV maximizes mural enhancement in acute small bowel obstruction. Euro J Radiol. 2016;85(5):950–6.CrossRefGoogle Scholar
  37. 37.
    ∙∙ Potretzke TA, Brace CL, Lubner MG, et al. Early small bowel ischemia: dual-energy CT improved conspicuity compared with conventional CT in a swine model. Radiology 2015;275(1):199–26. This paper shows the superiority of dual-energy CT over conventional CT in increasing the conspicuity of under perfused bowel via its ability to produce virtual monochromatic low–keV images and iodine overlay maps as demonstrated in a swine model of early ischemic bowel. This could have implications for the detection of blunt traumatic bowel injury which is often associated with subtle perfusion abnormalities or devascularization.Google Scholar
  38. 38.
    Fulwadhva UP, Wortman JR, Sodickson AD. Use of dual-energy CT and iodine maps in evaluation of bowel disease. Radiographics. 2016;36:393–406.CrossRefPubMedGoogle Scholar
  39. 39.
    Malhotra AK, Fabian TC, Katsis SB, et al. Blunt bowel and mesenteric injuries: The role of screening computed tomography. J Trauma. 2000;48:91–100.CrossRefGoogle Scholar
  40. 40.
    Brody JM, Leighton DB, Murphy BL, et al. CT of blunt trauma bowel and mesenteric injury: Typical findings and pitfalls in diagnosis. Radiographics. 2000;20:1525–37.CrossRefPubMedGoogle Scholar
  41. 41.
    Yu J, Fulcher AS, Turner MA, et al. Blunt bowel and mesenteric injury: MDCT diagnosis. Abdom Imaging. 2011;36:50–61.CrossRefPubMedGoogle Scholar
  42. 42.
    Scaglione M, Romano L, Bocchini G, Sica G, Guida F, Pinto A, Grassi R. Multidetector computed tomography of pancreatic, small bowel, and mesenteric traumas. Semin Roentgenol, 2012;47(4):362–370.Google Scholar
  43. 43.
    Hanks PW, Brody JM. Blunt injury to mesentery and small bowel: CT evaluation. Radiol Clin North Am. 2003;41:1171–82.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Matthew Dattwyler
    • 1
  • Uttam K. Bodanapally
    • 1
  • Kathirkamanathan Shanmuganathan
    • 1
    • 2
  1. 1.Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma CenterUniversity of Maryland School of MedicineBaltimoreUSA
  2. 2.Department of RadiologyUniversity of Maryland Medical CenterBaltimoreUSA

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