Bowel and mesenteric injury

1. Bowel and mesenteric injury
Dr. Devkant Lakhera

2. Bowel and mesenteric injury
• 1% to 5% of abdominal trauma
• Difficulty
 Clinical signs are often non specific (40% Negative lap)
 Polytrauma
 Goal – requirement of surgical intervention
• Delay in diagnosis - sepsis, peritonitis and death

3.  Plain radiographs are useful for evaluating
pneumoperitonium.
 FAST detects intra-abdominal collections.
 Angiography can be used to detect intra-mesenteric hemorrhage.
CT is the tool of choice in evaluating bowel and
mesenteric injury in hemodynamically stable
patient.
IMAGING MODALITIES

4. Sensitivity of CT
• 70-85 %
• More specific than diagnostic peritoneal lavage
• Reasons for missed diagnosis
Major injury to other organs
Support and monitoring devices that can cause artifact
absence of extraluminal gas.

5. CT findings in bowel and mesenteric injury
Findings Specific to Bowel Injury
• Bowel Wall Discontinuity
• Extraluminal Contrast Material
• Extraluminal Air
Findings Less Specific to Bowel Injury
• Bowel Wall Thickening
• Abnormal Bowel Wall Enhancement
• Mesenteric Features (stranding)
• Free intraperitoneal fluid

6. Sites of bowel injury
• Most common - Small bowel
{jejunum (near ligament of Trietz/D-J flexure) > ileum
(near ileocaecal valve)} (more shearing force)
• colon (transverse colon)
• Least common - stomach

7. Imaging – Plain
Radiography
• Preferred in hemodynamically stable
patients
• X-ray chest erect PA view

9. • lateral umbilical ligament sign (also known as inverted
"V" sign)
• cupola sign
• urachus sign
• right upper quadrant signs
• fissure for ligamentum teres sign
• hepatic edge sign
• lucent liver sign
• periportal free gas sign

10. Ultrasound
• either alone or with associated posterior
multiple reflection artifacts or dirty
shadowing.
• may be accompanied by posterior
artefactual reverberation echoes with a
characteristic comet-tail appearance.

11. Pneumoperitoneum

12. Bowel wall discontinuity and
Extraluminal air
• Fluid filled bowel loop
• Sealed perforation
• Small amount of air
65 yr with stab injury to left flank

13. Common sites of free air accumulation
• Accumulates behind anterior abdominal wall, below diaphragm
• Along peritoneal surfaces of liver and spleen.
• Other sites – Porta hepatis, mesentery, mesenteric / portal veins,

14. Other causes of free air
• Penetrating injury
• Mechanical ventilation
• Bladder rupture
• Barotrauma
• Diagnostic peritoneal lavage
• Pseudopneumoperitonieum

15. Extravastation of contrast
• Usually not given
extraluminal contrast (bladder injury)

17. Focal bowel wall thickening
• Normal thickness – 3mm
• Less likely to require surgical
intervention

18. Generalized wall thickening
• Shock bowel

19. Hypoperfusion complex
• Flattened inferior vena cava
• Narrowed aorta
• Increased enhancement of adrenal, kidneys and bowel
• Volume overload

20. ABNORMAL BOWEL WALL
ENHANCEMENT
• hypoperfusion or local
vascular injury
• increased vascular
permeability and leakage of
contrast material (injury)
• decreased enhancement of
the bowel wall can be a sign
of ischemia

21. FREE INTRAPERITONEAL
FLUID
• Traumatic intraperitoneal fluid - solid
organ, bowel, or mesenteric injury; bile
from a ruptured gallbladder or bile duct;
and urine from a ruptured bladder
• Bowel injury - fluid is seen only adjacent to
bowel or caught between the leaves of the
mesentery
Nontraumatic causes

23. Mesenteric injury
• Mesenteric hematoma
• Mesenteric vascular injury
• Extravastation

24. Mesenteric vascular injury
100 % specific
Urgent laparotomy
• include active contrast extravasation, beaded appearance
• of mesenteric vessels and abrupt termination of mesenteric vessels

25. • 50-year-old in a motor vehicle collision.
Suggested diagnostic angiography

26. • small-bowel mesenteric tear was
found, with active bleeding from a
jejunal branch of the superior
mesenteric artery

27. MESENTERIC INJURY
• mesenteric stranding, hematomas,
and beading or abrupt termination
of vessels

29. Omental injury

30. Significant mesenteric injury
• active mesenteric bleeding, disruption
of the mesentery
• mesenteric injury associated with
bowel ischemia
Insignificant mesenteric injury
Hematoma
Significant injury
Significant bowel injury
• complete tear of the bowel wall
• an incomplete tear that involves the serosa
and that extends to but does not involve the
mucosa.
Insignificant bowel injury
• hematoma and a tear limited to the serosa.

31. DIAPHRAGM
• Diaphragmatic rupture and subsequent
herniation of
• abdominal contents into thorax is nine
times more
• common on left side than right due to the
protective effect
• of the liver

32. Vascular Injuries in Trauma
• Direct signs - Laceration with active hemorrhage, intimal tear, dissection,
intraluminal thrombosis, pseudoaneurysm, narrowing, and presence of
arteriovenous fistulas
• Indirect signs- abnormalities of the perivascular tissues or end organs and
include presence of a perivascular hematoma or fat stranding and varying
degrees of end-organ hypoenhancement

33. Active contrast extravastation
• In all 3 layers
• Goal is to differentiate between arterial and venous bleed
• Active extravasation – Blush
 Intra- and extraperitoneal spaces
 adjacent to the injured vessel
 intraparenchymal or intraluminal bleeding when a solid or hollow
viscus is injured

34. • Arterial injury - arterial phase pooling of
contrast material, with attenuation
similar to that of the aorta
• Venous injury - in the portal venous
phase as a focus of extravascular
attenuation, also expanding on delayed
phase images,

35. Intimal tear
curvilinear hypoattenuating filling defect
• No evidence of organ ischemia
• With resolution on follow up

36. Vessel Dissection
• interposition of blood between the
intima/inner media and the outer
media/adventitia
• linear area of hypoattenuation,
representing the intima and inner media,
may project into the vessel lumen.

37. Pseudoaneurysm
• Pseudoaneurysms are contained
vascular injuries that may occur
when the arterial intima and media
are injured and flowing blood is
contained by the adventitia.

38. Complete / Partial occulsion

39. Vessel Contour Abnormalities
• irregular in contour, the differential diagnosis
includes dissection, intimal tear with partial
thrombosis, vasospasm, and perivascular
hematoma resulting in external compression

40. Thank you