Intestinal stenosis from mesenteric injury after blunt abdominal trauma

Factors associated with enteral nutrition tolerance after trauma laparotomy of the small bowel and mesenteric injuries by blunt trauma

BACKGROUND

In patients with blunt injury due to abdominal trauma, the common cause for laparotomy is damage to the small bowel and mesentery. Recently, postoperative early enteral nutrition (EEN) has been recommended for abdominal surgery. However, EEN in patients with blunt bowel and/or mesenteric injury (BBMI) has not been established. Therefore, this study aimed to identify the factors that affect early postoperative small bowel obstruction (EPSBO) and the date of tolerance to solid food and defecation (SF + D) after surgery in patients with BBMI.

METHODS

We retrospectively reviewed patients who underwent laparotomy for BBMI at a single regional trauma center between January 2013 and July 2021. A total of 257 patients were included to analyze the factors associated with enteral nutrition tolerance in patients with EPSBO and the postoperative day of tolerance to SF + D.

RESULTS

The incidence of EPSBO in patients with BBMI was affected by male sex, small bowel organ injury scale (OIS) score, mesentery OIS score, amount of crystalloid, blood transfusion, and postoperative drain removal date. The higher the mesentery OIS score, the higher was the EPSBO incidence, whereas the small bowel OIS did not increase the incidence of EPSBO. The amount of crystalloid infused within 24 h; the amount of packed red blood cells, fresh frozen plasma, and platelet concentrate transfused; the time of drain removal; Injury Severity Score; and extremity abbreviated injury scale (AIS) score were correlated with the day of tolerance to SF + D. Multivariate analysis between the EPSBO and non-EPSBO groups identified mesentery and small bowel OIS scores as the factors related to EPSBO.

CONCLUSION

Mesenteric injury has a greater impact on EPSBO than small bowel injury. Further research is needed to determine whether the mesentery OIS score should be considered during EEN in patients with BBMI. The amount of crystalloid infused and transfused blood components within 24 h, time of drain removal, injury severity score, and extremity AIS score are related to the postoperative day on which patients can tolerate SF + D.

Bucket-Handle Mesenteric Tears: A Comprehensive Review of Their Presentation and Management

Bucket-handle mesenteric tears remain a diagnostic challenge for clinicians. We aim to review the literature, including a single-surgeon series, to better understand their presentation and management.

Three electronic databases (Ovid Medline, Embase, and PubMed) were searched for original research articles, describing relevant cases, from database inception to October 2021 using the following Medical Subject Heading (MeSH) terms: mesenteric avulsion, mesenteric tear, and blunt abdominal trauma. A retrospective review of cases managed under a single surgeon at our unit was also performed. Data extracted included demographics, mechanism of injury, presenting features, diagnostic imaging, surgical management, and patient outcome.

In total, 19 studies were identified, including 22 patients (median age 34.5 years). The most common cause of injury was seat-belted road traffic accidents (77.3%), and patients commonly presented with abdominal pain (72.7%), tenderness (50%), positive seat-belt sign (54.5%), and haemodynamic compromise (45.5%). Computerised tomography scanning was the main imaging modality (68%), and the most common findings reported were abdominal free fluid (36.4%) and abdominal wall hernia (27.3%). The majority of patients were operated on within 24 hours of injury (68%), had a median length of stay of 14.5 days, and experienced an uncomplicated recovery (68%). There was no association between the development of complications and delayed surgical intervention >24 hours (p = 0.145). Our institution’s experience was similar, with 50% of patients undergoing surgical intervention within 24 hours. The median age was 32.5 years (50% female), and the median length of stay was 11 days.

A high index of suspicion, serial monitoring, including blood tests, and imaging, with a low threshold for early repeat imaging, can provide a useful guide for identifying patients with bucket-handle tears.

Post-Ischemic Bowel Stricture: CT Features in Eight Cases

Objective

To investigate the characteristic radiologic features of post-ischemic stricture, which can then be implemented to differentiate that specific disease from other similar bowel diseases, with an emphasis on computed tomography (CT) features.

Materials and Methods

Eight patients with a diagnosis of ischemic bowel disease, who were also diagnosed with post-ischemic stricture on the basis of clinical or pathologic findings, were included. Detailed clinical data was collected from the available electronic medical records. Two radiologists retrospectively reviewed all CT images. Pathologic findings were also analyzed.

Results

The mean interval between the diagnosis of ischemic bowel disease and stricture formation was 57 days. The severity of ischemic bowel disease was variable. Most post-ischemic strictures developed in the ileum (n = 5), followed by the colon (n = 2) and then the jejunum (n = 1). All colonic strictures developed in the “watershed zone.” The pathologic features of post-ischemic stricture were deep ulceration, submucosal/subserosal fibrosis and chronic transmural inflammation. The mean length of the post-ischemic stricture was 7.4 cm. All patients in this study possessed one single stricture. On contrast-enhanced CT, most strictures possessed concentric wall thickening (87.5%), with moderate enhancement (87.5%), mucosal enhancement (50%), or higher enhancement in portal phase than arterial phase (66.7%).

Conclusion

Post-ischemic strictures develop in the ileum, jejunum and colon after an interval of several weeks. In the colonic segment, strictures mainly occur in the “watershed zone.” Typical CT findings include a single area of concentric wall thickening of medium length (mean, 7.4 cm), with moderate and higher enhancement in portal phase and vasa recta prominence.

Post traumatic acquired multiple mesenteric defects

INTRODUCTION

Internal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.(1) Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2-0.9%.(2)

PRESENTATION OF CASE

In this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found.

DISCUSSION

In the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.(11) Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries. In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. (16)

CONCLUSION

The diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.

Isolated small bowel mesentery injury after steering wheel trauma

BACKGROUND

Isolated small gut mesentery injury after blunt abdominal trauma from the steering wheel in road traffic accidents is rare. These are always challenging to diagnose and pose a diagnostic dilemma.

OBJECTIVES

To study the pattern of small gut mesenteric injury by steering wheel blunt abdominal trauma in road traffic accidents in patients who had laparotomy.

PATIENTS AND METHODS

A 10-year retrospective study was done to study isolated small gut mesentery injury.

RESULTS

All patients who had isolated mesenteric small gut injury were males. Jejunal mesentery was involved in 13 whereas 4 had ileal mesentery injury. Tear were longitudinal or transverse.

CONCLUSIONS

Isolated small mesentery injury after blunt abdominal trauma from the steering wheel in road traffic accidents is rare. Tears are either longitudinal or transverse. Suture repair is to be done. Delay in reaching hospital or reaching the diagnosis could lead to morbidity and mortality. Isolated mesenteric injury should be considered in any patient with blunt abdominal trauma from steering wheel injury with no evidence of any solid organ injury in unstable patients.

Delayed Presentations of Blunt Mesenteric and Intestinal Trauma in the Wake of Injury

OBJECTIVE

To analyze the presentation and timing of blunt mesenteric and intestinal trauma requiring surgical intervention.

METHODS

The Hadassah-Hebrew University trauma registry was scanned for patients who required surgery following blunt mesenteric and/or bowel trauma. Demographic data, mechanism of injury, time to diagnosis and pathology reports were recorded. A literature search was also performed.

RESULTS

The majority of patients were injured in motor vehicle accidents (26/30, 86.7%). Patients were divided into three groups. Seventeen patients diagnosed within 4 h of admission were defined as the immediate group. Indication for surgery was hemodynamic instability and/or peritonitis. The most commonly injured region was the terminal ileum (10/17 patients, 59%). The second group (n = 4) had surgery within 2 weeks of injury (early group). These patients presented initially with hemodynamic instability. The operative findings were consistent with a low-flow state of the terminal ileum and cecum. The third group (n = 9) consisted of patients who were operated later than 2 weeks from the date of injury (late group). These patients presented with prolonged abdominal symptoms, chiefly partial small bowel obstruction. Operative findings were bowel strictures, most commonly of the terminal ileum (7/9 patients, 77.8%).

CONCLUSIONS

Acceleration-deceleration abdominal injury affects the terminal ileum more commonly. We propose that the ensuing clinical picture depends on the level of energy transmitted: high-energy trauma leads to extensive mesenteric and bowel tears and is diagnosed immediately. Low-energy trauma may lead to chronic ischemia, fibrosis and stricture-formation. The right colon appears to be more vulnerable to lowflow states following blunt trauma.

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.

Pathophysiology and management of bowel and mesenteric injuries due to blunt trauma

Injuries to the bowel and mesentery are uncommon in blunt trauma and rarely occur in isolation. Delay to diagnosis has a significant impact on morbidity and mortality. The literature tends to focus on the diagnosis of hollow viscus and mesenteric injury, with little written on its management. Studies are usually retrospective with a paucity of comparative trials. The use of computerized tomography (CT) scanning in blunt abdominal trauma has overshadowed other reports. Early-generation scanners had a relatively poor sensitivity in detecting bowel-related injuries, but the CT scan is now the primary modality for imaging stable patients. However radiological signs can be subtle and should be regarded as complementary to meticulous clinical assessment.

Ischaemic ileal stenosis following blunt abdominal trauma and demonstrated by CT

We report a case of blunt abdominal trauma in which delayed ischaemic ileal stenosis occurred. A 24-year-old man presented with symptoms and signs of bowel obstruction 2 weeks after blunt abdominal trauma. Enhanced CT clearly demonstrated a stenotic ileal loop with mural thickening, associated with a mesenteric haematoma. This abnormal ileal loop was resected.