Imaging of Blunt Traumatic Bowel and Mesenteric Injuries

Traumatic injury is one of the leading causes of emergent hospital evaluations. Specifically, blunt bowel and mesenteric injury (BBMI) account for 1% to 5% of abdominal traumas with a high morbidity and mortality, as clinical signs and nonspecific imaging findings make the initial diagnosis challenging. Understanding key imaging findings and the clinical symptoms can increase the radiologist's suspicion for BBMI and ultimately improve patient outcomes.

An Unusual Presentation of a Small Bowel Injury in an Adult Following a Fall From Height

Blunt trauma to the abdomen (BTA) poses a challenge to surgeons in diagnosing the exact intra-abdominal injuries, including hollow viscus injuries. This case report discusses a 40-year-old male patient, a case of BTA following a fall from a height, who did not present any features of peritonitis. Upon evaluation, the patient was found to have a small bowel obstruction in the distal jejunum. The patient was taken for exploratory laparotomy, and the inflammatory mass was removed. A side-to-side distal jejunal anastomosis was performed. This case report teaches us that not all small bowel injuries present as perforation peritonitis; they can also manifest as intestinal obstruction. Delays in diagnosis and treatment can lead to increased morbidity and complications.

Imaging findings in penetrating injuries in the paediatric population - Experience from a major trauma Centre

OBJECTIVE

The primary objective of this study is to assess common sites of injury and the associated imaging findings in penetrating injuries. We pay particular attention to gluteal, anterior abdominal wall and junctional zone injuries. The aim is to highlight areas of diagnostic uncertainty and discrepancy between imaging and surgical findings, to improve review areas in trauma reporting.

METHODS

A retrospective, observational study reviewing all paediatric admissions to the emergency department of a major trauma Centre with a penetrating injury, from 2015 to 2019.

RESULTS

Gluteal penetrating injuries are by far the most commonly sustained injury in the adolescent population, making up over 1/3 of cases. The vast majority of these cases sustained superficial injuries or shallow intramuscular haematomas, however in a small group (15%), serious vascular or rectal injuries were demonstrated on dual phase CT, requiring emergent surgical or endovascular treatment. Penetrating injuries to the anterior abdominal wall and junctional zone are less common but are associated with higher morbidity, with 43% of cases demonstrating solid organ or bowel injury. These cases also lead to an increased degree of diagnostic uncertainty.

CONCLUSION

Gluteal injuries are common and although the overall morbidity of these cases is low, these patients are at risk of serious and life threatening consequences such as vascular and rectal injury and it is imperative that these complications are considered and ruled out via dual phase CT or direct visualization. Anterior abdominal wall and junctional zone injuries are less common, but lead to greater morbidity and also greater diagnostic uncertainty. The use of other salient findings as described in this report can aid diagnostic accuracy and reduce discrepancies.

Trauma and 'Whole' Body Computed Tomography: Role, Protocols, Appropriateness, and Evidence to Support its Use and When

Imaging plays a crucial role in the immediate evaluation of the trauma patient, particularly using multi-detector computed tomography (CT), and especially in moderately to severely injured trauma patients. There are specific areas of relative consensus, while other aspects of whole-body computed tomography (WB-CT) use remain controversial and are subject to opinion/debate based on the current literature. Even a few hours of a delayed diagnosis may result in a detrimental outcome for the patient. One must utilize all the tools available to enhance the interpretation of images. It is also important to recognize imaging pitfalls and artifacts to avoid unnecessary intervention.

Comparison of Clinical Characteristics, Therapy, and Short-Term Prognosis between Blunt and Penetrating Abdominal Trauma: A Multicentric Retrospective Cohort Study

Objective

Large-scale studies on the characteristics and management of abdominal trauma in megacities in China are lacking. The aim of this study was to analyze and present the clinical patterns and treatment status of abdominal trauma in regional medical centers.

Methods

Cases of abdominal trauma treated at seven medical centers in Beijing from 2010 to 2021 were collected. Clinical information about age, sex, injury cause, geographic distribution, abbreviated injury scale/injury severity score (AIS/ISS) value, injury-hospital time, preoperative time, surgically identified organ injuries, type of surgery, causes of reoperation and 90-day mortality was included in this study. Clinical characteristics, treatment methods, and short-term prognoses (90-days survival) were compared between blunt abdominal trauma (BAT) and penetrating abdominal trauma (PAT) cases. Non-normally distributed data are described as medians (IQR), and the Mann‒Whitney U test was performed; qualitative data were analyzed using the X2 test. Univariate and multivariate survival analyses were performed by the Cox proportional hazards model.

Results

A total of 553 patients (86.98% male) with a median age of 36.50 (27.00-48.00) years were included. The BAT group had a significantly higher proportion of serious injury (P=0.001), lower initial hemoglobin level (P=0.001), and a lower laparoscopy surgery rate (P=0.044) compared to the PAT group. Additionally, more BAT cases were from the area around Beijing (P=0.008) and a longer injury-regional hospital time (10.47 (5.18-22.51) hours vs. 7.00 (3.80-15.38) hours, P=0.001). In the hollow viscus injury subgroup, the BAT group had a significantly longer injury-regional hospital time and preoperative time compared to the PAT group (injury-regional hospital time: 10.23 (6.00-21.59) hours vs. 7.07 (3.99-13.85) hours, P=0.002; preoperative time: 3.02 (2.01-5.58) hours vs. 2.81 (1.85-3.63) hours, P=0.047). The overall 90-day mortality was 11.9%, and longer injury-regional hospital time (HR: 1.01, 95% CI: 1.00-1.02, P=0.008), receipt of ICU treatment (HR: 4.69, 95% CI: 2.54-8.65, P=0.001), and severe ISSs (ISS > 25 vs. ISS < 16, HR: 2.78, 95% CI: 1.38-5.601, P=0.004) had a worse impact on survival.

Conclusion

More patients with BAT were transferred to higher-level hospital, leading to significantly longer prehospital and preoperation time. In the subgroup of hemodynamically stable individuals, more patients with BAT experienced hollow viscus injuries. For those patients, aggressive diagnostic laparoscopic exploration may be beneficial. Patients with longer injury-regional hospital intervals, the need for ICU care, and higher injury severity scores (ISSs) suffered from worse prognoses.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds

BACKGROUND

Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW.

METHODS

This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed.

RESULTS

Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99).

CONCLUSION

While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level II.

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.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries

INTRODUCTION

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.

MATERIALS AND METHODS

Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.

RESULTS

Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.

CONCLUSION

This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Mortality of hospital walk‐in trauma patients: a multicenter retrospective cohort study

Aim

To investigate the characteristics of patients who visited the emergency department by themselves after experiencing trauma and subsequently died, and to identify the prognostic factors of mortality in such patients.

Methods

Adult patients with trauma visiting the emergency department by themselves between 2004 and 2019 in Japan were identified using a nationwide trauma registry (the Japan Trauma Data Bank). The characteristics of patients who died were compared with those who survived, and multivariable logistic regression analysis was used to determine the independent association of each preselected variable with in‐hospital mortality (end‐point).

Results

Of the 9753 patients eligible for analysis, 4369 (44.8%) were men, and the median age was 75 years. Of these patients, 130 (1.3%) died in the hospital. The following factors had a significant association with in‐hospital mortality: age, male sex, Charlson Comorbidity Index (CCI) 3–4 and ≥5 with CCI = 0 as a reference, circumstances of injury (free fall and fall at ground level), Glasgow Coma Scale score, Shock Index ≥ 0.9, severe injuries of the head, abdomen and lower extremities, and Injury Severity Score ≥ 15.

Conclusions

Several risk factors, including older age, male sex, higher CCI, circumstances of injury (free fall and fall at ground level), lower Glasgow Coma Scale score, higher Shock Index, and severe injuries of the head, abdomen, and lower extremities, were identified as being associated with the death of trauma patients visiting the emergency department by themselves. Early identification of patients with these risk factors and appropriate treatment may reduce mortality posttrauma.

Multi-detector computed tomography in traumatic abdominal lesions: value and radiation control

Background, The context

A prospective study was conducted involving 81 patients (mean age, 20.79 years) with abdominal trauma who underwent ultrasonography and post-contrast CT on MDCT scanner. The total DLP for each patient was reviewed, and the effective dose was calculated. Purpose of the study to: explore the role of MDCT in assessing traumatic abdominal lesions, demonstrate radiation dose delivered by MDCT, and describe specific CT technical features to minimize radiation.

Results

The spleen was the most commonly injured organ (49.4%) followed by liver (39.5%) and kidney (24.7%). Pancreatic injury occurred in seven patients, whereas only two patients had intestinal injuries. One patient had adrenal injury. Minimal, mild and moderate free intra-peritoneal fluid collection was detected in 21 (25.9%), 47 (58%) and 10 (12.3%) patients, respectively. Only three (3.7%) patients had no collection. One patient had active uncontrolled bleeding and died. Radiation dose was below the detrimental level (calculated effective dose), with optimal image quality.

Conclusions

MDCT is sensitive to all types of traumatic abdominal lesions. Not only in determining the injury, but also in its grading. MDCT has affected the treatment directions, spotting a focus on conservative treatment by raising the diagnostic confidence. FAST cannot be the sole imaging modality. The individual radiation risk is small but real. Advancements in medical imaging reduce radiation risk.

Significant blunt bowel and mesenteric injury - Comparison of two CT scoring systems in a trauma registry cohort

PURPOSE

This study evaluated and compared two imaging-based scoring systems for the detection of significant blunt bowel and mesenteric injury (sBBMI) by emergency computed tomography (CT).

METHODS AND MATERIALS

We included all consecutive adult polytrauma patients admitted to our emergency department following a road traffic accident from January 2008 to June 2015, provided that intravenously contrast-enhanced whole-body CT examination was performed immediately after hospital admission. Two radiologists, blinded to patients' outcome, reviewed the CT examinations for distinctive direct intestinal or mesenteric vascular injury and indirect signs of abdominal injury. These findings were correlated with the patients' surgical or interventional radiology findings, autopsy, or clinical follow-up (>24 h). Two previously validated imaging-based bowel-injury scoring systems, the CT-based Faget score and the clinically and radiologically based Mc Nutt score (BIPS), were compared by applying each to our trauma cohort. Student t-test, chi-squared, and logistic regression were used in analyses.

RESULTS

Twenty-one of 752 analysed patients (2.8 %) had confirmed sBBMI. Active mesenteric bleeding, mesenteric and free pneumoperitoneum, small haemoperitoneum, non-focal bowel wall thickening, mesenteric/pericolic fat stranding, and anterior abdominal wall injury were significantly correlated with sBBMI, as did the two evaluated scoring systems (p < 0.001). However, multivariate logistic regression revealed the superiority of the Faget score to the McNutt score.

CONCLUSION

The prevalence of sBBMI among polytrauma patients is low. Early diagnosis is necessary to avoid increased mortality. Certain CT features are pathognomic of sBBMI and must not be overlooked. Scoring systems are helpful, especially when they are based on radiological signs.

Duodenal imaging on the spotlight: from A to Z

Abdominal computed tomography (CT) is frequently performed to evaluate gastrointestinal pathologic conditions. The majority of the gastrointestinal radiology literature has concentrated on the colon, stomach, and distal small bowel. The duodenum is often overlooked on imaging, namely on CT, but its anatomy (intra and retroperitoneal) and location in such close proximity to other viscera results in involvement by a multitude of primary and secondary processes, some of them exclusive to this bowel segment. While some conditions, like duplications, lipomas, and diverticula, are usually asymptomatic and are incidentalomas that have no pathologic significance, others are symptomatic and very relevant and should be recognized by every general radiologist: development conditions such as annular pancreas and gut malrotation; inflammatory processes such as ulcers and secondary involvement from pancreatitis; neoplastic conditions such as adenocarcinoma, lymphoma, or local extension from adjacent malignancies. They all can be reliably diagnosed with CT. In this article, we demonstrate the typical imaging features of various diseases involving the duodenum, such as developmental, traumatic, inflammatory, infectious, neoplastic, and postsurgical pathologic conditions in alphabetical order, focusing mainly on upper gastrointestinal series (UGIS) and CT but also some radiography, ultrasound, and magnetic resonance (MR) imaging.

Segmental Bowel Hypoenhancement on CT Predicts Ischemic Mesenteric Laceration After Blunt Trauma

OBJECTIVE. The objectives of this study were to examine the performance of CT in the diagnosis of ischemic mesenteric laceration after blunt trauma and to assess the predictive value of various CT signs for this injury. MATERIALS AND METHODS. In this retrospective study, consecutive patients with bowel and mesenteric injury diagnosed by CT or surgery from January 2011 through December 2016 were analyzed. Two radiologists evaluated CT images for nine signs of bowel injury. The outcome evaluated was ischemic mesenteric laceration. Univariable analysis followed by logistic regression was performed. RESULTS. The study included 147 patients (96 men and 51 women; median age, 35 years; age range, 23-52 years). Thirty-three patients had surgically confirmed ischemic mesenteric lacerations. CT signs that correlated with ischemic mesenteric laceration were abdominal wall injury, mesenteric contusion, free fluid, segmental bowel hypoenhancement, and bowel hyperenhancement adjacent to a hypoenhancing segment. The regression model developed after inclusion of clinical variables identified two predictors: segmental bowel hypoenhancement (adjusted odds ratio, 22.9 [95% CI, 7.9-66.2; p < .001] for reviewer 1 and 20.7 [95% CI, 7.2-59.0; p < .001] for reviewer 2) and abdominal wall injury (adjusted odds ratio, 5.26 [95% CI, 1.7-15.9; p = .003] for reviewer 1 and 5.3 [95% CI, 1.9-15.0; p = .002] for reviewer 2), which yielded an AUC of 0.87 for predicting injury. For reviewer 1 and reviewer 2, the sensitivities of CT in detecting the injury were 72.3% (95% CI, 54.5-86.7%) and 78.8% (95% CI, 61.0-91.0%), respectively, whereas the specificities were 94.7% (95% CI, 88.9-98.0%), and 92.1% (95% CI, 85.5-96.3%), respectively. CONCLUSION. CT has limited sensitivity but good specificity for detecting ischemic mesenteric laceration, with segmental bowel hypoenhancement considered the most predictive imaging sign.

Radiology and A Radiologist: A Keystone in the Turmoil of Trauma Setting

Traumatic injuries are one of the leading causes of morbidity and mortality. Precise diagnosis and management in the golden hour are key to decrease morbidity and mortality. History and physical examination alone are insufficient to avoid misdiagnosis. In this article, we tried to determine the role of a radiologist and an appropriate imaging modality in a trauma setting. We conducted a literature review of published research articles. We used the keywords imaging, trauma, imaging and trauma, and trauma imaging essentials were used on PubMed and Google Scholar. The articles published in the English language from 2015 to 2020 with full free text available were included. Using the medical subject heading (MeSH) strategy, "diagnostic imaging" (Major {Majr}) and "multiple trauma/diagnostic imaging" (Mesh) on PubMed, we identified 34 papers after applying the inclusion and exclusion criteria. Twenty articles were finally selected which included studies from 2015 to 2020 with articles focusing on the adult population and acute cases. A radiologist and imaging modalities are the essential parts of a trauma setting to lower morbidity and mortality. X-rays and Extended Focussed Assessment with Sonography for Trauma (eFAST) are the first-line imaging modality in the acute trauma setting. However, the CT scan is the most sensitive modality that should be done to avoid misdiagnosis depending upon the patient's history and physical examination.

Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic-therapeutic algorithm

Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.

Blunt Isolated Small Bowel Perforation Intervention: Does a Delay in Management Matter?

Purpose

Blunt small bowel injury is rare, and its timely diagnosis may be difficult. The effects of a delayed intervention on prognosis are unclear. We aimed to determine whether the time to surgical intervention affects outcomes in patients with blunt small bowel perforation.

Methods

The study was performed between March 2010 and December 2018 in adults (age >18 years) who initially underwent computed tomography and small bowel surgery only and survived more than one day postoperatively. They were categorized into three groups based on injury-to-surgery time intervals: ≤8, 8-24, and >24 h; similarly, they were also categorized into two groups of ≤24 and >24 h.

Results

Bowel resection, length of stay (LOS), intensive care unit (ICU) LOS, morbidity, and mortality were analyzed as outcomes in 52 patients. The number of patients in the three groups (≤8, 8-24, and >24 h) based on the time-to-surgery was 33, 13, and 6, respectively. On comparing the three groups, there were no significant differences in LOS (24 [18-35], 21 [10-40], and 28 [20-98] days, respectively; p=0.321), ICU LOS (2 [1-12], 4 [2-26], and 11 [7-14] days; respectively, p=0.153), mortality (3% (n = 1), 15% (n = 2), and 0%, respectively; p=0.291), and morbidity (46% (n = 15), 39% (n = 5), and 50% (n = 3), respectively; p=0.871). However, there was a significant difference between the groups in bowel resection (67% (n = 22), 31% (n = 4), and 83% (n = 5), respectively; p=0.037). Additionally, there was no significant difference in outcomes between the two groups (≤24 and >24 h) with small bowel perforation.

Conclusions

Delay in surgical intervention following blunt abdominal trauma may not affect the outcomes of patients with small bowel injuries, such as LOS, ICU LOS, morbidity, and mortality, except bowel resection.

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.

The Prognosis of Blunt Bowel and Mesenteric Injury-the Pitfall in the Contemporary Image Survey

Delayed diagnosis and intervention of blunt bowel and mesenteric injury (BBMI) is a hazard because of poor prognosis. Computed tomography (CT) is the standard imaging tool to evaluate blunt abdominal trauma (BAT). However, a high missed diagnosis rate for BMMI was reported. In this study, we would like to evaluate the presentation of CT in BBMI. Moreover, we want to evaluate the impact of deferred surgical intervention of BBMI on final prognosis. We performed a retrospective study from 2013–2017, including patients with BAT and BBMI who underwent surgical intervention. We evaluated clinical characteristics, CT images, and surgical timing, as well as analyzed the prognosis of BBMI. There were 6164 BAT patients and 188 BMI patients included. The most common characteristics of CT were free fluid (71.3%), free air (43.6%), and mesenteric infiltration (23.4%). There were no single characteristics of a CT image that can predict BBMI significantly. However, under close monitoring, we find that deferred intervention did not prolong the hospital and intensive care unit stays and did not worsen the prognosis and mortality.

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.

Blunt bowel and mesenteric trauma: role of clinical signs along with CT findings in patients' management

BACKGROUND

Bowel and/or mesentery injuries represent the third most common injury among patients with blunt abdominal trauma. Delayed diagnosis increases morbidity and mortality. The aim of our study was to evaluate the role of clinical signs along with CT findings as predictors of early surgical repair.

MATERIAL AND METHODS

Between March 2014 and February 2017, charts and CT scans of consecutive patients treated for blunt abdominal trauma in two different trauma centers were reread by two experienced radiologists. We included all adult patients who underwent contrast-enhanced CT of the abdomen and pelvis with CT findings of blunt bowel and/or mesenteric injury (BBMI). We divided CT findings into two groups: the first included three highly specific CT signs and the second included six less specific CT signs indicated as "minor CT findings." The presence of abdominal guarding and/or abdominal pain was considered as "clinical signs." Reference standards included surgically proven BBMI and clinical follow-up. Association was evaluated by the chi-square test. A logistic regression model was used to estimate odds ratio (OR) and confidence intervals (CI).

RESULTS

Thirty-four (4.1%) out of 831 patients who sustained blunt abdominal trauma had BBMI at CT. Twenty-one out of thirty-four patients (61.8%) underwent surgical repair; the remaining 13 were treated conservatively. Free fluid had a significant statistical association with surgery (p = 0.0044). The presence of three or more minor CT findings was statistically associated with surgery (OR = 8.1; 95% CI, 1.2-53.7). Abdominal guarding along with bowel wall discontinuity and extraluminal air had the highest positive predictive value (100 and 83.3%, respectively).

CONCLUSION

In patients without solid organ injury (SOI), the presence of free fluid along with abdominal guarding and three or more "minor CT findings" is a significant predictor of early surgical repair. The association of bowel wall discontinuity with extraluminal air warrants exploratory laparotomy.

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.