Selected topic: emergency radiology
The role of computed tomography in diagnosis of blunt intestinal and mesenteric trauma (BIMT)☆

https://doi.org/10.1016/j.jemermed.2004.02.012Get rights and content

Abstract

Blunt intestinal mesenteric trauma (BIMT) is a rare injury with a high morbidity and mortality. It is a diagnostic dilemma for Trauma Surgeons and Emergency Physicians. This study was undertaken to assess the role of computed tomography (CT) in BIMT. Data were analyzed from 1995 to 2002. Thirty-six cases of BIMT were identified: 16 isolated and 20 non-isolated injuries. Initial CT scan was abnormal in 74% (17 out of 23), and 83% on retrospect (2 additional cases). CT scans were abnormal (initial and repeat) in 96% (22 out of 23). The most common abnormalities were free fluid (78%), mesenteric stranding or edema (39%), bowel wall hematoma, or edema (30%). Free air was seen in 31% and oral contrast extravasation in 15% of cases of bowel perforation. CT scan findings in BIMT can be subtle and non-specific. Suspicion of BIMT warrants close observation and probably further diagnostic testing.

Introduction

Diagnosing blunt intestinal and mesenteric trauma (BIMT) is a constant challenge to Trauma Surgeons and Emergency Physicians. It occurs in less than 1% of blunt abdominal trauma victims 1, 2, 3, 4, 5. Delayed diagnosis results in high morbidity and mortality (6). BIMT is commonly associated with automobile accidents, sports injuries, industrial accidents, assaults and falls (7). In Australia, injuries are frequently caused by horse kicks to the abdomen and a 24-h period of observation in the hospital is routinely recommended (8). Motor vehicular crashes with rapid deceleration are the most common cause of BIMT (7). The mechanisms are: 1) crushing effect of seat belt restraints or steering wheel, 2) shearing forces between relatively fixed and mobile parts of the gastrointestinal tract, and 3) burst injuries (“blow out”) that occur when intraluminal pressure exceeds tensile strength of the intestinal wall. Blowout perforations are common in the small intestine, whereas linear seromuscular tears are frequently seen in the large intestine (7).

Hemodynamically unstable multiple trauma patients with significant associated abdominal injuries usually undergo rapid diagnostic studies and laparotomy with a diagnosis of BIMT as an incidental finding. When abdominal signs are equivocal or absent and the patient is hemodynamically stable, further investigations are warranted. The diagnostic peritoneal lavage (DPL), focused abdominal sonogram for trauma (FAST), computed tomography (CT) scan, and laparoscopy are key diagnostic tools 2, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25. These investigations may determine the presence and severity of injuries because clinical examination alone has inherent diagnostic limitations.

Recognition of early peritoneal signs on frequent bedside re-evaluation can lead to more timely intervention. However, local signs of peritonitis like rigidity, tenderness and rebound may be undetectable due to an altered sensorium resulting from drugs, alcohol intoxication, or central nervous system trauma. In a recent report, 68% of blunt trauma patients had neurological impairment or significant distracting injury compromising reliable clinical examination (2). Presence of fever, leukocytosis, and free air in the abdomen, or other CT scan abnormalities, may be the best clues to occult intestinal trauma, mandating therapeutic surgical intervention. CT scan abnormalities are often subtle and can be ignored or misinterpreted, further delaying timely intervention.

Blunt abdominal trauma patients with positive abdominal signs, including abdominal wall ecchymosis (AWE), contusion or seat belt mark, need close observation and reassessment due to the high association of BIMT 4, 26, 27, 28.

The Institutional Review Board of The Toledo Hospital and Toledo Children's Hospital, Level One Trauma Center approved this study to assess our experience regarding the role of CT scan of the abdomen and pelvis in BIMT.

Section snippets

Materials and methods

The present study was undertaken in 1998 to retrospectively analyze patients with BIMT from 1995 and prospectively accumulate data until 2002 at The Toledo Hospital and Toledo Children's Hospital. All patients with BIMT were analyzed for etiology, age, sex, site, injury severity score (ISS), associated injuries, intensive-care length of stay (ILOS), hospital length of stay (HLOS), and outcome.

Helical scanners performed all CT scans of the abdomen and pelvis. All CT scans of the abdomen and

Results

During the period of study there were 8797 patients admitted to the trauma service: 8405 blunt (95.5%) and 392 (4.5%) penetrating traumas. CT scans of the abdomen and pelvis were done in 20.5% (1719) of all blunt trauma admissions. Many patients with blunt trauma had insignificant or no abdominal trauma and had no CT scans. Other abdominal trauma patients with no CT scans were: patients with immediate deaths, hemodynamically unstable patients unfit for a trip to the CT scanner, patients

Discussion

Associated injuries in non-isolated BIMT resulted in higher injury severity scores compared with isolated BIMT with a mean ISS of 38.4 vs. 13.07, respectively (p = 0.000) and a higher mortality (35% vs.12.5%, respectively). Overall mortality in BIMT was 25% (9/36). When three patients who died in the Emergency Department immediately on arrival are excluded, the mortality was 18% (6/33); half of these deaths (3/6) occurred in the first 24 h. Mortality resulted from associated intra- and

Conclusions

Blunt intestinal and mesenteric trauma is comparatively uncommon and often associated with a delayed diagnosis. BIMT was not initially diagnosed in 35% (8 out of 23) of patients due to CT scan misinterpretation, false negative initial scans, or failure to diagnose BIMT in the presence of solid organ trauma. An algorithm for BIMT is outlined in Figure 12. In the absence of hard signs (contrast extravasation, free air), other subtle CT abnormalities mandate close observation and repeat scanning.

Acknowledgements

We thank Shekhar S. Raj, M.B.B.S., Adult Study Coordinator for his assistance in preparing the manuscript, Yahya A. H. Daoud, M.A., Director, Biostatistics Program for statistical assistance, and Rhonda Dressel, Trauma Data Systems Analyst for her help in data retrieval.

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    ☆

    Selected Topics: Emergency Radiology is coordinated by Jack Keene, md, of Emergency Treatment Associates, Rhinebeck, New York

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