Bowel and mesenteric trauma

Dr Henry Knipe et al.

Bowel and mesenteric trauma can result from blunt force, penetrating and iatrogenic trauma.

The bowel and mesentery are injured in ~2.5% (range 0.3-5%) of blunt force abdominal trauma 1,3,5,8. However, bowel and mesenteric injuries are more likely to occur after penetrating trauma 8.

Aetiology

Gunshot wounds (~75%) and stabbings (~20%) are the leading causes of bowel and mesenteric injury from penetrating trauma 8. Motor vehicle collisions are the most common cause of blunt trauma followed by falls, assaults and sports-related trauma 4,6.

Types

From most to least common sites of bowel injury 1,4,6:

The mechanism of bowel injury include crush/compression type, shearing type (from fixed point of mesentery) and burst type (from increased intra-luminal pressure) and can include 4:

  • perforation
  • mural haematoma or oedema
  • active haemorrhage
  • serosal tear
  • degloving (very rare)

Mesenteric injuries can include:

CT
Bowel injury
  • perforation
    • in blunt trauma, the presence of extra-luminal oral contrast media (if used) or bowel contents; extra-luminal free gas (especially in the absence of pneumothorax/pneumomediastinum) 2
    • in penetrating trauma, extra-luminal free gas is not specific to bowel perforation; extra-luminal contrast media/bowel contents leak and a wound track extending to bowel is considered the most sensitive; wall thickening/mesenteric contusion is less sensitive 2
  • mural haematoma: discontinuity in the bowel wall with mural thickening (>3-4 mm); may be complete (i.e. perforated) or incomplete 2,4
  • moderate/large volume of free fluid without solid organ injury can be suggestive of bowel or mesenteric injury 2-3
  • abnormal bowel wall enhancement: decreased due to mesenteric vascular interruption and small bowel ischaemia, or increased due to vascular permeability secondary to hypoperfusion 7
  • positive seatbelt sign increases the likelihood of traumatic bowel injuries 9
Mesenteric injury
  • active extravasation of contrast media is indicative of active bleeding and a significant mesenteric injury 3
  • intermesenteric free fluid or haematoma
  • beading and termination of mesenteric vessels 4
  • mesenteric infiltration: haziness and fat stranding 7
  • accumulation ('pooling') of contrast on multiphase imaging

Even with increasing non-operative management of traumatic abdominal organs (e.g. liver or spleen laceration), traumatic bowel and mesenteric injuries such as perforation or active mesenteric bleeding still require operative management 3.

  • shock bowel: diffuse bowel wall thickening (from oedema) that is hyperenhancing
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Article information

rID: 26357
Section: Pathology
Synonyms or Alternate Spellings:
  • Mesenteric injury
  • Traumatic bowel injury
  • Traumatic mesentery injury
  • Mesentery injury
  • Bowel and mesentery trauma

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Cases and figures

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    Figure 1: colon stab wound (gross pathology)
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    Case 1: small bowel
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    Figure 2: DJ flexure perforation
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    Case 2: mesenteric haematoma
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    Case 3: D-J flexure traumatic perforation
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    Case 4: jejunal tear
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    Case 5: colonic injury and mesenteric haematoma
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    Case 6: evisceration post penetrating injury
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    Case 7
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    Case 8: small bowel injury
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    Case 9
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    Case 10
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    Case 11: colonic injury from stabbing
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