Bowel and mesenteric trauma
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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 not surprisingly, bowel and mesenteric injuries are more frequent after penetrating trauma 8. Bowel injury has consistently been found to be the most common traumatic abdominopelvic injury missed on CT 11.
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.
From most to least common sites of bowel injury 1,4,6:
duodenum (D2 and D3 segments)
stomach (greater curvature)
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:
mural hematoma or edema
degloving (very rare)
Mesenteric injuries can include:
active bleeding from a laceration
visible bowel wall discontinuity 7
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
suggestive signs 7
mural hematoma: 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 2-3
intermesenteric fluid forming triangles
abnormal bowel wall enhancement: decreased due to mesenteric vascular interruption and small bowel ischemia, or increased due to vascular permeability secondary to hypoperfusion 7
positive seatbelt sign increases the likelihood of traumatic bowel injuries 9
active extravasation of contrast media is indicative of active bleeding and a significant mesenteric injury 3
intermesenteric free fluid, often forming triangles 7
beading and termination of mesenteric vessels 4, 7
abrupt termination of the mesenteric vessels 7
accumulation ('pooling') of contrast on multiphase imaging
suggestive signs 7
mesenteric infilatration: haziness and fat stranding
bowel wall thickening
Treatment and prognosis
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 edema) that is hyperenhancing