Bowel and mesenteric trauma

Dr Craig Hacking and 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 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:

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:

  • definitive signs:
    • visible bowel wall discontinuity 7
    • 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
  • suggestive signs 7
    • 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 2-3
    • intermesenteric fluid forming triangles
    • 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
  • definitive signs:
    • 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
    • mesenteric haematoma
    • bowel wall thickening

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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