Presentation
This man was riding his bicycle down a hill, when he hit a ditch in the road and landed on his face. He was treated under the maxillofacial team for a left anterior maxillary wall fracture. On day 2 post admission, he developed colicky abdominal pain and emesis. The scans of the CT abdomen/pelvis are shown here.
Patient Data
- There is a finding suggestive of small bowel obstruction, possibly closed loop, secondary to either small bowel or mesenteric injury. Loops of small bowel in the right sided abdomen appear focally dilated and fluid filled. There is a clear transition point posteriorly on the right, beyond which the small bowel is collapsed. There is stranding and distortion of the mesentery. Some of the dilated loops of small bowel have poorly enhancing mucosa suggesting venous ischemia.
- It is possible that the prior trauma has led to a mesenteric tear through which small bowel has herniated.
- The IVC is thin, suggesting profound volume depletion.
- New free intraperitoneal fluid is evident with layering in the pelvis.
Case Discussion
Blunt abdominal trauma is a cause of post traumatic small bowel obstruction (PTSBO) 1. Typically, small bowel obstruction post trauma presents at least 2 weeks after the initial insult. It is thought that in this time, micro-perforations heal with fibrotic tissue, leading to stricture formation 2. It is unusual for a case of small bowel obstruction to present within only 2 days, as was the case with our patient.
Signs of small bowel obstruction in our case include:
- dilated loops of small bowel
- transition point from dilated small bowel to collapsed small bowel
- stranding and distortion of the mesentery
- poorly enhancing mucosa
The management for post-traumatic small bowel obstruction is controversial. Some reports have suggested that primary excision of the affected bowel with re-anastomosis has a good clinical outcome 3. On the other hand, there have also been small case studies where five out of six patients with PTSBO were successfully conservatively managed 4.
Case contributed by A/Prof. Pramit Phal.
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