Presentation
Young man involved in a MVA presenting with abdominal pain.
Patient Data
There is a moderate amount of hemoperitoneum without evidence of solid organ injury. Two C-shaped mesenteric areas of increased attenuation with peripheric fat stranding can be observed, suspicious for mesenteric tears/lacerations. No focus of active bleeding can be detected. Also, there aren't any direct signs of bowel injury. Note diffuse haziness of the subcutaneous fat in the hypogastrium region in keeping with the "seatbelt" sign.
Key images of the mesenteric injuries (1,3) with the following annotated images (2,4), resembling bucket-handle tears. Image 5 showing pelvic free fluid of increased attenuation (54 HU) in keeping with hemoperitoneum.
Case Discussion
Due to the CT findings suspicious for mesenteric injury and the moderate amount of hemoperitoneum, along with the decreased hemoglobin (Hb of 7 g/dL), it was decided to bring the patient to the operating room. Exploratory laparotomy was performed, which revealed two mesenteric lacerations affecting 10-15 cm of jejunal loops with approximately 600 cc of hemoperitoneum. An additional laceration was found at the sigmoid mesocolon, with no clear correlated findings at the CT study. The surgery team resected the affected intestinal segments and the patient recovered satisfactorily from the postoperative period.
This case illustrates how the presence of hemoperitoneum with no associated solid organ injury, in the context of abdominal trauma, should raise the concern of bowel and/or mesenteric injury. Mesenteric lacerations are rare injuries that can only be diagnosed intraoperatively, but they can be suspected when encountering mesenteric areas of increased attenuation, fat stranding and bowel abnormalities. When only indirect findings of mesenteric/bowel injury are present, as was in this patient, the need for surgical intervention relies more on clinical judgment.
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