Presentation
Fall on a cinder block two days prior with peristent abdominal pain.
Patient Data
Free intraperitoneal air in the upper abdomen. Proximal small bowel dilated with oral contrast.
Abrupt transition with a thickened segment in the left mid abdomen. Adjacent small foci of extraluminal air and fluid.
Distal small bowel decompressed.
Annotated images.
Coronal image (red arrows) show the segment of thickened, injured bowel.
Axial image (yellow arrows) show the small amount of extraluminal fluid/air adjacent to the injured segment.
Case Discussion
This is a challenging case to diagnose confidently. Besides the free intraperitoneal air as a clue that there is a bowel injury, the change from dilated proximal to quite decompressed distal small bowel indicates intervening bowel injury/pathology. Thus, we must run the bowel!
The proximal small bowel is dilated and filled with oral contrast, which helps. Following the small bowel to the site of injury is key. It is challenging to see the injury on the axial images, but easier to lay it out on the coronal reformats (see annotated images). The small locules of air and fluid adjacent to this loop can increase confidence.
The surgeon was guided to this location and performed laparoscopic repair of an antimesenteric small bowel laceration.