Hypoperfusion complex - "shock bowel"

Case contributed by Dr Michael P Hartung

Presentation

Motorcycle accident with upper extremity injury and blood loss. CT obtained 10 hours after initial injury.

Patient Data

Age: 35 years
Gender: Female

Fluid-filled esophagus.

Small spleen (85 mL).

Mildly hyperenhancing gallbladder wall.

Diffuse mucosal hyperenhancement and submucosal edema of the large and small bowel. 

Peripancreatic fluid.

Small ascites. 

Flattened IVC. 

Small aorta (infrarenal AP diameter 1.0 cm).

Right acetabular and pelvic ring fractures with soft tissue/muscular injury of the upper thigh. 

Delayed images: persistent mucosal hyperenhancement of the bowel, persistent nephrograms. 

Case Discussion

Hypoperfusion complex due to blood loss and prolonged hypotension following an upper extremity injury. It reflects the body's sympathetic response to hypotension, and in this case, has the following manifestations:

  • shock bowel (splanchnic vasoconstriction results in increased mucosal permeability, resulting in leakage and mural interstitial fluid and contrast) 
  • hyperenhancing gallbladder wall 
  • small spleen
  • persistent nephrogram
  • peripancreatic fluid
  • flattened IVC
  • small aorta
  • ascites

Of note, a recent article supports that decreased splenic volume is actually the most sensitive indicator of hypoperfusion complex (34 of 35 patients with prior imaging had >30% decrease in volume). On average, patients with hypovolemic shock complex splenic volume was 107 mL, compared to 220 mL in the control population1.

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Case information

rID: 68821
Published: 18th Jun 2019
Last edited: 29th Aug 2019
Inclusion in quiz mode: Included
Institution: Tenwek Hospital

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