Shock bowel

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

Involved in a motor vehicle collision. Abdominal trauma.

Patient Data

Age: 37
Gender: Female
CT

No pneumothorax. Cardiomediastinal contour within normal limits. No mediastinal haematoma. No evidence of great vessel injury. Sternal irregularity was considered artifactual. No displaced rib fracture.

Significant free gas and fluid. Retroperitoneal gas also noted, in particular around the right kidney. Significant amount of abdominal wall subcutaneous gas also noted.

Left sided loops of small bowel are thickened and oedematous down to the level of ileum. This loop of the bowel appears disrupted at its distal aspect with no definite continuity to the rest of the bowel. 

There is contrast pooling adjacent to the superior mesenteric artery and vein as well as a smaller amount inferior to it adjacent to the small mesenteric branches within the pelvis. There is also contrast blush adjacent to the distal descending colon. These indicate multiple areas of active bleeding within the extensive mesenteric haematoma.

Completely effaced IVC is indicative of extreme hypovolaemia. 

Conclusion:

Extensive intra-abdominal free fluid and gas, with areas of active bleeding as described. The appearance is suspicious for hollow viscus injury/perforation.

The patient underwent laparotomy and bowel resection.

CT

Follow up CT seven days after laparotomy.

Large right inferolateral abdominal wall hypoattenuating collection noted, measuring 9x4cm on axial plane. This does not have an enhancing wall and is most likely a sterile liquefying haematoma or a seroma, rather than an infected collection.

Lateral descending colon hypoattenuating regions identified with subtle peripheral enhancement, which may represent small collections (3.7x1.9cm). They exhibit local mass effect on the colon, suggesting they may be trapped in peritoneal reflections (lateroconal fascia).

Small hypoattenuating regions also noted within the posterior aspect of the liver, which are probably temporal evolution of the small parenchymal lacerations undetectable on the initial scan. Given the appearance of these, hepatic/retrohepatic collections or abscesses were considered unlikely.

Small locule of intraperitoneal free gas. Bowel resection and anastomosis noted.

Left inferolateral abdominal wall defect with adjacent haematoma. Small free intra-abdominal fluid layering between the loops of bowel and within subhepatic region (no walled-off).

Gas within bladder, probably related to the recent catheterization attempt.

Bilateral pleural effusions with right basal segmental atelectasis.

The remainder of the findings stable.

Conclusion:

Possible lateral proximal para-descending colon collections as described.

Case Discussion

Bowel injury after blunt abdominal trauma. Hypovolaemic shock with CT signs of shock bowel, and flattened IVC.

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Case information

rID: 34893
Case created: 13th Mar 2015
Last edited: 13th Dec 2015
Inclusion in quiz mode: Included

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