Traumatic bowel and abdominal aortic injuries

Case contributed by Dr Henry Knipe

Presentation

Passenger in high speed motor vehicle collision.

Patient Data

Age: 30
Gender: Male

No solid organ injury identified. Perihepatic, right paracolic and pelvic free fluid. Haematoma surrounding the ascending colon / caecum. Loops of small bowel are mildly thick walled. 

The abdominal aorta inferior to the IMA origin is abnormal with a "target sign" on axial images and filling defects on the coronal images. These reflect a traumatic abdominal aortic injury. 

Seatbelt pattern of subcutaneous bruising. 

The patient proceeded to trauma laparotomy with operative findings of ischaemic right colon, small bowel and mesenteric injuries. The patient underwent a small bowel resection and right hemicolectomy. 

MACROSCOPIC DESCRIPTION:

1. "Small bowel": A segment of small bowel, 65mm long by 15mm in diameter. The serosal surface is congested with multiple sutures. One margin inked blue, second inked green. The mucosal surface is focally congested and the wall is stitched. No suspicious mass is identified. The remaining mucosal surface is unremarkable.

2. "Large intestine": Right hemicolectomy comprising terminal ileum, appendix, caecum and part of ascending colon. The serosal surface on the caecum and the ascending colon is congested. The wall is purple and the mucosal surface is flat and dusky. Proximal end inked. The appendix is unremarkable.

DIAGNOSIS:

  1. Small bowel: Small bowel with evidence of trauma.
  2. Large intestine: Colon with evidence of submucosal haemorrhage and inflammation. Features may been seen in relation to trauma and ischaemia.

Case Discussion

This case has a few learning points:

  1. Bowel and mesenteric trauma is difficult to recognise on CT - this patient had substantial traumatic injuries to bowel and mesentery and the findings are underwhelming on CT. There are often occult with findings of unexplained free fluid / haematoma being the only real evidence. 
  2. Abdominal aortic injuries are rare, but in patients who survive to hospital intimal tears / dissections such as these are the most common. 
  3. Seatbelt sign is associated with severe intra-abdominal injuries. Its presence should increased diagnostic suspicion of these injuries. 
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Case information

rID: 39864
Case created: 24th Sep 2015
Last edited: 27th Sep 2015
Inclusion in quiz mode: Included

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