Presentation
Passenger in high speed motor vehicle collision.
Patient Data
No solid organ injury identified. Perihepatic, right paracolic and pelvic free fluid. Hematoma surrounding the ascending colon / cecum. 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 ischemic 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, cecum and part of ascending colon. The serosal surface on the cecum 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:
- Small bowel: Small bowel with evidence of trauma.
- Large intestine: Colon with evidence of submucosal hemorrhage and inflammation. Features may been seen in relation to trauma and ischemia.
Case Discussion
This case has a few learning points:
- Bowel and mesenteric trauma is difficult to recognize 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 / hematoma being the only real evidence.
- Abdominal aortic injuries are rare, but in patients who survive to hospital intimal tears / dissections such as these are the most common.
- Seatbelt sign is associated with severe intra-abdominal injuries. Its presence should increased diagnostic suspicion of these injuries.