Presentation
Alleged motor vehicle accident with vague lower abdominal pain. Patient was front car passenger.
Patient Data
Significant amount of localized free fluid at the anterior pararenal space surrounding the pancreas, second part and third part of duodenum. Significant fat stranding seen at this region. The pancreas appears to be enhanced homogenously without obvious laceration or intraparenchymal hematoma. No dilatation of pancreatic duct. Common bile duct and intrahepatic ducts are normal.
The D2 and D3 duodenum collapsed without significant reduction in bowel wall enhancement or thickening of bowel. No proximal gastric dilatation. However, the proximal jejunum appears to have thickened bowel wall with abnormally high intramural density content up to 100HU which can represent intramural hematoma.
No pneumoperitoneum. Significant mesenteric fat streakiness and intermesenteric fluid seen at the jejunal mesenteric branches. No active contrast extravasation and abrupt termination of superior mesenteric artery.
Positive seat belt sign as presence of ecchymosis in horizontal fashion across the lower abdomen.
High density collection noted at the right paracolic gutter, pelvic region and pouch of Douglas as they have attenuation of 60 to 70 HU in keeping with hematoma. Minimal ascites at the Morrison pouch and perisplenic region.
Anterior wedging noted at the L1 vertebral body and anterosuperior endplate fracture in keeping with compression fracture. No retropulsed bony fragment and preserved vertebral alignment.
Subcutaneous hematoma is also noted at the posterior back from T12 to L2 level.
Case Discussion
Overall CT features are suggestive of retroperitoneal duodenum (D2/D3) and proximal jejunum bowel loops injury associated with jejunal mesentery injury in view of the presence of suggestive signs:
jejunal mural hematoma
moderate amount of anterior pararenal space, right posterior pararenal space and pelvic hematoma without major solid organ injury
intermesenteric fluid especially at jejunal mesentery.
positive seatbelt sign (anterior lower abdomen and posterior back at L1 level) as well as L1 compression fracture
These radiological signs are suggestive signs though there are no definitive signs such as extraluminal pneumoperitoneum.
The patient was treated conservatively and recovered uneventfully. This case showed the importance of recognizing seatbelt injury and specifically looking for pancreatic laceration, thoracolumbar fracture, and bowel and mesentery injuries related to seatbelt injuries.
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