Traumatic small bowel and mesenteric injury
Driver involved in road traffic accident. Restrained by seatbelt. Abdominal pain. Bruising over chest and lower abdomen.
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Free fluid is present in both paracolic gutters, the small bowel mesentery and pooling in the pelvis. There is a density gradient indicating there has been bleeding and this is not just simple fluid. The distal small bowel is thick walled and hypoenhancing over a length of 15 cm, approximately 15 upstream from the ileocecal valve. A band of high attenuation streaking is present across the lower anterior abdominal wall fat indicating a lap belt injury. No free gas seen.
No solid organ, pulmonary or skeletal injury. No contrast extravasation.
A sudden deceleration causes bruising of the chest and abdominal walls by the seatbelt. As well as being visible on clinical examination, the seatbelt sign is visible as fat stranding on trauma CT. A careful inspection of signs of small bowel and mesenteric injury secondary to blunt trauma should follow. The signs seen in this particular study include:
- free fluid with a gradient indicating hemoperitoneum
- fluid within the leaves of the mesentery
- bowel wall thickening and hypoenhancement - likely due to bowel ischemia because of shearing of mesenteric vessels
In this case, a conservative management path was followed with no clinical deterioration and no requirement for operative intervention.