Bowel and mesenteric injury

Bowel and mesenteric injury

1. Bowel and mesenteric injury Dr. Devkant Lakhera

2. Bowel and mesenteric injury 1% to 5% of abdominal trauma Difficulty Clinical signs are often non specific (40% Negative lap) Polytrauma Goal – requirement of surgical intervention Delay in diagnosis - sepsis, peritonitis and death

3. Plain r a d i o g r a phs a r e u se ful for e v a l u a ti n g p n e u mop e r ito n i u m . F A S T d et e c t s int ra - a b d omin al collec t io n s. Angi o g r a p hy ca n b e u se d t o de t e ct int r a - me s e n ter i c h e mo r r h a g e. C T is the t o o l o f ch o i ce i n e v a l u a ti n g bowel and mesenteric injury in hemodynamically stable patient . IMAGING MODALITIES

4. Sensitivity of CT 70-85 % More specific than diagnostic peritoneal lavage Reasons for missed diagnosis Major injury to other organs Support and monitoring devices that can cause artifact absence of extraluminal gas.

5. CT findings in bowel and mesenteric injury Findings Specific to Bowel Injury Bowel Wall Discontinuity Extraluminal Contrast Material Extraluminal Air Findings Less Specific to Bowel Injury Bowel Wall Thickening Abnormal Bowel Wall Enhancement Mesenteric Features (stranding) Free intraperitoneal fluid

6. Sites of bowel injury Most common - Small bowel {jejunum (near ligament of Trietz /D-J flexure) > ileum (near ileocaecal valve)} (more shearing force) colon (transverse colon) Least common - stomach

7. Imaging – Plain Radiography Preferred in hemodynamically stable patients X-ray chest erect PA view

8. lateral umbilical ligament sign (also known as inverted "V" sign) cupola sign urachus sign right upper quadrant signs fissure for ligamentum teres sign hepatic edge sign lucent liver sign periportal free gas sign

9. Ultrasound either alone or with associated posterior multiple reflection artifacts or dirty shadowing. may be accompanied by posterior artefactual reverberation echoes with a characteristic comet-tail appearance.

10. Pneumoperitoneum

11. Bowel wall discontinuity and Extraluminal air Fluid filled bowel loop Sealed perforation Small amount of air 65 yr with stab injury to left flank

12. Common sites of free air accumulation Accumulates behind anterior abdominal wall, below diaphragm Along peritoneal surfaces of liver and spleen. Other sites – Porta hepatis, mesentery, mesenteric / portal veins,

13. Other causes of free air Penetrating injury Mechanical ventilation Bladder rupture Barotrauma Diagnostic peritoneal lavage Pseudopneumoperitonieum

14. Extravastation of contrast Usually not given extraluminal contrast (bladder injury)

15. Focal bowel wall thickening Normal thickness – 3mm Less likely to require surgical intervention

16. Generalized wall thickening Shock bowel

17. Hypoperfusion complex Flattened inferior vena cava Narrowed aorta Increased enhancement of adrenal, kidneys and bowel Volume overload

18. ABNORMAL BOWEL WALL ENHANCEMENT hypoperfusion or local vascular injury increased vascular permeability and leakage of contrast material (injury) decreased enhancement of the bowel wall can be a sign of ischemia

19. FREE INTRAPERITONEAL FLUID Traumatic intraperitoneal fluid - solid organ, bowel, or mesenteric injury; bile from a ruptured gallbladder or bile duct; and urine from a ruptured bladder Bowel injury - fluid is seen only adjacent to bowel or caught between the leaves of the mesentery Nontraumatic causes

20. Mesenteric injury Mesenteric hematoma Mesenteric vascular injury Extravastation

21. Mesenteric vascular injury 100 % specific Urgent laparotomy include active contrast extravasation, beaded appearance of mesenteric vessels and abrupt termination of mesenteric vessels

22. 50-year-old in a motor vehicle collision. Suggested diagnostic angiography

23. small-bowel mesenteric tear was found, with active bleeding from a jejunal branch of the superior mesenteric artery

24. MESENTERIC INJURY mesenteric stranding, hematomas, and beading or abrupt termination of vessels

25. Omental injury

26. Significant mesenteric injury active mesenteric bleeding, disruption of the mesentery mesenteric injury associated with bowel ischemia Insignificant mesenteric injury Hematoma Significant injury Significant bowel injury complete tear of the bowel wall an incomplete tear that involves the serosa and that extends to but does not involve the mucosa. Insignificant bowel injury hematoma and a tear limited to the serosa.

27. DIAPHRAGM Diaphragmatic rupture and subsequent herniation of abdominal contents into thorax is nine times more common on left side than right due to the protective effect of the liver

28. Vascular Injuries in Trauma Direct signs - Laceration with active hemorrhage, intimal tear, dissection, intraluminal thrombosis, pseudoaneurysm, narrowing, and presence of arteriovenous fistulas Indirect signs- abnormalities of the perivascular tissues or end organs and include presence of a perivascular hematoma or fat stranding and varying degrees of end-organ hypoenhancement

29. Active contrast extravastation In all 3 layers Goal is to differentiate between arterial and venous bleed Active extravasation – Blush Intra- and extraperitoneal spaces adjacent to the injured vessel intraparenchymal or intraluminal bleeding when a solid or hollow viscus is injured

30. Arterial injury - arterial phase pooling of contrast material, with attenuation similar to that of the aorta Venous injury - in the portal venous phase as a focus of extravascular attenuation, also expanding on delayed phase images,

31. Intimal tear curvilinear hypoattenuating filling defect No evidence of organ ischemia With resolution on follow up

32. Vessel Dissection interposition of blood between the intima/inner media and the outer media/adventitia linear area of hypoattenuation, representing the intima and inner media, may project into the vessel lumen.

33. Pseudoaneurysm Pseudoaneurysms are contained vascular injuries that may occur when the arterial intima and media are injured and flowing blood is contained by the adventitia.

34. Complete / Partial occulsion

35. Vessel Contour Abnormalities irregular in contour, the differential diagnosis includes dissection, intimal tear with partial thrombosis, vasospasm, and perivascular hematoma resulting in external compression

36. Thank you