Imaging abdomen trauma mesenteric bowel trauma part 6 Dr Ahmed Esawy

An Article By

Dr. Ahmed Esawy

MBBS M.Sc MD

• BMI can result from both blunt and penetrating

trauma.

• Plain radiograms are useful for evaluating

pneumoperitonium.

• FAST could detects intra-abdominal collections.

• CT is the tool of choice in evaluating BMI.

• Angiography can be used to detect intra-mesentric

hemorrhage.

BOWEL AND MESENTERIC INJURY

• Bowel discontinuity disrupted loop:

• Extra luminal air

• Intramural air

• Extraluminal Oral Contrast Material

• Bowel wall thickening

• Bowel wall enhancement

• Mesenteric infiltration

• Intraperitoneal fluid

• Retroperitoneal fluid

CT FINDINGS IN BOWEL MESENTERIC INJURY BMI INJURIES

Abdominal CT scan reveals free fluid

(black arrow), free intraperitoneal air(white arrowhead)

, retroperitoneal air (black arrowhead) and

intraperitoneal contrast material (white arrow).

Traumatic Duodeno-Jejuneal Perforation

On a CT scan obtained at a lower level, a large

quantity of free contrast material outlines a pelvic

small-bowel loop (white arrows)

Abdominal CT scan shows a thick-walled

duodenum (arrow), outlined by extraluminal

retroperitoneal air (arrowheads).

CT scan of the pelvis reveals foci of

retroperitoneal air that have escaped from the

duodenal perforation (arrowhead).

Abdominal CT scan demonstrates intramural air

in the ileum (solid arrow) and adjacent interloop

free fluid (open arrows

CT scan obtained at a lower level shows mucosal

enhancement (arrowhead) of a more distal ileal segment.

Traumatic Jejuneal And Mesentric Laceration

CT scan obtained at a lower level reveals interloop

fluid (solid arrow) and mesenteric stranding (open

arrow) in the absence of bowel-wall thickening,

findings that are more suggestive of mesenteric injury

than of parenchymal organ damage

Abdominal CT scan shows

hemoperitoneum surrounding the intact

liver capsule (arrowheads).

Colonic Laceration with pericolic hematoma Middle colic artery laceration in a 38-year-old man.CT

scan shows a lobulated hyperattenuating area (arrow) that represents extravasation of contrast

material within an otherwise nonopacified hematoma (arrowheads)

Distal jejunal perforation & mesenteric

hematoma, in a 51-year-old woman. On a CT scan,subtle collections of intramural air (black

arrow) and intraperitoneal air (white arrows) in the region of the thick-walled jejunum

Abdominal CT scan demonstrates an

intraparenchymal liver laceration (white

arrow) and adrenal hematoma (black

arrow), with surrounding retroperitoneal

blood (arrowhead).

periduodenal hematoma thought to be from

the other injuries masks the duodenal

injury (arrows), which could be suspected

on the basis of its ill-defined wall and

adjacent blood

Contusion of the second portion of the

duodenum in a 36-year-old man

Abdominal CT scan reveals a thick-

walled and ill-defined duodenum

(straight arrows) and free and

retroperitoneal air (curved arrows),

findings that suggest duodenal injury

air and fluid (open arrows) adjacent to the right

colon. These findings were thought to be

associated with the duodenal injury because

both the duodenum and right colon reside in the

anterior pararenal space. Black arrow indicates

free air. The thick-walled jejunum (solid white

arrow) was normal at surgery

TRANSECTION OF THE SECOND PORTION OF THE DUODENUM AND FULL-

THICKNESS PERFORATION OF THE RIGHT COLON IN A 46-YEAR-OLD WOMAN

CT

FINDINGS

1-Free Intraperitoneal Air

A

B

2-FREE

RETROPERITONEAL

AIR

3-Extraluminal

Oral Contrast

Material

4-Bowel Wall Defect

Direct visualization of a defect in the

bowel wall due to perforation is

rare, but visualization of such a

defect is diagnostic Even with

careful retrospective review

5-Bowel Wall Thickening

focal small bowel thickening on the left side (arrows). Note the fluid at the mesenteric

root (M). There is a moderate amount of free fluid (F); the free fluid was predominantly

located within the pelvis. A small jejunal perforation was found at surgery.

Bowel wall thickening in a 4-year-old boy

6-FOCAL

HEMATOMA

FOCAL HAEMATOMA

FOCAL HAEMATOMA

Active hemorrhage

Mesenteric

Pseudoaneurysm Mesenteric pseudoaneurysms are rare.

high likelihood of bowel ischemia or infarction .

As with pseudoaneurysms within other abdominal structures, there is a high likelihood of continued or renewed hemorrhage.

Mesenteric pseudoaneurysm

a large mesenteric tear with right colonic ischemia was found

right side with an enhancing pseudoaneurysm (*) and evidence of active hemorrhage (arrowheads).

large hematoma (H) F = free

intraperitoneal fluid.

ABDOMINAL AORTIC INJURY

The spectrum of aortic pathology ranges from intimal disruption to pseudo-

aneurysm formation. Unlike the thoracic aorta, which is screened easily with

chest radiographs, there is no adequate screening examination for the

abdominal aorta.

Aortic Injuries: pathology

They are TEARS not dissections, so best terminology

would be: Traumatic Aortic Injury or TAI

The lesion is an aortic wall TEAR, not a dissection.

The tear is through the intima and media, with the thin but tough adventitia containing the blood volume as a pseudoaneurysm for a time.

When the adventitia fails, the patient usually immediately expires

ABDOMINAL AORTIC INJURY

CT, CTA and conventional contrast aortography are

the main imaging procedures.

Incomplete rupture of the descending aorta in a 51-year-old man with blunt thoracic trauma from a traffic accident.

CT image (a) (b) show a saccular outpouching of the descending aorta. The outpouching is demarcated from the aortic lumen by a collar (arrowheads), and there is only a small periaortic hematoma. The nasogastric tube is not deviated.

. CT image of the aortic isthmus shows complete transection of the aortic wall (arrowheads) with a periaortic hematoma and hemomediastinum.

Anteroposterior chest radiograph shows a

widened upper mediastinum with a faint left

apical extrapleural cap (arrows).

Complete aortic rupture in a 48-year-old

woman with blunt thoracic trauma from a

skydiving accident. The lesion was

successfully repaired at surgery; however,

the patient subsequently died due to

severe brain injury

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Complex aortic dissection and bilateral hemothorax in a 44-year-

old woman with blunt thoracic trauma from a motorcycle accident.

(a) Axial CT image of the aortic arch shows the intimomedial flap,

which divides the aorta into true (T) and false (F) lumin

DIAPHRAGMATIC INJURY

Traumatic diaphragmatic hernia can result from either penetrating (e.g., knife and

bullet wounds) or blunt (e.g., motor vehicle accidents, falls, and crushes) injury.

Diaphragmatic rupture is recognized in about 0.5% of blunt trauma survivors in

various series.

Traumatic Rupture of the Right Diaphragm

Right diaphragmatic rupture and duodenal contusion in a 43-year-old man. (a)

Abdominal CT scan shows a posterior right rib fracture (arrow) at the site of a

diaphragmatic hematoma (black arrowheads).

a CT scan obtained at a lower level, extension of the diaphragmatic hematoma

into the posterior pararenal space

(arrow) was erroneously thought to be the source of the periduodenal

hematoma in the anterior pararenal space.

Subcutaneous air (white arrowheads in a and b) from barotrauma is visible

PELVIC HEMATOMA

Hemorrhage associated with pelvic trauma, with

or without pelvic fracture, is common and can

arise from venous, osseous, or arterial sources or

any combination of the above. Typically, pelvic

hemorrhage is treated first using external

fixation, which usually is successful in treating

venous and osseous bleeding through a

tamponade effect.

PELVIC HEMATOMA

Continued bleeding may indicate an arterial source, surgical exploration for such patients is difficult and complex due to difficulties in visualization of the hemorrhagic arteries.

In many centers catheter angiography and embolization is considered the standard for diagnosis and treatment for pelvic trauma.

CT is also necessary for diagnosis of the site of hematoma and associated fractures.

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