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GI Injuries Jurnal
GI Injuries Jurnal
www.carjonline.org
Trauma and Emergency Room Imaging / L’imagerie des urgences et des traumatismes
Abstract
Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of
trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in
detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This
pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and
abdominal trauma.
Resume
Les lesions aux visceres creux du systeme gastro-intestinal consecutives a un traumatisme thoracique et abdominal ne sont pas courantes:
elles n’aggravent que de 0,6 a 1,2 % des traumatismes. Toutefois, leur detection precoce reduit considerablement le taux de morbidite et de
mortalite. Puisque l’examen physique ne permet pas de deceler efficacement ce type de lesions, de nombreux services d’urgence ont recours a
la tomodensitometrie avec injection de produit de contraste pour poser un diagnostic. Cet essai descriptif vise a analyser l’incidence des
lesions aux visceres creux du systeme gastro-intestinal, ainsi que les mecanismes et les signes qui leur sont associes, dans un contexte de
traumatisme contondant au thorax et a l’abdomen.
Ó 2015 Canadian Association of Radiologists. All rights reserved.
Key Words: Hollow viscus injury; Gastrointestinal tract; Blunt trauma; Computed tomography
Trauma is the leading cause of death in individuals under of such injuries on CT is crucial for patient management and
the age of 45 years and the fourth leading cause of death for prognosis [6]. This review aims to identify general and
all ages [1]. The death rate due to trauma was 180,000 in specific radiological signs of gastrointestinal HVI in patients
2007 within the United States alone [1]. The incidence of with blunt chest and abdominal trauma, with a focus on
hollow viscus injury (HVI) following blunt abdominal CECT findings. In addition, the epidemiology, mechanism of
trauma (BAT) and chest trauma is between 0.6%-1.2%, and injury, and management of such injuries is briefly reviewed.
5% with severe BAT [1e5]. Contrast-enhanced computed
tomography (CECT) is the diagnostic modality of choice in
the assessment of hemodynamically stable patients with General Findings
blunt chest and abdominal trauma [2]. Timely identification
Although a variety of imaging signs are usually present in
HVI, more specific findings may not be sensitive and the
more sensitive signs are not highly specific [1]. For example,
* Address for correspondence: Nima Kokabi, MD, Department of
Radiology and Imaging Sciences, Emory University Hospital Midtown, 550 for an average-size patient, collimation of 1.25 mm (4-slice
Peachtree Street NE, Atlanta, Georgia 30308, USA. and 16-slice) or 0.6 mm (64-slice), 120 kVp, and 300 mA
E-mail address: nima.kokabi@emory.edu (N. Kokabi). may be appropriate [7], however, the use of dynamic scan
0846-5371/$ - see front matter Ó 2015 Canadian Association of Radiologists. All rights reserved.
http://dx.doi.org/10.1016/j.carj.2014.11.003
HVI in BAT / Canadian Association of Radiologists Journal 66 (2015) 158e163 159
Pneumoperitoneum
Figure 2. Severely distended stomach with intraluminal heterogeneous dense material (white arrows) and active extravasation (red arrows). No pneumoperitoneum.
Contained rupture with large amount of intraluminal hemorrhage found during surgery (A-D). This figure is available in colour online at http://carjonline.org/.
transmural perforation is generally treated via surgical Gastric injuries are commonly seen in younger populations
debridement, primary closure, and mediastinal drainage. In and have the highest mortality compared to other HVI
critical patients or those at high risk for surgery, esophageal (28.2%) [12]. The main mechanism of injury is significant
exclusion and diversion is the most prudent option [10]. blunt force on a distended stomach, especially after a recent
meal. Motor vehicle accidents are the main source of gastric
Stomach injuries, particularly if they involve trauma to the left side of
the chest or use of lap belts [13]. The main mechanism of
Gastric injuries occur in 0.4%-1.7% of all BAT and are the injury is tearing by deceleration. The most commonly
third most common HVI after the small bowel and colon [1]. affected areas are the anterior wall, followed by the greater
Figure 3. Duodenal perforation. Thickened heterogeneously enhancing duodenal wall with extraluminal fluid (white arrows) and air (yellow arrow) on initial
contrast-enhanced computed tomography (CECT) (A, B). Leaking of oral contrast and pooling around the duodenum on follow-up exam (white arrows) (C, D).
This figure is available in colour online at http://carjonline.org/.
HVI in BAT / Canadian Association of Radiologists Journal 66 (2015) 158e163 161
Figure 4. Mesenteric hematoma with ischemic injury to jejunum and ileum with hyperdense fluid (yellow arrows) within the mesentery and bowel wall thickening
(white arrows) more prominent in areas of mesenteric hematoma (A, B). Normal appearing more distal small bowel (blue arrows). Multiple corresponding
segments of bowel were found to be ischemic during exploratory laparotomy. This figure is available in colour online at http://carjonline.org/.
curvature, lesser curvature and the posterior wall [9]. The Duodenal contusion is suspected if there is wall thick-
most commonly associated injuries include those to the ening (>4 mm), high-density intramural hematoma, or
spleen and thorax [13]. edema. Presence of focal wall discontinuity, periduodenal
CECT may show nonspecific signs such as free intra- fluid, perirenal fluid/gas, or extraluminal gas in the retro-
abdominal fluid, or more specific signs such as a distended peritoneum is suggestive of duodenal perforation. Extra-
stomach, extraluminal gas or oral contrast, and intramural luminal pooling of oral contrast or active extravasation from
hematoma [13] (Figure 2). Management is typically con- the gastroduodenal artery may be seen [1,9] (Figure 3).
servative for cases with wall thickening and mural hema- Pancreatic head or duct involvement, major vessel or biliary
toma. More severe injuries such as perforation or active tree injuries are associated injuries.
extravasation are managed surgically [13]. Management of isolated duodenal hematomas is usually
conservative, although gastric outlet obstruction syndrome
may develop in the early stages. Surgical management is
Small Bowel reserved for more severe injuries such as perforation,
pancreatic head involvement or duct, major vessels, or biliary
Duodenum tree injuries.
Figure 5. Traumatic herniation (yellow arrows) of descending colon posterior to the left lateral abdominal muscles with mildly thickened bowel wall (A, B). There
is also fluid present in the herniation sac better appreciated on coronal reformats (*). This figure is available in colour online at http://carjonline.org/.
162 N. Kokabi et al. / Canadian Association of Radiologists Journal 66 (2015) 158e163
Figure 6. Traumatic colonic rupture involving the cecum with pneumoperitoneum (white arrows) and retroperitoneum, free fluid, and stranding (yellow arrows)
(A, B). This figure is available in colour online at http://carjonline.org/.
mechanisms of injury include crushing forces of the bowel On CT, the presence of focal wall discontinuity, extravasa-
against the spine. In particular, a Chance fracture and/or tion of oral contrast and intraperitoneal air may indicate
seatbelt sign should raise suspicion for SBI [5]. Associated bowel perforation. Free retroperitoneal air may be identified
mesenteric tears causing a compressive hematoma can indicating an injury to the ascending and descending colon or
compromise blood supply and lead to bowel infarction rectum if found in the pelvis. Free retroperitoneal air is less
(Figure 4). Rupture occurs most commonly on the anti- commonly found as an isolated finding and is not specific for
mesenteric border [9]. CT findings include bowel wall hema- colonic injury as it may indicate duodenal perforation,
toma and thickening of >4 mm. Extraluminal free fluid pneumothorax, or pneumoemediastinum [14]. Pericolonic
(typically hypoattenuating, <20 HU) may be commonly seen. and mesocolic fat stranding may be seen on CT (Figure 6).
Because small bowel does not typically contain gas, perfora- Unlike SBIs, blunt colonic injuries often require prompt
tion may occur in the absence of pneumoperitonium [9]. surgical intervention, as patients with colon injury are at high
Peritoneal irritation develops slowly as the contents in the risk for serious complications such as abscess or sepsis, as well
small bowels have neutral pH, are enzymatically inactive and as increased hospital stay [6]. Furthermore, a delay in surgery
have a low bacterial count [16,17]. Use of oral or rectal contrast of more than 6 hours in patients with uncontrolled colonic
in BAT has been questioned as it poses a risk of aspiration, as injury has been previously found to be a predictor of poorer
well as slow progression due to paralytic ileus resulting in an outcomes [19,20]. Because no individual test or combination
estimated wait of >90 minutes for adequate opacification of of diagnostic modalities in current use adequately detects
the bowels, while hindering the detection of intraluminal colonic injury [6], timely referral for operative management in
hemorrhage [15,18]. cases of suspected colonic injury is crucial in reducing surgical
Management is conservative for intramural hematoma delay and preventing complications.
without perforation. Exploratory laparotomy is required for sus-
pected perforation, vessel injury, or risk of bowel ischemia [12]. Conclusion
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