A 23 y.o. male was a restrained passenger in an MVC. His car struck a pole and he complains of abdominal pain.
What do you notice in the pelvis?
Do you see any abnormality in the bowel?
Our patient had an injury to the bowel mesentery caused by a high speed crash. He had a seat belt sign across the chest and abdomen. He had a small hemoperitoneum, L2 spinous process fracture, and pneumatosis of the bowel.
Free fluid is shown above.
The mesenteric blood supply can be avulsed off the bowel leading to ischemia. This is referred to as a bucket handle injury.
The bowel loop that has been detached from the mesentery is known as the handle. These tears occur with rapid deceleration commonly when the person is wearing a seat belt. The mesenteric injuries are thought to be the result of shearing forces at points where part of the bowel is fixed and part is mobile.Common sites of injury are the proximal jejunum where the duodenum is fixed in the retroperitoneum and the jejunum is mobile, the ileocecal valve when the R colon is fixed in the retroperitoneum and the distal ileum is mobile, and the sigmoid colon which is mobile and attached to the retroperitoneal descending colon.
Between 1-6% of patients with blunt abdominal trauma have mesenteric or hollow visceral injuries with 70% occurring in the small bowel. In addition to bucket handle devascularization of bowel, perforations can occur on the antimesenteric surface. It is estimated that the force needed to perforate the bowel wall is 120-140 mmHg.
Although CT is the gold standard for diagnosing these injuries, the sensitivity for detection is variable with reports of 59-95% sensitiivity. Signs of bowel wall injury, such as pneumoperitoneum, extraluminal contrast or focal wall defects are rarely seen. A traumatic lumbar hernia can be helpful in making the diagnosis because it suggests significant deceleration occurred. If the injury is unrecognized, the devascularized bowel goes on to become necrotic and perforate leading to sepsis.
Our patient had free fluid in the pelvis and a lumbar hernia. In spite of the fact he was altered due to cannabis ingestion, he complained of persistent lower abdominal pain and was taken to the OR. He had devasculaization of the small bowel at the jejunum and proximal small bowel requiring a 20 cm resection, a devascularized segment of mid ileum requiring a 20 cm resection and a serosal tear of the sigmoid colon which was oversewn. His abdomen was left open to assess the viabllity of the sigmoid and he was taken back to the OR two days later for closure.
Extein J, Allen B,Shapiro M, Jaffe T. CT findings of traumatic bucket-handle mesenteric injureis. Gastrointestinal Imaging, Review AJR 209, decenber , 2017 doi: 10.2214/AJR.17.17927.
de Castro PJ, Gomes G, Mateus N, et al. Small bowel perforation and sesentery injury after an unusual blunt abdominal trauma-Case report. Int J surg Case Rep 2015;7:51-53.
Fakhry S, Watts D, Luchette F, et al. current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury; analysis from 275,557 trauma admissions for the EAST melti-institutional HVI trial. J Trauma 2003;54(2):295-306.